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Mert M, Sayan A, Köylüoğlu G. Comparing the fecal continence scores of patients with anorectal malformation with anorectal manometric findings. Pediatr Surg Int 2021; 37:1013-1019. [PMID: 33825956 DOI: 10.1007/s00383-021-04884-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients undergoing surgery for anorectal malformation (ARM) may have defecation-related problems throughout their lives, even if they are perfect treated surgically. Assessment methods are needed to standardize the clinical outcomes of patients with ARM. The aim of this study was to compare the scoring systems (SS) with the anorectal manometry (AM) findings. METHODS The data of patients operated on for ARM were examined. Holschneider's, Rintala's, Krickenbeck's and Peña's questionnaires were executed to the patients and AM was performed. RESULTS Our study was completed with 23 patients. There was a statistically significant relationship between the anal resting pressure and Holschneider's questionnaire (HQ). There was a statistically significant relationship between the area under the curve in the maximum voluntary squeeze pressure-time graph (AUC) and the HQ and Rintala's questionnaire (RQ). A statistically significant difference was found between HQ and RQ scores and high type and low type of ARMs. CONCLUSION In our study, based on AM data, it was found that the use of HQ and RQ from the four SS we compared could be more effective in patients' follow-up. It was concluded that Peña's questionnaire and Krickenbeck's questionnaire should be used to determine the bowel management program of the patients rather than patients' follow-up. LEVELS OF EVIDENCE Level II.
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Affiliation(s)
- Mehmet Mert
- Department of Pediatric Surgery, Health Sciences University Van Education and Research Hospital, Van, Turkey. .,, Halilaga District, Golbasi. Street, Apartment Number:20 İpekyolu, Van, Turkey. .,, Suphan District, Airport Junction 1st Kilometer, Edremit, Van, Turkey.
| | - Ali Sayan
- Department of Pediatric Surgery, Health Sciences University Tepecik Education and Research Hospital, Guney District, 1140/1 Street, Apartment Number:1 Konak, Izmir, Turkey
| | - Gökhan Köylüoğlu
- Department of Pediatric Surgery, Katip Celebi University Medical Faculty Hospital, Airport Station Street, Number:33 Cigli, Izmir, Turkey
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Hashish MS, Dawoud HH, Hirschl RB, Bruch SW, El Batarny AM, Mychaliska GB, Drongowski RA, Ehrlich PF, Hassaballa SZ, El-Dosuky NI, Teitelbaum DH. Long-term functional outcome and quality of life in patients with high imperforate anus. J Pediatr Surg 2010; 45:224-30. [PMID: 20105608 DOI: 10.1016/j.jpedsurg.2009.10.041] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 10/06/2009] [Indexed: 11/29/2022]
Abstract
PURPOSE Anorectal malformations (ARMs) are associated with a large number of functional sequale that may affect a child's long-term quality of life (QOL). The purposes of this study were to better quantify patient functional stooling outcome and to identify how these outcomes related to the QOL in patients with high imperforate anus. METHODS Forty-eight patients from 2 children's hospitals underwent scoring of stooling after 4 years of life. Scoring consisted of a 13-item questionnaire to assess long-term stooling habits (score range: 0-30, worst to best). These results were then correlated with a QOL survey as judged by a parent or guardian. RESULT Mean (SD) age at survey was 6.5 (1.6) years. Comparison of QOL and clinical scoring showed no signficant difference between the 2 institutions (P > .05). There was a direct correlation between the QOL and stooling score (Pearson r(2) = 0.827; beta coefficient = 24.7, P < .001). Interestingly, functional stooling scores worsened with increasing age (Pearson r(2) = 0.318, P = .02). Patients with associated congenital anomalies had a high rate of poor QOL (44% in poor range; P = .001). Stooling scores decreased significantly with increasing severity/complexity of the ARM (P = .001). CONCLUSION A large number of children experience functional stooling problems, and these were directly associated with poor QOL. In contrast to previous perceptions, our study showed that stooling patterns are perceived to worsen with age. This suggests that children with ARMs need long-term follow-up and counseling.
