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den Hollander VEC, Trzpis M, Broens PMA. Relation between the internal anal sphincter and defecation disorders in patients with anorectal malformations. J Pediatr Gastroenterol Nutr 2024; 79:525-532. [PMID: 38946687 DOI: 10.1002/jpn3.12302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 06/05/2024] [Accepted: 06/11/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVES To investigate associations between the rectoanal inhibitory reflex (RAIR), type of congenital anorectal malformations (ARMs), type of operation that patients with ARM had undergone, and objectively measured fecal incontinence and defecation problems. METHODS We retrospectively included 69 pediatric patients with ARM. All underwent anorectal function tests at the University Medical Center of Groningen during the last 10 years. We assessed anorectal physiology using the Rome IV criteria and anorectal function tests. RESULTS We found the reflex in 67% of patients and all types of ARMs. All patients who had not been operated on, and those who had undergone less extensive surgery possessed the reflex. In contrast, patients who underwent posterior sagittal anorectoplasty, 44% possessed it. We found no difference between mean rectal volumes in patients with and without the reflex (251 vs. 325 mL, respectively, p = 0.266). We found that over time, patients without the reflex seemed to develop significantly higher rectal volumes than patients who had it. We did not find a significant difference between the reflex and fecal incontinence; however, it seems that the absence of the reflex, resting anal sphincter pressure, and fecal incontinence are related. CONCLUSION The RAIR seems present in patients with ARM irrespective of their malformation type. Corrective surgery, however, may impair this reflex. Seemingly, its absence results in constipation with enlarged rectal volumes and fecal incontinence. Every effort should be made to preserve this reflex during surgery and to use extensive surgical procedures as sparingly as possible.
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Affiliation(s)
- Venla E C den Hollander
- Department of Surgery, Anorectal Physiology Laboratory, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Monika Trzpis
- Department of Surgery, Anorectal Physiology Laboratory, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Paul M A Broens
- Department of Surgery, Anorectal Physiology Laboratory, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Division of Pediatric Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Evans-Barns HME, Tien MY, Trajanovska M, Safe M, Hutson JM, Dinning PG, King SK. Post-Operative Anorectal Manometry in Children following Anorectal Malformation Repair: A Systematic Review. J Clin Med 2023; 12:jcm12072543. [PMID: 37048627 PMCID: PMC10094903 DOI: 10.3390/jcm12072543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/02/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Despite surgical correction, children with anorectal malformations may experience long-term bowel dysfunction, including fecal incontinence and/or disorders of evacuation. Anorectal manometry is the most widely used test of anorectal function. Although considerable attention has been devoted to its application in the anorectal malformation cohort, there have been few attempts to consolidate the findings obtained. This systematic review aimed to (1) synthesize and evaluate the existing data regarding anorectal manometry results in children following anorectal malformation repair, and (2) evaluate the manometry protocols utilized, including equipment, assessment approach, and interpretation. We reviewed four databases (Embase, MEDLINE, the Cochrane Library, and PubMed) for relevant articles published between 1 January 1985 and 10 March 2022. Studies reporting post-operative anorectal manometry in children (<18 years) following anorectal malformation repair were evaluated for eligibility. Sixty-three studies were eligible for inclusion. Of the combined total cohort of 2155 patients, anorectal manometry results were reported for 1755 children following repair of anorectal malformations. Reduced resting pressure was consistently identified in children with anorectal malformations, particularly in those with more complex malformation types and/or fecal incontinence. Significant variability was identified in relation to manometry equipment, protocols, and interpretation. Few studies provided adequate cohort medical characteristics to facilitate interpretation of anorectal manometry findings within the context of the broader continence mechanism. This review highlights a widespread lack of standardization in the anorectal manometry procedure used to assess anorectal function in children following anorectal malformation repair. Consequently, interpretation and comparison of findings, both within and between institutions, is exceedingly challenging, if not impossible. Standardized manometry protocols, accompanied by a consistent approach to analysis, including definitions of normality and abnormality, are essential to enhance the comparability and clinical relevance of results.
