Practice Variability in Anorectal Malformations Management Across Europe: a TEPS-EUPSA Survey with Analysis of Center Volume Effects.

Objective To evaluate management strategies for anorectal malformations (ARM) across Europe and assess the impact of institutional case volume on clinical decision-making. Methods A cross-sectional online survey developed within the Trainees in European Paediatric Surgery (TEPS) and endorsed by the European Paediatric Surgeons' Association (EUPSA) Network Office was distributed among pediatric surgeons involved in ARM care. The questionnaire addressed diagnostic workup, surgical management, perioperative care and long-term follow-up. European responses were analyzed and compared by institutional case volume. Results A total of 94 responses from 21 countries were analyzed. Substantial variability was observed across all domains of care. Ultrasound-based screening and invertogram were widely used, whereas high-pressure distal colostography was variably applied. MRI and vaginoscopy were used more selectively. Primary neonatal repair in cases with the rectum located <1 cm from the perineal skin was commonly performed, and staged reconstruction was most frequently undertaken at 3-6 months. Non-divided stomas were more frequently used in high-volume centers (p = 0.002), with increasing center volume associated with higher odds of their use (OR 2.98, 95% CI 1.51 - 5.87, p = 0.002). Routine anal dilations were reported by 44.7% of respondents and were less common in high-volume centers (p = 0.005); increasing volume was associated with lower odds of routine dilation (OR 0.38, 95% CI 0.20 - 0.72, p = 0.003). Conclusion ARM management across Europe remains highly variable. Institutional case volume is associated with practice differences, particularly in stoma configuration and postoperative dilation strategies.