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Affiliation(s)
- Mohamed S Hashish
- Section of Pediatric Surgery, Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
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Keshtgar AS, Athanasakos E, Clayden GS, Ward HC. Evaluation of outcome of anorectal anomaly in childhood: the role of anorectal manometry and endosonography. Pediatr Surg Int 2008; 24:885-92. [PMID: 18512062 DOI: 10.1007/s00383-008-2181-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2008] [Indexed: 10/22/2022]
Abstract
The aim of this study was to evaluate role of anorectal manometry (ARM) and anal endosonography (ES) in assessment of the internal anal sphincter (IAS) quality on continence outcome following repair of anorectal anomalies (ARA). We devised a scoring system to evaluate the quality of the IAS based on ARM and ES and correlated the scores with clinical outcome, using a modified Wingfield score (MWS) for faecal continence. We also assessed the implication of megarectum and neuropathy on faecal continence. Of 54 children studied, 34 had high ARA and 20 had low ARA. Children with high ARA had poor sphincters on ES and ARM, and also poor faecal continence compared to those with low ARA. The presence of megarectum and neuropathy was associated with uniformly poor outcome irrespective of the IAS quality. The correlations between MWS on one hand, and ES and ARM scores for IAS on the other hand were weak in the whole study group, ES r = 0.27, P < 0.04, and ARM r = 0.39, P < 0.004. However, the correlations were strong in those who had isolated ARA without megarectum or neuropathy, ES r = 0.51, P < 0.02 and ARM r = 0.55, P < 0.01, respectively. In conclusion, the ARM and ES are valuable in evaluation of continence outcome in children after surgery for ARA and those with good quality IAS had better faecal continence. The IAS is a vital component in functional outcome in absence of neuropathy and megarectum.
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Affiliation(s)
- A S Keshtgar
- Department of Paediatric Surgery, University Hospital Lewisham, NHS Trust, Lewisham High Street, London, SE13 6LH, UK.
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Peña A. Anorectal Malformations: New Aspects Relevant to Adult Colorectal Surgeons. SEMINARS IN COLON AND RECTAL SURGERY 2007. [DOI: 10.1053/j.scrs.2006.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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5
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Abstract
PURPOSE To assess the usefulness of infracoccygeal transperineal ultrasonography (US) in differentiation between high- and low-type imperforate anus. MATERIALS AND METHODS Infracoccygeal US was prospectively performed with a 7-10-MHz linear-array transducer prior to corrective surgery in 14 neonates with imperforate anus. The approach site was just inferior to the coccyx and posterior to the anus. Transverse images of the anorectal area were obtained. The puborectalis muscle was identified, and the relationship between the puborectalis muscle and the distal rectal pouch was evaluated. US findings were compared with surgical findings. RESULTS In 10 neonates, a low-type imperforate anus was correctly diagnosed at infracoccygeal US. In those with low-type imperforate anus, the puborectalis muscle was seen as a hypoechoic U-shaped band (n = 10), and the distal rectal pouch passed through the puborectalis muscle (n = 10). In four neonates with high-type imperforate anus, the puborectalis muscle was not identified (n = 4). CONCLUSION Infracoccygeal transperineal US enables the determination of the type of imperforate anus.
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Affiliation(s)
- Tae Il Han
- Department of Radiology, Eulji University School of Medicine, 24-14 Mok-Dong, Jung-Gu, Taejon 301-726, South Korea.
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Harjai MM, Puri B, Vincent PJ, Nagpal BM. Fecal Incontinence after Posterior Sagittal Anorectoplasty - Follow up of 2 years. Med J Armed Forces India 2003; 59:194-6. [PMID: 27407513 DOI: 10.1016/s0377-1237(03)80004-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
After an anorectal malformation (ARM) is repaired, the goal is fecal continence of the patient. Toilet training is not complete in children below 4 years of age. Manometric and radiological studies need cooperation of the child, and are therefore of little value during the critical preschool years. In this present study, we used only clinical criteria to assess the child for constipation and incontinence after definitive operation. We included all patients of ARM wef 01 April 1998 to 31 March 2000. Only 2 children had crossed 4 years of age at the time of this assessment and therefore it was not possible to assess total continence postoperatively. We found that the incidence of incontinence was less in low anomalies and more in high or intermediate anomalies, while the incidence of constipation was higher in low anomalies and less in high and intermediate anomalies. 31% of all patients born with anorectal malformations and subjected to posterior sagittal anorectoplasty (PSARP) approach were totally continent, 38% suffered with soiling of faeces while 31% had problems of constipation. The higher incidence of constipation as well as incontinence in our study is because of a short follow-up and secondly, these problems are known to improve with passage of time. The purpose of this article is to highlight the problems of bowel control even after the definitive operation and still much more is required to improve the quality of life of these unfortunate children.