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Rajasegaran S, Tan WS, Ezrien DE, Sanmugam A, Singaravel S, Nah SA. Utility of postoperative anorectal manometry in children with anorectal malformation: a systematic review. Pediatr Surg Int 2022; 38:1089-1097. [PMID: 35727358 DOI: 10.1007/s00383-022-05152-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2022] [Indexed: 10/18/2022]
Abstract
Children with anorectal malformation (ARM) often continue to have disturbances in bowel function long after reconstructive surgery. Anorectal manometry may be utilized to evaluate bowel function in these children. We aimed to describe the reported protocols and manometric findings in children with ARM post-reconstructive surgery and to investigate the correlation between manometric evaluation and bowel functional outcome. PubMed, EMBASE, and Google Scholar databases were searched from 1980 to 2021. Data were reviewed and extracted independently by two authors, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Included studies were English articles reporting postoperative assessment of children (≤ 18 years) with ARM using anorectal manometry. From 128 articles obtained in the initial search, five retrospective cohort studies and one prospective study fulfilled inclusion criteria. The rectoanal inhibitory reflex and mean anal resting pressure were parameters most often reported to correlate with postoperative bowel function. The least reported parameters among the studies were high-pressure zone, rectal volume, and rectal sensation. Anorectal manometry could be an objective method providing important information for personalized management of postoperative ARM patients with bowel function issues, but lack of standardized protocols limits a comprehensive analysis of their utility.
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Affiliation(s)
- Suganthi Rajasegaran
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Wei Sheng Tan
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.,Paediatric Surgery Unit, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Don Evana Ezrien
- Paediatric Surgery Unit, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Anand Sanmugam
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.,Paediatric Surgery Unit, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Srihari Singaravel
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.,Paediatric Surgery Unit, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Shireen Anne Nah
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia. .,Paediatric Surgery Unit, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia.
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Banasiuk M, Dziekiewicz M, Dobrowolska M, Skowrońska B, Dembiński Ł, Banaszkiewicz A. Three-dimensional High-resolution Anorectal Manometry in Children With Non-retentive Fecal Incontinence. J Neurogastroenterol Motil 2022; 28:303-311. [PMID: 35362455 PMCID: PMC8978114 DOI: 10.5056/jnm20216] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 04/14/2021] [Accepted: 05/07/2021] [Indexed: 12/30/2022] Open
Abstract
Background/Aims Three-dimensional high-resolution anorectal manometry (3D-HRAM) is a precise tool to assess the function of the anorectum. Our aim is to evaluate children diagnosed with non-retentive fecal incontinence (NRFI) using 3D-HRAM. Methods In all children diagnosed with NRFI, manometric parameters and 3-dimensional reconstructions of the anal canal subdivided into 8 segments were recorded. All data were compared to raw data that were obtained from asymptomatic children, collected in our laboratory and published previously (C group). Results Forty children (31 male; median age, 8 years; range, 5-17) were prospectively included in the study. Comparison of the NRFI group and C group revealed lower values of mean resting pressure (74.4 mmHg vs 89.2 mmHg, P < 0.001) and maximum squeeze pressure (182 mmHg vs 208.5 mmHg, P = 0.018) in the NRFI group. In the NRFI group, the thresholds of sensation, urge and discomfort (40 cm3, 70 cm3, and 140 cm3, respectively) were significantly higher than those in the C group (20 cm3, 30 cm3, and 85 cm3, respectively; P < 0.001). In the NRFI group, 62.5% presented a mean resting pressure above the fifth percentile, and 82.5% of patients presented a maximum squeeze pressure above the fifth percentile. The comparisons between segments obtained from these patients and those obtained from the C group revealed several segments with significantly decreased pressure values in the NRFI group. Conclusions Our study demonstrated lower pressure parameters in children with NRFI. In patients with normal resting pressures, 3D-HRAM may reveal segments with decreased pressures, which may play a potential role in the pathomechanism of incontinence.
