Anal atresia

　　Anal atresia belongs to a midline malformation and is common in clinical practice. Due to the developmental disorder of the original anus, it does not凹 into the formation of the anal canal. The rectum develops basically normally, and its blind end is at the edge of the bulbocavernosus muscle or near the lower end of the vagina. The perineum is often underdeveloped, flat, and covered by intact skin. It may be complicated with bulbar urethral fistula, lower vaginal segment fistula, or vestibular fistula.

　　Anal atresia can be complicated with bulbar urethral fistula, lower vaginal segment fistula, and vestibular fistula.

　　1, Bulbar urethral fistula

　　Urine fistula to other parts for excretion, not excreted from the urethra, such as in women, may be due to urethrovaginal fistula, urine flowing out from the vagina.

　　2, Lower vaginal segment fistula

　　Due to the fistula, vaginal secretions and menstrual blood may partially or completely flow out from other parts of the fistula, such as the urethra, causing an increase in urethral secretions.

　　3, Vestibular fistula

　　It is a rectal vestibular fistula with normal anal appearance, which is one of the common perianal diseases in female children. It is manifested by normal anal appearance, the formation of a fistula between the rectum and the anterior fornix of the vagina, with most fistulas less than 0.5cm in diameter. During the excretion of loose stools, feces may be excreted from the fistula, and the perineum is red and swollen; when the feces are dry and hard, there are no special clinical manifestations, but some children may have a fistula diameter greater than 1.0cm, and most of the feces are excreted from the fistula, which can completely manifest as fecal incontinence.

　　After the child with anal atresia is born, there is no meconium excretion, the anal area is covered by skin, and there is a shock feeling in the anal area when crying. In the inverted position X-ray lateral film, the distal end of the rectum is exactly at the pubococcygeal line or slightly below it. The ultrasound puncture method measures that the blind end of the rectum is about 1.5cm from the anal area.

　　After the child is born, there is no meconium excretion, and vomiting, abdominal distension, and other symptoms of intestinal obstruction appear soon. Local examination shows that the perineum is flat in the central area, the anal area is covered by skin, and in some cases, there is a small凹 with obvious pigmentation, with radiating wrinkles. Stimulation of this area can produce a circular muscle contraction reaction. When the baby cries or holds his breath, there is a protrusion in the central area of the perineum. Placing a finger in this area can produce a shock feeling. When the baby is placed in a buttock-high head-low position, percussion on the anal area is tympanic.

　　There is currently no effective preventive measure for anal atresia, which can only be detected, diagnosed, and treated early to prevent the occurrence of complications. Good postoperative care for anal atresia is an effective measure to prevent postoperative complications.

　　One, pay attention to keeping warm after surgery, and strengthen basic care.

　　Pay attention to keeping warm, enter the incubator, the temperature inside the incubator should be 28℃～30℃ suitable, the relative humidity inside the incubator should be maintained at 65%, and a special person should be assigned to watch over it. Skin should be wiped daily, and baby powder should be sprinkled in the skin creases for protection. After the umbilical cord is cleaned with 3% hydrogen peroxide, apply 2.5% iodine alcohol and then 95% alcohol for deiodination; when there is secretion in the eyes, use a cotton swab to wipe it off and drop 0.25% chloramphenicol eye drops.

　　2. Continuous oxygen therapy, keep the respiratory tract unobstructed to prevent aspiration, and prevent pulmonary complications

　　(1) Continuous oxygen therapy of 1 to 2L/min. Pay attention to observe the insertion depth of the oxygen tube to avoid inserting it too deeply or too shallowly.

　　(2) Determine if the child has sputum. If secretions are found, gently wipe them away with a clean gauze. If there is sputum in the throat, use an infant suction catheter to suck it out under central aspiration. The inspiratory pressure should not exceed 60 to 100 mmHg (8.0 to 13.3 kPa). When suctioning, insert the suction catheter into the trachea. At this time, do not suction. Wait for the catheter to withdraw about 1 cm, and rotate it while withdrawing and suctioning. The suction time should not exceed 10 to 15 seconds. The technique should be gentle and fast, and should not be harsh, pulling back and forth, to avoid damaging the mucosa.

　　(3) Turn the child over regularly, and gently tap the chest and back before suctioning. When tapping, the five fingers should be joined together and slightly curved towards the palm, forming a cavity between the fingers and palm. Use vibration to transmit the secretions into the respiratory tract for easy removal, preventing pulmonary complications.