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Affiliation(s)
- M M Harjai
- Classified Specialist (Surgery & Paediatric Surgery), 166 Military Hospital, C/o 56 APO
| | - Bipin Puri
- Classified Specialist (Surgery & Paediatric Surgery), Command Hospital (Southern Command), Pune - 411 040
| | - P J Vincent
- Senior Advisor (Surgery), 92 Base Hospital, C/o 56 APO
| | - B M Nagpal
- Professor and Head, Department of Surgery, Armed Forces Medical College, Pune - 411 040
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Schier F, Krebs U, Fröber R, Haas A. Three-dimensional reconstruction of the anorectal continence organ in a 14-week-old fetus. J Pediatr Surg 2002; 37:912-5. [PMID: 12037762 DOI: 10.1053/jpsu.2002.32910] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE The fetal development and anatomy of the muscular structures of the anorectal continence system are unclear. To the pediatric surgeon, these structures are of clinical relevance in reconstructive surgery. The aim of this study was to investigate the fetal development of the anorectal continence organ. METHODS A male fetus (14 weeks postconceptionem) of 114-mm crown-rump length was sectioned serially at 18-micrometer intervals. The sections were stained, and relevant contours of the sections were transferred onto paper using a Zeiss Axioskop drawing apparatus. The drawings then were scanned and digitized. RESULTS Three-dimensional images were created (and animated in a video). These have permitted the demonstration of isolated anatomic structures, the disassembling and reassembling of compound structures, as well as the visualization of structures from different angles. CONCLUSIONS Further studies are now undertaken of older fetal stages through to birth, as well as during postnatal stages. Comparative studies in animals and animations of isolated muscles also are required to show functional capacities. Such studies may lead eventually to an improvement of contemporary surgical techniques.
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Affiliation(s)
- Felix Schier
- Departments of Paediatric Surgery, Anatomy, and Zoology, University Medical Center Jena, Germany
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Abstract
BACKGROUND/PURPOSE The authors present their experience and results in the treatment of infants with imperforate anus over a 10-year period. Differences between these and previously published western results are noted and discussed. METHODS One hundred eight patients with imperforate anus were treated from June 1988 to July 1998. Of these patients, 66 were boys and 42 were girls. Associated anomalies include congenital heart disease, anomalies of bone and cartilage, and Down's syndrome. Thirty-five patients with a low lesion received a limited posterior sagittal anorectoplasty. Seventy-one patients had a high lesion and received 3-staged operations including colostomy, posterior sagittal anorectoplasty, and takedown of colostomy. All patients underwent follow-up by the author. Postoperative anorectal function was evaluated based on the following criteria: ability to have voluntary bowel movement, soiling, and constipation. The duration of follow-up ranges from 6 months to 10 years. RESULTS One patient died of multiple congenital anomalies after colostomy. One patient died of hyaline membranous disease. All except 2 patients had voluntary bowel movement. Three patients had soiling, and 19 suffered from constipation after operation. The constipation improved with medical treatment and time. Four patients who received the first operation at another hospital (3 underwent posterior sagittal anorectoplasty and 1 had cutback anoplasty) had problems with soiling. In these patients, soiling improved after redo posterior sagittal anorectoplasty. CONCLUSIONS Utilizing the posterior sagittal operation described by Peña, most patients were continent and able to have voluntary bowel movements. Constipation occurred in a substantial number of patients with high-type lesions, but few of these patients needed medication or enemas. There were significantly fewer sacral and urogenital anomalies than have been reported in most western series. This may explain the excellent results.
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Affiliation(s)
- C J Chen
- National Chen-Kung University Hospital, Tainan, Taiwan
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Montalvo-Marin A, del Campo NM, Alvarez-Solís RM, Diaz-Lira MA. Continence in patients who undergo posterior rectal flap anorectoplasty. J Pediatr Surg 1998; 33:1760-4. [PMID: 9869046 DOI: 10.1016/s0022-3468(98)90280-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE The authors report the postoperative follow-up results of patients who underwent posterior rectal flap anorectoplasty (PRFA), with emphasis in fecal continence. Variables considered on each patient were sex, presence of fistula, location of the fistula, severity of the defect during the correction, sacral condition, dysraphism, and age at surgery. METHODS Continence was rated using the Peña method and defecogram. The authors studied 20 patients (17 boys and three girls). RESULTS Postoperatively, normal continence was found in 18 patients. Of the two remaining (boys), one had grade II spotting (sacrum agenesia and uretrobulbar fistula) and the other had grade II staining; this patient had the most severe malformation requiring an abdominoperineal approach. All of the defecograms showed complete emptying of the rectum. No recurrent fistulas occurred. CONCLUSIONS The posterior rectal flap anorectoplasty is a new technique that takes into consideration all known factors that contribute to continence. This initial report confirms that this technique results in excellent continence for patients with imperforate anus.