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Affiliation(s)
- Marcin Banasiuk
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Poland
| | - Marcin Dziekiewicz
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Poland
| | - Magdalena Dobrowolska
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Poland
| | - Barbara Skowrońska
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Poland
| | - Łukasz Dembiński
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Poland
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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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Ambartsumyan L, Shaffer M, Carlin K, Nurko S. Comparison of longitudinal and radial characteristics of intra-anal pressures using 3D high-definition anorectal manometry between children with anoretal malformations and functional constipation. Neurogastroenterol Motil 2021; 33:e13971. [PMID: 32902923 DOI: 10.1111/nmo.13971] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/07/2020] [Accepted: 07/24/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pathophysiology of fecal incontinence (FI) in children with anorectal malformations (AM) is not well understood. Standard or high-resolution anorectal manometry (ARM) does not identify radial asymmetry or localize abnormal sphincter function. 3D high-definition anorectal manometry (HDARM) provides detailed topographic and 3D pressure gradient representation of anal canal. AIMS To compare intra-anal pressure profiles between children with AM and controls using HDARM and to determine the association between manometric properties and reported predictors of fecal continence (AM type, spinal anomaly, and sacral integrity). METHODS HDARM tracings of 30 children with AM and FI referred for ARM were compared with 30 age and sex-matched children with constipation. 2D pressure profiles were used to measure length of high-pressure zone (HPZ). Longitudinal and radial measurements of sphincter pressure at rest and squeeze were taken along each segment in 3D topographic views and compared between groups. KEY RESULTS 3D measurements demonstrated longitudinal and radial differences between groups along all quadrants of HPZ. At rest, intra-anal pressures were lower along the four segments longitudinally across the anal canal and radially along the quadrants in AM group (P < .01). At squeeze, all quadrant pressures were lower in segments 1-4 in AM group (P < .01). Sensation was abnormal in AM group (P < .01). Intra-anal pressures longitudinally and radially were not associated with predictors of fecal continence. CONCLUSIONS AND INFERENCES Children with AM had abnormal sensation and lower pressures longitudinally and radially along all quadrants of anal canal. Manometric properties at rest were not associated with reported predictors of fecal continence.
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Affiliation(s)
- Lusine Ambartsumyan
- Division of Gastroenterology & Hepatology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Michele Shaffer
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Kristen Carlin
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, Boston, Massachusetts, USA
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Higashidate N, Fukahori S, Hashizume N, Ishii S, Saikusa N, Sakamoto S, Kurahachi T, Tanaka Y, Ohtaki M, Yagi M. Does clinical score accurately support fecoflowmetry as a means to assess anorectal motor activity in pediatric patients after anorectal surgery? Asian J Surg 2020; 43:1154-1159. [PMID: 32169517 DOI: 10.1016/j.asjsur.2020.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/23/2020] [Accepted: 02/25/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE We investigated the relationship between Krickenbeck score (KS) and fecoflowmetry (FFM) parameters and assessed the characteristics of this new questionnaire test by comparing Kelly's clinical score (KCS) in pediatric patients with anorectal surgery for anorectal malformation (ARM) and Hirschsprung's disease (HD). METHODS We enrolled pediatric patients who underwent anorectal surgery for ARM or HD. Bowel function was assessed with KS and KCS thereafter, FFM and anorectal manometry (AM) were conducted. Patients were divided into subgroups according to each parameter of the scoring system and each FFM parameter was compared among the KCS or KS subgroups, respectively. Moreover, correlation analyses were conducted between FFM and AM parameters. RESULTS The comparison of FFM parameters among the subgroups of KCS showed that Fmax in the KCS staining 2 group was significantly higher than that in KCS staining 1 group and the Fmax in KCS sphincter squeeze 1 group was significantly higher than that in KCS sphincter squeeze 0 group. Moreover, Fmax in the KCS "good" group was significantly higher than that in the KCS "fair" group. The comparison of FFM parameters among the subgroups of KS parameters showed that TR in the no soiling group was significantly higher than that in the KS grade 2 soiling group. FFM and AM parameters showed a significant positive correlation between Fmax and voluntary squeezing anal pressure. CONCLUSION FFM clarified the different characteristics of two scoring systems, namely, KCS reflects the anal sphincter performance, whereas the KS soiling score might reflect the tolerance and evacuation ability.
