PSARP

PSARP in India

PSARP (Posterior Sagittal Anorectoplasty) is a surgery procedure, which is applied to fix anorectal malformations (ARM) - defects congenital in the formation of the anus and rectum. Mostly it is carried out on infants and children.

Overview

• Abbreviated form: Posterior Sagittal Anorectoplasty.
• Goal: To form a normal anal opening and to reinstate the correct relationship between the rectum and the anal canal.
• Invented by: Dr. Alberto Peña in 1980.
• Category: Pediatric reconstructive surgery.

Indications

PSARP is normally conducted on:

• Imperforate anus (no anal aperture)
• Rectourethral fistula (rectum is connected to urethra)
• Rectovaginal fistula (rectum unites with vagina)
• Other complicated anorectal malformations.

Procedure Steps

• Positioning: the child is positioned in prone (face-down) posture.
• Incision: The ridge is incised in the sacrum up to the perineum.
• Dissection: The surgeon finds and isolates the rectum in regard to other internal organs, such as the urethra or vagina.
• Fistula sealing: The abnormal connection (fistula) is also cautiously sealed.
• Reconstruction: The rectum is pulled down via the muscle complex to the normal level.
• Anoplasty: The new anus is constructed at the right position.

Postoperative Care

• The child might colostomized at first but later this is closed after healing has taken place.
• In order to avoid narrowing, anal dilatations are performed on a regular basis.
• It should be bowel trained and kept clean.

Posterior sagittal anorectoplasty in India

Posterior Sagittal Anorectoplasty (PSARP) represents a surgical method of repairing occurrence in the congenital malformation of the anorectum (ARM) - anorectum and anus that do not develop normally in infants. It is a routine pediatric operation, particularly of infants who were born with imperforable anus or rectal fistulas.

Purpose

The goal of PSARP is to:

• Form an effective anus that lies in the right location.
• Divide and rejoin any abnormal fistulas between the rectum and the urinary or genital tract.
• Maintain continence by repairing by the use of the muscle complex involved in bowel control.

Best hospitals for PSARP surgery in India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Factors Affecting PSARP surgery cost in India

The significant factors which influence the cost of Posterior Sagittal Anorectoplasty (PSARP) surgery in India are as follows:

Surgeon’s fees

• The experience of the surgeon, reputation, training (in particular, pediatric colorectal surgery) adds to the fee. More complicated defects require greater expertise on the part of the surgeon → higher charge.

Hospital / Facility charges

• Private are more expensive. Branding and specialization of hospital (children hospital, specialty pediatric surgery center) is an additional cost.

Room type chosen

• General ward, semi-private, private room. Deluxe or private rooms would be much more expensive.

Operating room (OR) charges

• Time in OR, special equipment utilization advanced monitoring requirement, anaesthesia, etc. Surgeries that are more complicated consume more OR time.

Fees of anaesthesia & anaesthetist

• It depends on type of anaesthesia, the length of it, risk factors (e.g. whether a child has some underlying health problems).

Investigations / Preoperative imaging

• Pelvic MRI / ultrasound, spinal, contrast to identify fistula, etc. Additional assessment is more expensive.

Postoperative care

• ICU (where necessary) and ward stay, dressing and wound care, pain management. In case he/she develops complications, the cost increases.

Consumables & medications

• Sutures, surgical equipment, disposable products (catheters, gloves, dressings), antibiotics, analgesics. It is more expensive to have a lot of or a more complex or high quality consumable.

Comorbid conditions / pre-existing conditions 

• In case the child has other health problems (heart, lung, nutrition status etc.), the risk is bigger → more tracking, may be longer stay, more drugs.

Fistula repair / malformation complexity

• Simple vs complex (two or more fistulas, high vs low anomalies, cloacal anomalies) alter the complexity of the surgery, duration, and care needed in the postoperative period.

Geographic location / city

• The charges of hospitals, cost of living, and salary of staff will be higher in big metros (Delhi, Mumbai, Bangalore etc.). The smaller cities can be cheaper.

Hospital class / amenities

• The ones with the best facilities, high level of pediatric ICU/NICU, high nurse to patient ratio, etc. will be more expensive.

Length of hospitalization

• The longer the duration (pre-op + post-op) the more room, food, nursing, consumables etc cost.

Post-operative treatment, dilatations, revisions

• PSARP may often necessitate postoperative dilatations, a potential colostomy closure done in stages and occasional revisions - these increase overall cost.

