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Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies. The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Background Functional outcomes after definitive surgical reconstruction in the management of Anorectal malformations (ARM) patients have not been adequately studied in the third-world countries. Objective This retrospective cross sectional analytical study aimed at evaluating the functional outcome and attributable factors following the definitive reconstruction surgery among children with ARM at Muhimbili National Hospital. Methods Patients with ARM who underwent definitive reconstruction surgery between 2017 and 2021 were recruited in the current study using the consecutive sampling method. The functional outcome and severity were assessed using the modified Krickenbeck scoring system.Analysis was performed using STATA version 16.0. Results 116 pediatric patients with ARM who underwent definitive surgical repair were reviewed, the mean age was 4.4 (SD1.8) years. The male-to-female ratio was 1.1:1. The functional outcome was voluntary bowel movement (VBM), constipation, and soiling with a prevalence of 63%, 22%, and 15% of patients respectively. Babies born preterm shows significant association with constipation with P- the value of 0.003, OR 13.26, and 95% CI 2.48–70.87. Abdominal perineal pull-through among patients who had High ARM showed a significant association with soiling ( P -value 0.001, OR 0.03, and 95% CI of 0.01–0.16). Conclusion In the current study we identified that there is no significant variation in ARM functional outcome between males and females.However some factors such as the type of surgery, patient body weight and the complexity of anorectal malformation were all decisive factors for achieving the optimum Voluntary Bowel Bovement (VBM) following ARM repair surgery.

BackgroundMultiple structures in the anorectal area are closely related to defecation, voiding and sexual function. Although laparoscopic-assisted anorectal pull-through is widely accepted as a minimally invasive surgical technique, controversy still exists for ARMs with rectourethral fistulas. Intraoperative injuries more or less involve the perirectal sphincters and neurovascular tissue.MethodsSeventeen selected infants with ARMs underwent robot-assisted anorectal pull-through (RAARP) between October 2016 and January 2018. The application of nerve- and sphincter-sparing technique in RAARP was detailed. The feasibility and early outcomes were evaluated.ResultsAll procedures were completed without conversion. The robotic system facilitated clear dissections between different anatomical layers. Under direct vision, the fistula was easier to repair, and the rectal pouch was precisely placed in the center of the striated muscle complex. During the follow-up of 11.6 months, 13 patients resumed normal defecation. The other four children experienced mild constipation or fecal incontinence. Their continence and defecation functions showed favorable evolution.ConclusionRAARP is a safe and effective alternative for the treatment of ARMs, which provides an advantage in further minimizing the injury to perirectal nerves and sphincters.

Background Anorectal malformations and Hirschsprung’s disease are congenital conditions impacting the digestive system, with a particularly uncommon co-occurrence, estimated at 2–3% of all ARM cases. This case series explores this rare association through three distinct cases, each presenting unique clinical challenges and insights. Methods We report a series of five patients with ARM who were concurrently diagnosed with HD based on clinical and radiological evaluations, with definitive confirmation obtained through rectal biopsy. In cases where HD was diagnosed after the complete surgical repair of ARM, the patients underwent a Swenson-like pull-through procedure. Notably, the anastomosis was created approximately 3 cm from the anal verge, rather than the conventional 3 cm from the dentate line. Results This study reviewed the records of 136 ARM patients treated at our center over five years, identifying five cases with concurrent HD. In three of these cases, HD was initially overlooked and diagnosed only after ARM repair. These patients underwent a Swenson-like pull-through procedure. During follow-up, two patients achieved good bowel control without fecal soiling, while the third had regular bowel movements and satisfactory growth, albeit with occasional episodes of enterocolitis managed medically. The remaining two cases were identified earlier, following colostomy, which led to a different management approach. Conclusion This case series underscores the critical importance of considering HD in patients with ARM who present with persistent, atypical gastrointestinal symptoms post-surgical repair of their ARM. Preservation of the aganglionic neoanal canal with a subsequent Swenson pull-through appeared beneficial to achieve good postoperative continence.