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Affiliation(s)
- Naruki Higashidate
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan.
| | - Suguru Fukahori
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Naoki Hashizume
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Shinij Ishii
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Nobuyuki Saikusa
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Saki Sakamoto
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Tomohiro Kurahachi
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Yoshiaki Tanaka
- Division of Medical Safety Management, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Masahiro Ohtaki
- Department of Pediatric Surgery, Tsuruoka Municipal Shonai Hospital, 4-20 Izumi-cho, Tsuruoka, Yamagata, 997-8515, Japan
| | - Minoru Yagi
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
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Magnetic resonance imaging evaluation after anorectal pull-through surgery for anorectal malformations: a comprehensive review. Pol J Radiol 2018; 83:e348-e352. [PMID: 30627258 PMCID: PMC6323548 DOI: 10.5114/pjr.2018.77791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 07/23/2017] [Indexed: 11/30/2022] Open
Abstract
Anorectal malformations (ARM) include congenital anomalies of the distal anus and rectum with or without anomalies of the urogenital tract. Posterior sagittal anorectoplasty (PSARP) and minimally invasive laparoscopically assisted anorectal pull-through (LAARP) procedure are now mainly used to surgically treat ARMs. Magnetic resonance imaging (MRI) is the modality of choice for interval follow-up assessment of structural and functional outcome after these surgeries to assess future bowel continence. Well-developed pelvic musculature has been found to be a reflector of better anal continence after ARM surgery. Thus, MRI plays an important role in evaluating the external sphincter complex, puborectalis, and levator ani muscles. Other parameters that need to be noted include the position of the neoanus, rectal diameter, anorectal angle, presence or absence of megarectum, and other ancillary anomalies in the spine. Thus, MRI due to superior soft-tissue resolution is the modality of choice and indispensable for post-operative pelvic evaluation in children.
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Kyrklund K, Pakarinen MP, Rintala RJ. Manometric findings in relation to functional outcomes in different types of anorectal malformations. J Pediatr Surg 2017; 52:563-568. [PMID: 27624562 DOI: 10.1016/j.jpedsurg.2016.08.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 08/18/2016] [Accepted: 08/21/2016] [Indexed: 02/06/2023]
Abstract
AIMS To compare anorectal manometry (AM) in patients with different types of anorectal malformations (ARMs) in relation to functional outcomes. METHODS A single-institution, cross-sectional study. After ethical approval, all patients ≥7years old treated for anterior anus (AA), perineal fistula (PF), vestibular fistula (VF), or rectourethral fistula (RUF) from 1983 onwards were invited to answer the Rintala bowel function score (BFS) questionnaire and to attend anorectal manometry (AM). Patients with mild ARMs (AA females and PF males) had been treated with minimally invasive perineal procedures. Females with VF/PF and males with RUF had undergone internal-sphincter saving sagittal repairs. RESULTS 55 of 132 respondents (42%; median age 12 (7-29) years; 42% male) underwent AM. Patients with mild ARMs displayed good anorectal function after minimally invasive treatments. The median anal resting and squeeze pressures among patients with mild ARMs (60 cm H2O and 116 cm H2O respectively) were significantly higher than among patients with more severe ARMs (50 cm H2O, and 80cm H2O respectively; p≤0.002). The rectoanal inhibitory reflex was preserved in 100% of mild ARMs and 83% of patients with more severe malformations after IAS-saving sagittal repair. The functional outcome was poor in 4/5 patients with an absent RAIR (BFS≤11 or antegrade continence enema-dependence). Rectal sensation correlated significantly with the BFS. CONCLUSIONS Our findings support the appropriateness of our minimally invasive approaches to the management of mild ARMs, and IAS-saving anatomical repairs for patients with more severe malformations. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kristiina Kyrklund
- Department of Pediatric Surgery, Hospital for Children and Adolescents, University of Helsinki.
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, Hospital for Children and Adolescents, University of Helsinki
| | - Risto J Rintala
- Department of Pediatric Surgery, Hospital for Children and Adolescents, University of Helsinki
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Eltayeb AA, Shehata GA. Sphincter-saving anorectoplasty for correction of anorectal malformations. SURGICAL PRACTICE 2015. [DOI: 10.1111/1744-1633.12134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
| | - Ghaidaa A. Shehata
- Faculty of Medicine; Department of Neurology; Assiut University; Assiut Egypt
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Pelvic floor in females with anorectal malformations--findings on perineal ultrasonography and aspects of delivery mode. J Pediatr Surg 2015; 50:622-9. [PMID: 25840075 DOI: 10.1016/j.jpedsurg.2014.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 07/15/2014] [Accepted: 08/06/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Advice on the mode of delivery to females born with anorectal malformation (ARM) is needed. The primary aim was to evaluate the anatomy of the pelvic floor muscles in females with ARM operated with posterior sagittal anorectal plasty (PSARP). The second aim was to correlate the extent of muscle defects to the bowel symptoms. METHODS This interventional study with perineal 4D/3D ultrasonography describes the smooth muscles in the intestinal wall (neo-IAS), external sphincter, levators and anal canal using a muscle score (0-6 worst). The bowel symptoms were prospectively registered with Krickenbeck criteria score (0-7 worst). RESULTS Forty females with different subtypes of ARM, median age 13 (4-21), were followed up regarding bowel symptoms. Seventeen were examined with ultrasonography. Bowel symptoms were similar for those examined with ultrasonography and those not, median score 5 and 3 (1-7) respectively, (p=0.223, Fisher's exact test). All the females had at least one muscular defect. There was no significant correlation between muscle defects and bowel symptoms (p=0.094, Spearman's correlation). CONCLUSION Females with ARM have considerable defects in the pelvic floor without any significant correlation to bowel symptoms. All women with ARM would benefit from individualized predelivery evaluations and caesarian section should be considered.