Pediatric PSARP surgery in India

PSARP (Posterior Sagittal Anorectoplasty) is a surgical operation performed on children/infants to correct the anorectal malformations (ARM). These are hereditary malformations whereby the anus or rectum (or both) fail to develop correctly or are attached in an abnormal way to the urinary or genital tract (fistulas). The operation works to restore a normal anus, put the rectum in place, seal up any abnormal connections as well as maintain continence. 

Indications

Some of the ARMs on which PPSARP is performed include:

• Imperforate anus (no anal opening) 
• Fistulas such as rectourethral (Male), rectovaginal or vestibular (Female). 
• High vs intermediate anomalies (i.e. placement of the rectum in relation to pelvic floor and other structures) 
• At times with other surgery (when more complicated, multiple fistulas, cloacal malformations) 

Timing & Staging

The process of PSARP varies according to the age, health and the nature of anomaly in the child:

• Certain PSARPs are performed neonatally (extremely early) in case of possibilities. 

Others are staged:

• Colostomy with fecal diversion, PSARP, and colostomy closure. 
• Others use 2-stage or 3-stage (based on complexity). 

Surgical Procedure (what is involved in PSARP)

The surgery will involve a rough procedure of:

Pre-operative assessment

• Anatomical imaging: e.g. distal colostogram, inverted film or lateral invertogram, ultrasound etc. 
• Evaluate any related abnormalities (urinary, spinal, vertebral, renal) since ARMs is sometimes associated with other developmental anomalies. 

Anaesthesia & Positioning

• General anaesthesia
• Infant lying flat (on his back) or in such a position that the perineum could be accessed well. 

Incision

• In the midline between the sacral area and the perineum, posterior sagittal incision. 

Dissection

• Rectal pouch/ fistula independent of surrounding structures (urinary tract, genital tract)
• Determine sphincter muscles, retain or repair the muscle complex surrounding the rectum. 

Rectal pull-through + anoplasty

• Get rectum to point through the sphincter complex, form new anal opening in proper place.
• Close any fistula if present. 

Alternative: Abdominal openness.

• In other high anomalies, the abdominal-perineal approach may be combined. In other instances laparoscopic aid can be employed. 

Postoperative care

• Wound treatment, observation of infection or hemorrhage.
• Anal dilations (a procedure to avoid anus stenosis or constriction) typically beginning a few weeks after the surgery. 
• Close colostomy in case a staged treatment was employed, when healing is fit.

Top surgeons for PSARP in India

• Dr. Nitin Goel
• Dr. Shandip Kumar Sinha
• Dr. Anand Sinha
• Dr. Anurag Krishna

Conclusion

Surgical repair of anorectal malformations (ARM) in children is a gold-standard procedure, which is called Posterior Sagittal Anorectoplasty (PSARP). It enables clear pelvic anatomy, proper reconstruction of the rectum and anal canal and maintenance of the sphincter mechanism- important in bowel control in the long run. PSARP can provide great anatomical and functional results, and the vast majority of children with the experience of competent pediatric colorectal surgeons develop good continence and almost normal quality of life. Nevertheless, success in the long term is based on:

• Early diagnosis and early surgery,
• Effective postoperative treatment such as anal dilatements and bowel management, and
• Periodic follow-up of continence training and observation of such complications as constipation or anal stenosis.

PSARP in India with GetWellGo

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• Language Support
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• Case manager assigned to every patient to provide seamless support in and out of the hospital like appointment booking
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FAQ

1. At what age is PSARP conducted?

• Normally, PSARP is performed at 3 to 6 months of age basing on the health of the baby and malformation. In complicated scenarios, colostomy (temporary stool opening) can be done initially, and PSARP can be done later as a staged one.

2. Why is PSARP a better method than other methods?

• PSARP directly allows the visibility of structures in the pelvis, allows precise repair of the rectum, fistula closure and saves the muscles that maintain continence. This leads to improved bowel management in the long term as opposed to the previous procedures.

3. What is the duration of the surgery?

• The process typically takes 3-5 hours, depending on the complexity of the anomaly and the presence or absence of any other repair (e.g. fistula closure).

4. Is PSARP unipolar or multi-polar surgery?

It can be either:

• Single-stage PSARP: Not done, unless the condition of the baby makes it possible.
• Two or three phase PSARP: Step by step - colostomy, then PSARP, and lastly colostomy closure after recovery.

5. What happens during a post-operative recovery?

• The healing process of a wound requires about 23 weeks.
• The onset of anal dilatations occurs a few weeks after surgery to avoid constructions.
• Introductions of soft food gradually follow.
• The training of full bowel process lasts a few months.

6. What is the Success rate of PSARP surgery?

• Its success is between 85-95 percent as per the complexity of the defect, skills of the surgeon and quality of the post-operative treatment. A majority of children develop bowel continence and bowel control.a