Laparoscopic Technique in the Management of High Anorectal Malformations: A Propensity Score-Matched Outcome Study Using a Large Inpatient Database

Background: Posterior sagittal anorectoplasty (PSARP) has been the standard for management of children with high anorectal malformations (ARMs). Recently, there has been an increase in the use of laparoscopy in its management. We analyzed the outcomes of laparoscopically assisted anorectal pull-through (LAARP) compared to PSARP using a large inpatient database. Methods: Kids' Inpatient Database was analyzed for ARM (ICD-9-CM 751.2) between 1997 and 2012. Perineal fistulas and low/intermediate ARM were excluded. Propensity score (PS)-matched analyses were performed using 37 variables. Cases were weighted to provide national estimates. Results: Of the overall 29,106 cases, 7428 patients <2 years underwent surgical repair. LAARP was performed in 178 patients. Eighty-eight percent were male. Most were of Caucasian (n = 71; 45%), followed by Hispanic (n = 41; 26%) descent. Most were performed in 2009 and 2012 (n = 149; 83%). Most were covered by Medicaid (88; 49%), followed by private insurance (80; 45%). Median length of stay (LOS) was 4 (interquartile range = 3) days. The majority were performed in a children's hospital (n = 90; 88%). On PS-matched analysis, LAARP had shorter median LOS (4 [3]) compared to PSARP (6 [15]) days, P = .003. Rates of reoperation, wound infection, wound dehiscence, and mortality were unchanged between approaches. Cost was lower for LAARP (47,969 [49,450]) versus PSARP (56,110 [160,314]) U.S. dollar , P = .002, whereas total charges did not differ significantly. Conclusions: A minimal access approach to a complex procedure requires significant time and resources to be adopted as standard. PSARP is an important example, as increased availability of laparoscopy, and therefore, access to the procedure for patients will greatly affect resource utilization and recovery for the patient. As demonstrated, the LOS and cost is significantly lower for the LAARP procedure in comparison to the traditional approach. Future research will clarify boundaries to introducing the laparoscopic approach as a potential standard technique in the next decade.