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Arnoldi R, Macchini F, Gentilino V, Farris G, Morandi A, Brisighelli G, Leva E. Anorectal malformations with good prognosis: variables affecting the functional outcome. J Pediatr Surg 2014; 49:1232-6. [PMID: 25092082 DOI: 10.1016/j.jpedsurg.2014.01.051] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 12/20/2013] [Accepted: 01/15/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this study was to investigate the outcome of patients operated for anorectal malformations (ARMs) with good prognosis. METHODS Thirty patients underwent clinical evaluation by Rintala score and anorectal manometry recording anal resting pressure (ARP), rectoanal inhibitory reflex (RAIR), and rectal volume (RV). The results were analysed with regard to sex, type of ARM, surgical timing of posterior sagittal anorectoplasty (PSARP), neurospinal cord dysraphism (ND), neonatal colostomy, and institution where they underwent surgery. RESULTS 6/30 (20%) presented ND despite normal sacrum. 17/30 (57%) patients had a normal Rintala score. ND and neonatal colostomy were significantly associated with a pathologic score (p=0.0029 and p=0.0016). Patients with ND had significantly lower ARP compared to patients with normal spine (23.5±7.2mmHg vs 32±7.9mmHg, p=0.023). ARP was significantly lower in patients with neonatal colostomy compared to patients with primary repair (25.22±10.24mmHg vs 32.57±6.68mmHg, p=0.026). RAIR was present in only 2/6 (33%) patients with ND, while in 21/24 (87.5%) without ND (p=0.015) and in 4/9 (44%) patients with neonatal colostomy, while in 19/21 (90.5%) patients submitted to primary repair (p=0.014). CONCLUSIONS Neurospinal cord dysraphism may be present despite normal sacral ratio. From a clinical point of view, patients with good prognosis ARMs are not completely comparable to healthy children. Neurospinal cord dysraphism and neonatal colostomy seem to worsen the clinical and manometric (ARP and RAIR) outcomes of these patients.
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Affiliation(s)
- Rossella Arnoldi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy.
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Valerio Gentilino
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Giorgio Farris
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Giulia Brisighelli
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
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Longitudinal and radial characteristics of intra-anal pressures in children using 3D high-definition anorectal manometry: new observations. Am J Gastroenterol 2013; 108:1918-28. [PMID: 24169274 DOI: 10.1038/ajg.2013.361] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 09/14/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The pathophysiology of fecal incontinence is not well understood. Standard or high-resolution anorectal manometry (ARM) provides simple two-dimensional (2D) intra-anal pressure measurements and do not identify radial asymmetry or localize abnormal sphincter function. 3D high-definition ARM (HDARM) has 256 pressure sensors distributed circumferentially and provides a detailed topographical and 3D pressure gradient representation of the anal canal. The objective of this study was to use HDARM to characterize intra-anal pressure profiles in children during rest and squeeze. METHODS HDARM manometric tracings of 30 children with constipation referred for ARM were reviewed. 2D pressure profiles using high-resolution manometry were used to measure the length of the high-pressure zone (HPZ). The HPZ was divided into four equal segments from the anal verge to adjust for the variable sphincter length. Longitudinal and radial measurements of the HPZ during rest and squeeze (anterior, left, posterior, right quadrants of the HPZ) were taken along each segment in 2D and 3D topographical views. A 3D reconstruction combining all patients was then constructed. RESULTS Mean age was 149.3±1.8 months and mean HPZ length was 3.0±0.1 cm. Using 2D manometry, the mean peak HPZ pressure at rest was 72.0±2.5 mm Hg, and was located in the second segment of the HPZ. The mean peak HPZ pressure at squeeze was 202.9±13.1, and was located in the second segment. 3D measurement demonstrated both longitudinal and radial asymmetry along the anterior, left, posterior, and right quadrants of the HPZ. Left and right quadrant pressures were higher than anterior and posterior pressures at the anal verge and segment 1 during rest and squeeze. Anterior pressures were lower than posterior pressures longitudinally and radially in segments 2, 3, and 4 both during rest and squeeze. Our findings also suggest that in pediatrics it may be necessary to adjust pressure measurement to the anal canal length to get a more accurate picture. CONCLUSIONS 3D HDARM allows for a detailed characterization of intra-anal pressures. 3D topographic pressure measurements demonstrate longitudinal and radial asymmetry of the anal canal at rest and during squeeze. This is the first time longitudinal and radial asymmetry of the anal canal has been described in children. 3D HDARM may allow for a better understanding of the mechanisms of fecal continence in children.
