P2.P316: Utilization and outcomes of Heineke-Mikulicz anoplasty for treatment of skin-level strictures

Background: The Heineke-Mikulicz anoplasty (HMA) is a technique for addressing skin-level postoperative anal strictures following posterior sagittal anorectoplasty (PSARP), posterior sagittal anorectovaginourethroplasty (PSARVUP) or as a primary treatment for congenital anal stenosis (CAS). We aimed to evaluate the outcomes with HMA as a treatment for postoperative anal strictures and primary management of congenital anal stenosis.

Methods: A retrospective review was conducted for patients with a history of ARM or CAS who underwent HMA for skin-level anal strictures. Data were collected regarding indication for HMA, most recent anorectoplasty preceding HMA (primary or redo), timing of HMA, extent of stricturoplasty, change in caliber of anus, postoperative outcomes, and complications. Descriptive statistical analysis was performed. To identify factors associated with need for repeat HMA, comparisons were performed with Fisher’s exact tests, Wilcoxon rank-sum tests, and Cochran-Armitage tests for trend as applicable.

Results: From 2014-2024, 141 patients with history of ARM or CAS underwent HMA. Median age at time of HMA was 4 years [IQR 2-6] with median follow up time of 3.0 years [IQR: 1.0-4.0]. There were 137 (97.2%) patients with ARM and 3 (2.1%) with CAS. The indications for HMA were routine postoperative exam under anesthesia (24.8%), difficulty stooling (19.2%), stricture found on exam in office (18.4%), and stricturoplasty prior to stoma reversal (16.3%). HMA was performed after primary PSARP or PSARVUP in 37.6% of patients and after redo surgery in 60.3%. The median time from anorectoplasty to HMA was 153.3 days [IQR: 0.25 – 2.0]. Of those that underwent HMA, 14.2% required repeat HMA. There was no statistically significant association between primary versus redo operation and need for repeat HMA (p=0.4). Patients who did not require repeat HMA had a median increase in Hegar size by 7 while those who did increased by 6. There was a significant trend between number of quadrants where HMA was performed and need for repeat HMA (Figure 1). None of the patients who underwent HMA for CAS required repeat anoplasty. One patient required 3 HMAs. One patient developed a perianal abscess within 1 week of HMA and another had slight wound breakdown successfully treated with metronidazole.

Conclusion: HMA is a safe outpatient procedure that can successfully treat skin-level anal strictures in most patients with postoperative strictures following PSARP and PSARVUP or as primary management for CAS. Patients with strictures after PSARP or PSARVUP can frequently be managed with a one-time HMA. HMA should be considered as an alternative to dilation for skin-level anal strictures, especially in an older patient after redo surgery.