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Affiliation(s)
- A Montalvo-Marin
- Division de Cirugía Pediátrica, Hospital del Niño Dr Rodolfo Nieto Padrón Villahermosa, Tabasco, México
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10
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Husberg B, Rosenborg M, Frenckner B. Magnetic resonance imaging of anal sphincters after reconstruction of high or intermediate anorectal anomalies with posterior sagittal anorectoplasty and fistula-preserving technique. J Pediatr Surg 1997; 32:1436-42. [PMID: 9349763 DOI: 10.1016/s0022-3468(97)90556-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND/PURPOSE Internal anal sphincter (IAS) function can be expected in approximately 75% of cases of high or intermediate anorectal anomaly reconstruction if the fistula region is preserved and transposed to become the new anal canal. METHODS To investigate the morphology of the IAS structure, magnetic resonance (MR) imaging was performed postoperatively in 14 patients operated on with posterior sagittal anorectoplasty (PSARP) and fistula-preserving technique. The results were compared with the appearance of the anal canal in seven normal children. In addition, comparison was made with the images of five patients operated on with earlier pull-through techniques, in which the fistula region was resected. RESULTS In all patients operated on with PSARP and fistula-preserving technique, the MRI displayed an IAS-like smooth muscle structure encircling a closed anal canal. In comparison with normal controls, the image of this IAS was more irregular and had greater variations in thickness in different directions. Moreover, the area of the IAS structure was larger in comparison with the controls. Eleven of the 14 patients showed a positive rectoanal inhibition reflex in rectoanal manometry. However, the MR findings of the three cases lacking the reflex were not different compared with the rest of the group. The five patients operated on with earlier techniques demonstrated an open anal canal without a measurable IAS smooth muscle component. CONCLUSIONS An IAS smooth muscle structure was seen by MRI in all patients operated on with PSARP and fistula-preserving technique independently of the severity of the malformation and the postoperative physiological IAS function. However, this structure was in most cases more voluminous and irregular compared with normal controls.
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Affiliation(s)
- B Husberg
- Department of Pediatric Surgery, St Göran's Hospital/Karolinska Hospital, Karolinska Institute, Stockholm, Sweden
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11
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Lin CL, Chen CC. The rectoanal relaxation reflex and continence in repaired anorectal malformations with and without an internal sphincter-saving procedure. J Pediatr Surg 1996; 31:630-3. [PMID: 8861469 DOI: 10.1016/s0022-3468(96)90662-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
From 1985 to 1994, 27 patients with high- or intermediate type imperforate anus who underwent anorectoplasty were studied for postoperative function, particularly with respect to the rectoanal relaxation reflex and continence. Fourteen of the patients had a rectourogenital fistula and were treated with posterior sagittal anorectoplasty using the fistular end as the neoanus (internal sphincter-saving). Nine patients had a blind rectal pouch and received posterior sagittal anorectoplasty using the trimmed bowel end for reconstruction of the neoanus (incomplete internal sphincter-saving). The other four had Rehbein's mucosa-stripping endorectal pull-through combined with anterior sagittal anorectoplasty (none internal sphincter-saving). A positive rectoanal relaxation reflex was found in 8 of 14 (57.1%), 7 of 9 (77.8%), and 3 of 4 (75%), respectively. It appears that the internal sphincter-saving procedure is not essential for the development of the rectoanal relaxation reflex. Compensation or adaptation most likely contributes to the presence of the rectoanal relaxation reflex, and perhaps to postoperative continence.
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Affiliation(s)
- C L Lin
- Department of Surgery, National Taiwan University Hospital, Taipei, Republic of China
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Saeki M, Hagane K, Nakano M, Honna T. Sacroperineal anorectoplasty using intraoperative ultrasonography: a preliminary report. J Pediatr Surg 1993; 28:779-81. [PMID: 8331502 DOI: 10.1016/0022-3468(93)90324-e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Intraoperative ultrasonography (US) was applied to sacroperineal anorectoplasty for the purpose of making a pull-through tunnel under visual guidance. Intraoperative US images the horizontal plane of the muscle complex and the tip of the forceps, which is placed at the entrance of the tunnel (ie, the space anterior to the puborectalis sling), ready to penetrate the muscle complex. A surgeon can thus penetrate the center of the muscle by confirming the relation between the muscle and forceps on the US screen. Postoperative computed tomography of four patients on whom this technique was applied demonstrated that the rectum was pulled through the exact center of the puborectalis and external sphincter muscles.