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Single-stage repair versus traditional repair of high anorectal malformations, functional results’ correlation with Kelly’s score and postoperative magnetic resonance imaging findings. ANNALS OF PEDIATRIC SURGERY 2013. [DOI: 10.1097/01.xps.0000430522.75504.b3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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15
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Pre- and postoperative rectal manometric assessment of patients with anorectal malformations: should we preserve the fistula? Dis Colon Rectum 2013; 56:499-504. [PMID: 23478618 DOI: 10.1097/dcr.0b013e31826e4a38] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Surgical correction of congenital anorectal malformations could be complicated by fecal incontinence. Some authors believe that preservation of the fistula is associated with improved outcome. Rectal manometry is a well-established method to evaluate postoperative functional outcome in these patients and can demonstrate successful transplantation of the fistula. OBJECTIVE Herein, we report the results of our series of patients with anorectal malformations and an externally accessible fistula, who underwent pre- and postoperative rectal manometry studies. DESIGN This is a prospective cohort study. SETTINGS This study was conducted at a tertiary neonatal and pediatric surgical center. PATIENTS Patients with anorectal malformations, who underwent preoperative rectal manometry of the fistula and postoperative rectal manometry of the neoanus between January 2002 and December 2011 were included. MAIN OUTCOME MEASURES Pre- and postoperative rectal manometry results were compared by using paired t test or contingency tables (p values <0.05). RESULTS Twelve female patients with rectoperineal (n = 7, 58%) or rectovestibular (n = 5, 42%) fistula were treated by anterior sagittal anorectoplasty or minimal posterior sagittal anorectoplasty. Complete transposition of the fistula was achieved in all patients. Normal presence of rectoanal inhibitory reflex was demonstrated in all pre- and postoperative rectal manometry studies. There were no differences between pre- and postoperative rectal manometry in the length of the high-pressure zone (2.3 ± 0.6 cm vs 2.5 ± 0.8 cm (p = 0.5)) and resting pressure (59.4 ± 18.2 mm Hg vs 62.1 ± 19.2 mm Hg (p = 0.62)). At a median follow-up of 665 days (range, 290-1165 days), all patients have voluntary bowel movements, with no incontinence or soiling. LIMITATIONS This study is limited by its small sample size and by single-institution bias. CONCLUSION Preoperative rectal manometry of rectoperineal or rectovestibular fistula showed the presence of functional anal structures within the fistula in all patients. We speculate that fistula-preserving surgery in patients with anorectal malformations is associated with improved bowel function outcome.