　　3. Establish a venous infusion channel to maintain effective blood volume

　　Choose an appropriate site with a relatively thick and straight vein and a suitable pediatric venous catheter. After successful puncture, fix it properly to ensure the smooth input of blood and fluids. Pay attention to adjusting the speed of fluid input (if possible, use an infusion pump to adjust the speed) to prevent complications such as pulmonary edema and heart failure. Administer intravenous antibiotics to prevent infection. If necessary, supplement amino acids, fat emulsion, and fresh plasma to ensure that the child has sufficient nutrition and to enhance the body's resistance.

　　4. Keep the gastrointestinal decompression unobstructed and prevent the gastric tube from falling out

　　Due to varying degrees of abdominal distension in the child, sufficient gastrointestinal decompression must be performed. After the gastric tube is implanted, it is fixed next to the collar and shoulder of the outerwear. Check frequently whether the gastric tube is patent and whether it has slipped out. The gastric tube is generally removed after 24 to 48 hours without vomiting after surgery.

　　5. Strengthen breastfeeding

　　Give the child a small amount of water to drink when the abdominal distension of the child disappears. After the catheter is removed, breastfeeding can be performed, and the child is fed 30ml of milk every 2 to 3 hours, without discomfort. Gradually increase the amount to 50ml.

　　6. Care for the urinary catheter

　　Remove the indwelling urinary catheter within 24 to 48 hours after surgery.

　　7. Strictly observe vital signs

　　Closely observe the changes in the condition, measure body temperature, heart rate, respiration, urine volume, and milk intake every 4 hours, and make detailed records.

　　8. Care for anal stoma

　　After surgery, keep the lower limbs flexed and abducted, and generally remove the inserted anal tube within 48 to 72 hours after surgery. The suture lines of the anal incision should be allowed to fall off naturally. Keep the wound ventilated and dry to reduce infection. Wash the wound with warm salt water after each defecation and wipe with iodophor to prevent the incision from being contaminated by urine and feces. Keep the surrounding skin clean and dry, and apply compound zinc oxide ointment to prevent skin erosion.

　　According to the clinical manifestations of the child with anal atresia, abdominal plain film, abdominal MRI, anal inspection, abdominal CT, rectal examination, ultrasound and puncture should be performed, and a treatment plan should be formulated according to the results.

　　In addition to general treatment after anal atresia surgery, dietary therapy can also be used to alleviate symptoms.

　　1) Take 4 grams of Jilin ginseng and 3 grams of American ginseng and stew lean meat.

　　2) Take 4-5 shiitake mushrooms and stew lean meat or chicken breast (drink the soup).

　　3) Take 15 grams of radix astragali, 21 grams of dangshen, 30 grams of dioscorea opposita, and 15 grams of lotus seeds and stew lean meat.

　　4) Take 30 grams of tufuling, 30 grams of Job's tears, and 3 plums and stew grass carp or water turtle.

　　5) Take 17 grams of dangshen, 21 grams of shi shi, 10 grams of goji berries, and 15 grams of Job's tears and stew lean meat or chicken.

　　6) Take 3 grams of Tianqi, 3 grams of ginseng (or red ginseng) and stew lean meat or chicken.

　　Children with anal atresia should undergo surgical treatment as soon as possible after diagnosis, usually perineal analoplasty, or sacral perineal analoplasty can also be adopted.

　　1. Surgical Incision

　　Make an X-shaped incision in the central perineum or in the middle of the area that can induce crural contraction, about 1.5cm long. Cut the skin, flip over four skin flaps, and you can see the annular external sphincter fibers below.

　　2. Find the Free Rectal Blind End

　　Use a forceps to钝性分离 soft tissue through the middle of the sphincter muscle towards the deep layer, and you can find the blue rectal blind end. Pass two thick silk threads through the muscle layer of the blind end for traction. Since the rectal blind end is exactly located within the puborectalis muscle ring, it should be separated upwards close to the intestinal wall. The blind end should be freed for about 3cm to allow the rectum to be pulled out smoothly to the anal orifice. The rectum must be freed sufficiently long, as it is very easy to cause intestinal wall retraction and scar stenosis after operation if it is pulled down and sutured with insufficient length. During separation, you should also avoid injury to the urethra, vagina, and rectal wall.

　　3. Incise the Rectum

　　Make a cruciate incision at the rectal blind end and use a suction apparatus to remove meconium or let it flow out naturally and wipe it clean. Pay attention to protect the wound surface and avoid contamination as much as possible. If contamination occurs, it should be carefully flushed with physiological saline.

　　4. Anastomosis and Fixation

　　Several needles are used to fix the rectal blind end with surrounding soft tissue, and the intestinal wall and perianal skin are sutured with fine silk thread or catgut suture in 8-12 places. Pay attention to the cross-fit of the intestinal wall and skin flap, so that the scar after healing is not on the same plane. Begin to dilate the anus about 10 days after the operation to prevent anal stenosis.