A newborn with high anorectal malformation and progressive kidney obstruction undergoes staged surgical treatment at Sarvodaya Hospital.
A newborn baby boy was brought to Sarvodaya Hospital, Sector 8, Faridabad, around four hours after birth after the attending paediatrician at the hospital where he was delivered noticed that he had no anal opening.
During pregnancy, an antenatal anomaly scan had also detected swelling in the baby's left kidney (hydronephrosis). This finding required further evaluation and guidance to understand its significance and the care the newborn might need after birth.
Following delivery, the absence of an anal opening revealed another congenital condition: high anorectal malformation (ARM). Further evaluation also confirmed a significant kidney abnormality that required timely intervention.
The Paediatrics and Paediatric Surgery teams at Sarvodaya examined the baby, counselled the parents and planned a carefully staged course of treatment to address both conditions.
In high anorectal malformation, the anal opening, rectum and surrounding perineal muscle complex do not develop in their normal form and position. The rectum may also have an abnormal connection with the urinary system.
Since the baby had no normal passage for stool, immediate surgical intervention was necessary. In such cases, the first procedure is generally performed within the initial 24 hours after birth to divert stool and prevent its accumulation inside the intestine, which can lead to serious complications.
The paediatric surgical team performed a high sigmoid loop colostomy, creating a temporary opening (stoma) in the abdomen through which stool could pass into a collection bag.
This was the first stage of treatment. It provided a safe route for stool while allowing the team to evaluate the baby's anatomy and plan the definitive correction at a later stage.
Anorectal malformation can be associated with abnormalities in other organs, particularly the kidneys and urinary system. Around 30% of children with ARM may have an associated renal abnormality.
In this baby, swelling in the left kidney had already been detected during the antenatal scan. Postnatal evaluation showed that the swelling was progressive. Further ultrasound examination revealed significant dilatation of the kidney's urine-collecting system due to narrowing at the pelviureteric junction (PUJ), the point where the kidney connects to the ureter.
Although kidney swelling detected during pregnancy settles on its own in many babies, this was not the case here. The progressive obstruction raised concerns about the risk of damage to kidney function.
To protect the kidney from further damage, the team decided to intervene without waiting for the later stages of anorectal reconstruction.
At around two months of age, the baby underwent left pyeloplasty with DJ stent placement, along with diagnostic cystoscopy. Pyeloplasty is a procedure that corrects the narrowed PUJ to improve the flow of urine from the kidney into the ureter. A temporary DJ stent was placed to support urine drainage during recovery.
The baby recovered well following the procedure and was discharged after a four-day hospital stay. The DJ stent was subsequently removed during a follow-up procedure.
As the baby recovered and continued follow-up, further evaluation was undertaken to understand the exact anatomy of the anorectal malformation before planning the final reconstruction.
A specialised investigation called a pressure-augmented colostogram was performed. It revealed a rectoprostatic fistula, an abnormal connection between the rectum and the urinary passage near the prostate.
Identifying this fistula was particularly important for surgical planning. The abnormal connection needed to be separated from the urinary tract before bringing the rectum down to its intended anal position. Otherwise, the abnormal passage could persist and lead to urinary complications, including urinary tract infections.
At around five months of age, the baby underwent the definitive correction of the anorectal malformation.
Dr. Shweta K. Sharma and the Paediatric Surgery team performed a Posterior Sagittal Anorectoplasty (PSARP).
In this procedure, the surgeon approaches the affected area through a carefully placed incision along the midline between the buttocks. The abnormal connection between the rectum and urinary tract is separated, and the rectum is brought down to the intended anal opening.
However, this surgery involves much more than creating a passage for stool. The rectum must be positioned precisely within the surrounding sphincter muscle complex, while preserving the muscles and nerves responsible for bowel control.
The procedure was completed with a minimally invasive approach, which means a smaller incision (cut) and faster recovery. The baby was stable at discharge.
The temporary colostomy remains in place, and its closure is planned as the next stage, approximately two months after the reconstructive surgery.
So far, the baby is doing well and progressing through his developmental milestones.
Normally, the rectum, which is the last part of the large intestine, connects to the anus, allowing stool to pass out of the body. An anorectal malformation (ARM) is a congenital condition in which the anus, rectum or their connection does not develop normally.
The condition can vary in severity. Some babies have an anal opening that is narrower than normal or positioned incorrectly, while others are born without a visible anal opening. In more complex cases, the rectum may end higher inside the pelvis or form an abnormal connection with another structure through a passage called a fistula.
In high anorectal malformation, the rectum and surrounding muscle complex are not formed in their normal position. Depending on the type of defect, the rectum may also connect abnormally with the urinary tract. This was seen in the present case, where investigations identified a rectoprostatic fistula.
Anorectal malformations may also occur alongside congenital abnormalities affecting other organs, including the kidneys, urinary system, heart and spine. Therefore, identifying the type of malformation and checking for associated conditions are important parts of a child's evaluation.
Anorectal malformations develop during pregnancy, as the baby's lower digestive tract forms. In most cases, the exact cause is not known, and there is no established way to prevent these birth defects.
Detecting ARM before birth can also be difficult. It is generally identified during the newborn's physical examination after delivery rather than through routine antenatal scans.
However, pregnancy scans can detect certain associated abnormalities. For instance, kidney swelling (hydronephrosis), as seen in this baby, may be identified during an antenatal anomaly scan.
Such findings need appropriate follow-up and specialist guidance. Timely counselling with a paediatric surgeon can help parents understand possible associated conditions, the investigations that may be required after birth and the treatment options available.
A detailed newborn examination after delivery is equally important to identify conditions that may not have been apparent during pregnancy.
Anorectal malformations are usually identified soon after birth during a newborn's physical examination. Some signs that need attention include:
These signs require immediate medical assessment. In particular, an absent anal opening in a newborn is a surgical concern that should not be ignored or left until symptoms worsen.
Early identification allows doctors to determine the type of malformation, evaluate associated abnormalities and initiate the appropriate treatment without unnecessary delay.
Complex anorectal malformations require detailed evaluation and an individualised treatment plan. The surgeon needs to understand where the rectum ends, whether it has an abnormal connection with the urinary tract, and how the surrounding muscles and nerves are formed.
Treatment may involve multiple surgeries at different stages, depending on the type of malformation and the child's overall condition. In some babies, an initial colostomy is required, followed by definitive reconstruction and subsequent closure of the temporary opening.
Surgical precision is particularly important in anorectal reconstruction. The rectum must be brought down and positioned accurately within the sphincter muscle complex, while protecting the muscles and nerves that help maintain bowel control. Damage to these structures or incorrect positioning can affect the child's ability to control stool later in life.
Associated conditions also need attention in their own right. As seen in this case, the progressive kidney obstruction required a separate surgical intervention alongside the treatment for anorectal malformation.
At Sarvodaya, Mother & Child Care services, along with specialised Paediatrics and Paediatric Surgery care, support the evaluation and management of complex conditions involving newborns and children. Such cases require coordinated care, careful surgical planning and regular follow-up to monitor the child's progress.
Antenatal scan findings involving the kidneys or other organs should be discussed with the appropriate specialists. Timely counselling with a paediatric surgeon can help parents understand possible associated conditions and prepare for the care their baby may need after birth.
An absent anal opening in a newborn requires immediate medical attention. A complete evaluation is equally important because birth defects may involve more than one organ, and some associated conditions may need separate treatment.
Although complex birth defects can be challenging, many are correctable with the right evaluation, timely intervention and a carefully planned surgical approach. Early specialist guidance and appropriate follow-up can help protect the child's long-term health and development.
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