IntroductionThe levator ani (LA) complex in high-type imperforate anus (H-IA), low-type imperforate anus (L-IA), and Hirschsprung’s disease (HD) patients as controls were documented using magnetic resonance imaging (MRI) and compared for symmetry.Materials and methodsMean left:right LA thickness ratio (LA ratio), and deviation of the LA from the pubococcygeal line (PCL; LA angle) were calculated from thin-slice MRI images (axial 2 mm, coronal 2 mm, and sagittal 3 mm) of the puborectalis and pubococcygeus taken parallel to the PCL under sedation in H-IA (n=14), L-IA (n=16), and HD (n=9).ResultsMRI scans were performed between January 2018 and June 2021. LA were significantly thinner in H-IA (1.78±0.46 mm) compared with L-IA (2.97±0.55 mm) and controls (2.87±0.32 mm), p<0.0001. LA ratio was significantly lower in H-IA (0.71±0.15) compared with L-IA (0.93±0.04), and controls (0.91±0.06), p<0.0001. Mean LA-angle was significantly different in H-IA, 10.8° (range 6°–19°), versus L-IA and controls, both zero degrees (range 0°–5°), p<0.0001, respectively.ConclusionsLA was confirmed to be significantly asymmetric in H-IA. Because outcome of surgical repair involving a midline incision, such as posterior sagittal anorectoplasty could be impaired, pediatric surgeons are advised to plan surgical intervention for H-IA carefully and appropriately.

Anorectal malformation (ARM) is a prevalent early pregnancy digestive tract anomaly. The intricate anatomy of the embryonic cloaca region makes it challenging for traditional high-throughput sequencing methods to capture location-specific information. Spatial transcriptomics was used to sequence libraries of frozen sections from embryonic rats at gestational days (GD) 14 to 16, covering both normal and ARM cases. Bioinformatics analyses and predictions were performed using methods such as WGCNA, GSEA, and PROGENy. Immunofluorescence staining was used to verify gene expression levels. Gene expression data was obtained with anatomical annotations of clusters, focusing on the cloaca region's location-specific traits. WGCNA revealed gene modules linked to normal and ARM cloacal anatomy development, with cooperation between modules on GD14 and GD15. Differential gene expression profiles and functional enrichment were presented. Notably, protein levels of Pcsk9, Hmgb2, and Sod1 were found to be downregulated in the GD15 ARM hindgut. The PROGENy algorithm predicted the activity and interplay of common signaling pathways in embryonic sections, highlighting their synergistic and complementary effects. A competing endogenous RNA (ceRNA) regulatory network was constructed from whole transcriptome data. Spatial transcriptomics provided location-specific cloaca region gene expression. Diverse bioinformatics analyses deepened our understanding of ARM's molecular interactions, guiding future research and providing insights into gene regulation in ARM development.

Background Early diagnosis and treatment of anorectal atresia, a common congenital abnormality in calves, are crucial for preventing complications and ensuring the animal’s survival. Typically, newly born calves with this condition are present with an inability to defecate due to an absence of or an obstructed anal opening, often accompanied by abdominal pain and distension. History, physical examination, and radiographic imaging are frequently utilized diagnostic tools. This study aimed to evaluate the effectiveness of needle aspiration as a supportive diagnostic technique for anorectal atresia in bovine calves under field conditions and to assess its role in decision-making to proceed with surgical intervention. Results A total of 116 male calves, aged six hours to five days, were examined through clinical inspection, needle aspiration, and plain radiography. Clinical findings indicated that 62 cases had atresia ani, while 54 calves were diagnosed with atresia ani et recti. In cases without detectable swelling under the base of the tail, even with manually applied pressure on the abdomen, needle aspiration and radiographic findings showed positive results in 46.30% of calves. These cases were characterized by a radiolucent, distended rectal end close to the perineal skin surface (≤ 5 cm). Conversely, 53.70% of animals had negative aspiration results, with radiographic evidence of gas accumulation at the rectal end located > 5 cm from the perineal surface. Additionally, successful creation of an artificial anus at the perineum was achieved in cases with a rectal end near the skin surface. Whereas cases with a far rectal end more than 5 cm were subjected successfully to right flank laparo-typhlostomy. Conclusions Needle aspiration is a straightforward, non-invasive technique that proves highly valuable in facilitating diagnosis and guiding surgical decisions in calves with anorectal atresia, particularly in cases where bulging is not observed upon manual abdominal pressure. It is most effective when the rectal end is within five centimeters proximal to the perineal skin surface.

