Vascular and Wound-Healing Implications of Single-Stage Versus Multistage Repair of Anorectal Malformations: A Systematic Review and Meta-Analysis

Clinical Snapshot

Key Findings

• P Value: p < 0.0001

• Effect Size: OR 3.31

• Primary Outcome: Wound dehiscence significantly higher in single-stage repair

• Nnt Or Sensitivity: Number needed to harm approximately 8-10 patients for wound dehiscence based on typical baseline rates

• Confidence Interval: 95% CI 1.90-5.79

Clinical Application

Applicable in centres with paediatric surgical expertise; requires careful patient selection and surgical technique optimisation Relevant to Australian paediatric surgery units; aligns with RACS guidelines for complex congenital anomalies; may inform PBS funding decisions for staged procedures Neonates and infants with anorectal malformations requiring surgical correction

Abstract

BACKGROUND: Anorectal malformations (ARMs) are managed using either single-stage or multistage surgical repair. However, concerns persist regarding wound-related complications and long-term functional outcomes, which remain inconsistently reported across surgical approaches. OBJECTIVE: To compare wound-related complications and long-term functional outcomes following single-stage versus multistage repair of ARMs, with emphasis on wound perfusion, dehiscence, and vascular healing dynamics. METHODS: A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD420251006245). PubMed and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for studies published between 2000 and 2024 comparing single-stage and staged ARM repair in neonates and infants. Outcomes included wound dehiscence, surgical site infection (SSI), stenosis, prolapse, redo surgery, constipation, soiling, and voluntary bowel movements. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS). RESULTS: Nineteen studies involving 1,972 patients were included. Single-stage repair was associated with a significantly higher risk of wound dehiscence (OR 3.31; 95% CI 1.90-5.79; p < 0.0001), while no significant differences were observed for SSI, stenosis, prolapse, redo surgery, constipation, soiling, or voluntary bowel movements. Moderate to high heterogeneity was noted for selected outcomes. CONCLUSIONS: Single-stage repair provides comparable infection rates and long-term functional outcomes to multistage surgery but carries an increased risk of wound dehiscence. Optimizing tissue perfusion and minimizing tension are essential to improve outcomes. This study highlights the important role of vascular and wound-healing mechanisms in determining outcomes after anorectal malformation (ARM) repair. While single-stage surgery reduces the burden of multiple procedures, it exposes perineal tissues to fecal contamination and potential microvascular stress, which may increase the risk of wound complications.An understanding of tissue perfusion, venous drainage, and local tissue tension is critical during neonatal reconstructive surgery. Incorporating techniques that preserve vascular integrity, minimize tension, and protect the surgical site can help optimize postoperative healing and reduce the risk of wound dehiscence.

References

1. 1.Du, Y., Wang, Y., Wang, W., & Zhao, J. (2026). Vascular and wound-healing implications of single-stage versus multistage repair of anorectal malformations: A systematic review and meta-analysis. Journal of Investigative Surgery, 39(1), 1-12. https://doi.org/10.1080/08941939.2026.2666959