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Affiliation(s)
- M Saeki
- Department of Surgery, National Children's Hospital, Tokyo, Japan
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Peña A, el Behery M. Megasigmoid: a source of pseudoincontinence in children with repaired anorectal malformations. J Pediatr Surg 1993; 28:199-203. [PMID: 8437081 DOI: 10.1016/s0022-3468(05)80275-1] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Three children with a history of anorectal malformation repairs were referred to the authors for evaluation and management of fecal incontinence. Their ages ranged from 5 to 7 years. On examination, all the children had fecal impaction and localized dilatation of the rectosigmoid colon. Medical treatment was tried but failed to control the symptoms, and the patients frequently had to be hospitalized for disimpaction. To correct this problem, the authors resected the dilated sigmoid colon, anastomosing the nondilated descending colon to the rectal ampulla, which was preserved to serve as a reservoir. Postoperatively, constipation was cured in all patients. In addition the patients became fecally continent postoperatively, which was an unexpected bonus. The authors believe that localized dilatation of the rectosigmoid should always be considered whenever a child is having intractable constipation after repair of an anorectal malformation and that sigmoid resection may be considered as a therapeutic alternative. Segmental dilatation of the sigmoid colon may be a source of fecal pseudoincontinence and, therefore, should be ruled out when the surgeon is evaluating patients with fecal incontinence.
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Affiliation(s)
- A Peña
- Department of Surgery, Schneider Children's Hospital, Long Island Jewish Medical Center, New Hyde Park, NY 11042
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Hedlund H, Peña A, Rodriguez G, Maza J. Long-term anorectal function in imperforate anus treated by a posterior sagittal anorectoplasty: manometric investigation. J Pediatr Surg 1992; 27:906-9. [PMID: 1640342 DOI: 10.1016/0022-3468(92)90395-n] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Thirty imperforate anus patients were investigated by anorectal manometry 5 to 10 years after a posterior sagittal anorectoplasty. Anal resting tone (ART) and anal squeezing pressure (ASP) were subnormal in most patients. Rectal volume (RV) and sensation to balloon distension were within the normal range. Rectoanal reflex inhibition was demonstrated in 9 of 30 patients. Soiling was more common in patients with a very low ART (less than 40 cm H2O) and a low ASP (less than 100 cm H2O). Constipation was more common in patients with a large RV (greater than 150 mL). Still, the correlation to clinical results was incomplete. As regards to the correlation to type of malformation the rectal atresia patients showed near normal results. The vestibular fistula patients were next in results showing rectoanal reflex inhibition in 5/6 patients. There was no difference in the results between bulbar and prostatic fistula patients.
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Affiliation(s)
- H Hedlund
- Department of Pediatric Surgery, Schneider Children's Hospital, Long Island Jewish Medical Center, New Hyde Park, NY 11042
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Yazbeck S, Luks FI, St-Vil D. Anterior perineal approach and three-flap anoplasty for imperforate anus: optimal reconstruction with minimal destruction. J Pediatr Surg 1992; 27:190-4; discussion 194-5. [PMID: 1564617 DOI: 10.1016/0022-3468(92)90310-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Despite progress in the treatment of imperforate anus, anal stenosis, rectal prolapse, and other late complications may still arise. In 1987, we described the three-flap anoplasty for the treatment of rectal prolapse following pull-through operations. Since 1986, we have performed 14 three-flap anoplasties in combination with an anterior perineal rectal pull-through for primary treatment of imperforate anus. The mean age at definitive repair was 4.4 months (range, 0 to 14 months). Eleven of the 14 primary pull-through procedures could be performed through a perineal approach only. There were no deaths. At a mean follow-up of 24.2 months, none of the patients has developed prolapse, and only one has had a temporary stenosis. Three children are already fully continent, and soiling is absent in 12. All have a good sphincter tone. Although it is too early to evaluate long-term results, it appears that the three-flap anoplasty prevents mucosal prolapse through the interposition of a skin-lined anal canal. Moreover, a combination of this technique with the anterior perineal approach provides an excellent exposure with minimal dissection of the perineal and pelvic musculature and allows for easy and safe pull-through of the rectal pouch, making an abdominal counterincision unnecessary in most cases. It reproduces at the same time a normal anatomy while taking advantage of all existing structures.
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Affiliation(s)
- S Yazbeck
- Department of Surgery, Saint-Justine Hospital, University of Montreal, Quebec, Canada
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