Background High-resolution anorectal manometry (HARM) is widely used for diagnosis and assessment of constipation and fecal incontinence. However, limited information is available on HARM-identifiable characteristics in patients with functional anorectal pain (FARP). This study explored the pathogenesis of FARP by investigating their anorectal physiological and psychological characteristics using HARM. Methods 140 patients with FARP who had undergone standard HARM examinations at our institution between January 2021 to January 2023, were retrospectively included for analysis. 110 controls underwent the standard HARM examinations at our institution. Pain was assessed in the FARP group using the visual analog scale (VAS) and psychological status using the Hamilton Anxiety and Depression scales. Results The mean age was 53.8 ± 11.5 years (range 22–80) in the FARP group and 51.03 ± 12.11 years (range 28–75) in the control group. The mean VAS score in the FARP group was 5.57 ± 2.24. Sensation of desire to defecate, sensation of urgency to defecate, and maximum tolerable sensation were significantly lower in the FARP group, compared with the control group ( P  < 0.05), demonstrating rectal hypersensitivity. The residual anal canal pressure during defecation, anal resting pressure, and maximum squeeze pressure were significantly lower in the FARP group ( P  < 0.01 vs. controls). The anal resting pressure was positively correlated with these sensory thresholds. In addition, anxiety was detected in 63.8% and depression in 59% of patients with FARP. Conclusions The pathophysiology of FARP may involve rectal hypersensitivity and abnormal anal sphincter pressure. FARP is often accompanied by anxiety and depression. HARM may be used as a diagnostic tool for assessing pathophysiology of FARP.

Rectoperineal congenital anorectal malformations (CARMs) are diagnosed by examining the perineum, combined with electric stimulation (ES) of the anal sphincter performed under anesthesia. This procedure may be troublesome because it is based on the observed contractibility of the sphincter. We aimed to add 3-dimensional high-resolution anorectal manometry (3D-HRAM) to the procedure and to assess its value for diagnosing rectoperineal forms of CARM. We prospectively included 66 patients younger than 24 months who presented with constipation and were suspected of CARM, idiopathic constipation, or Hirschsprung disease. The patients were assessed between 2015 and 2021 at University Medical Center Groningen, the Netherlands. All patients underwent 3D-HRAM, followed by the standard diagnostic procedure for either CARM or Hirschsprung disease. Of the 51 patients who underwent both 3D-HRAM and ES, we observed that patients with rectoperineal CARM revealed a pressure gap along the anterior part of the anal sphincter. Based on this observation, we diagnosed 35 patients with CARM. Subsequently, all 35 diagnoses were confirmed with ES. Sixteen patients were diagnosed as not having CARM, 100% of whom were in agreement with the gold standard-ES. Both the specificity and sensitivity of 3D-HRAM for diagnosing rectoperineal CARM were 100%. We consider 3D-HRAM a reliable tool for diagnosing and excluding rectoperineal CARM. Using this method in patients suspected of CARM might keep infants from undergoing unnecessary interventions requiring anesthetics, such as ES. By providing objective insight into the functional capabilities of the anal sphincter, anorectal manometry adds to the diagnosis.

Anorectal malformation (ARM), a common congenital anomaly of the digestive tract, is a result of insufficient elongation of the urorectal septum. The cytoplasmic protein Receptor of Activated C‐Kinase 1 (Rack1) is involved in embryonic neural development; however, its role in embryonic digestive tract development and ARM formation is unexplored. Our study explored the hindgut development and cell death mechanisms in ARM‐affected rats using spatial transcriptome analysis. We induced ARM in rats by administering ethylenethiourea via gavage on gestational day (GD) 10. On GDs 14–16, embryos from both normal and ARM groups underwent spatial transcriptome sequencing, which identified key genes and signalling pathways. Rack1 exhibited significant interactions among differentially expressed genes on GDs 15 and 16. Reduced Rack1 expression in the ARM‐affected hindgut, verified by Rack1 silencing in intestinal epithelial cells, led to increased P38 phosphorylation and activation of the MAPK signalling pathway. The suppression of this pathway downregulated Nqo1 and Gpx4 expression, resulting in elevated intracellular levels of ferrous ions, reactive oxygen species (ROS) and lipid peroxides. Downregulation of Gpx4 expression in the ARM hindgut, coupled with Rack1 co‐localisation and consistent mitochondrial morphology, indicated ferroptosis. In summary, Rack1, acting as a hub gene, modulates ferrous ions, lipid peroxides, and ROS via the P38‐MAPK/Nqo1/Gpx4 axis. This modulation induces ferroptosis in intestinal epithelial cells, potentially influencing hindgut development during ARM onset. Spatial transcriptome sequencing of normal and anorectal malformation (ARM) rat embryos revealed that Rack1, as a hub gene, was decreased in the ARM hindgut on GD15 and GD16, and increased intracellular ferrous ions, reactive oxygen species, and lipid peroxides through the P38/Nqo1/Gpx4 axis, inducing ferroptosis in intestinal epithelial cells, which may affect the hindgut development in rat with ARM.