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Letter to the Editor regarding the article "Anorectal malformations and neurospinal dysraphism: is this association a major risk for continence?". Pediatr Surg Int 2011; 27:549-50. [PMID: 21400032 DOI: 10.1007/s00383-011-2875-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2011] [Indexed: 10/18/2022]
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Kumar S, Al Ramadan S, Gupta V, Helmy S, Debnath P, Alkholy A. Use of anorectal manometry for evaluation of postoperative results of patients with anorectal malformation: a study from Kuwait. J Pediatr Surg 2010; 45:1843-8. [PMID: 20850630 DOI: 10.1016/j.jpedsurg.2010.04.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Revised: 03/29/2010] [Accepted: 04/22/2010] [Indexed: 11/30/2022]
Abstract
PURPOSE The objective of this study is to use anorectal manometry for functional assessment of early postoperative results after corrective surgery for anorectal malformations (ARMs) in children and compare manometric observations with age-matched controls. Parents were counseled and management strategies were planned according to the manometric assessments. METHODS From August 2005 to September 2009, 32 patients who underwent surgery for ARM were assessed postoperatively with anorectal manometry using a water-perfused anorectal motility catheter to record anal canal length or high-pressure zone, resting pressure of anal canal (RP), and rectoanal inhibitory reflex (RAIR). These patients were divided in 2 groups (infants, <1 year; children, >1 year) according to the age at the time of performance of anorectal manometry that was done at 6 months or later following stoma closure or anoplasty. RESULTS Out of these 32 patients, high anomaly was present in 13, whereas 19 had low type of defect. Manometric anal canal length of the children with high and low ARM was 2.10 ± .44 and 2.25 ± .53 cm, respectively, which was significantly shorter than that of their age-matched controls(P < .05). In patients with high ARM, RP in infants (17 ± 7.7 mm of Hg) and children (21 ± 9.4 mm of Hg) was lower than that of controls (RP in infants = 42.43 ± 8.19 mm of Hg, RP in children = 43.43 ± 8.79 mm of Hg, P < .001). In patients with low ARM, RP in infants (34 ± 8.6 mm of Hg, P = .002) and children (26 ± 9.9 mm of Hg, P = .001) was lower than that in controls. Presence of RAIR was demonstrated in 5 (38.4%) of 13 patients with high ARM and in 11 (57.9%) of 19 cases with low ARM. Parental counseling was done after this early evaluation, and management strategies like bowel management program and biofeedback training were planned according to the results of the tests. CONCLUSION Our anorectal manometric results suggest that patients with ARM had short anal canal with lower RP and impaired RAIR, which could affect the ultimate functional outcome in these patients. Thus, postoperative anorectal manometric evaluation of the patients with ARM can give more realistic information about future continence and might help in planning future treatment strategies like bowel management program or biofeedback training.
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Affiliation(s)
- Sunil Kumar
- Department of Pediatric Surgery, Ibn Sina Hospital, Ministry of Health, 25427 Safat, Kuwait.
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Manometric tests of anorectal function in 90 healthy children: a clinical study from Kuwait. J Pediatr Surg 2009; 44:1786-90. [PMID: 19735826 DOI: 10.1016/j.jpedsurg.2009.01.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Revised: 01/07/2009] [Accepted: 01/07/2009] [Indexed: 11/22/2022]
Abstract
BACKGROUND/PURPOSE Anorectal manometry is a noninvasive test used to evaluate conditions like slow-transit constipation, anorectal outlet obstruction, and Hirschsprung disease and to assess postoperative results after Hirschsprung and anorectal malformations. This cross section study was designed to have normal manometric values of anorectal function in healthy children of different ages in Kuwait so that control values are available for comparisons with various pathological states. METHOD Anorectal manometry was conducted in 90 children aged 3 days to 12 years without any symptoms related to lower gastrointestinal tract. They were divided in 3 age groups (group 1-neonates up to 1 month, group 2-infants from 1 month to 1 year, and group 3-children more than 1 year). Water perfused system with anorectal catheter with 4 side holes was used to record length of anal canal or high-pressure zone, resting pressure of anal canal, and rectoanal inhibitory reflex (RAIR). RESULT Anorectal manometry was successfully done in all 90 children of different age groups without any complications. High-pressure zone or anal canal length was 1.67 +/- 0.34 cm in neonates, 1.86 +/- 0.6 cm in infants, and 3.03 +/- 0.52 cm in children. Mean resting pressure of anal canal was 31.07 +/- 10.9 mm Hg in neonates, 42.43 +/- 8.9 mm Hg in infants, and 43.43 +/- 8.79 mm Hg in children. Rectoanal inhibitory reflex was present in all of them. Mean RAIR threshold volumes of 9.67 +/- 3.6, 14.0 +/- 9.5, and 25.0 +/- 11.6 mL was required for noenates, infants, and children, respectively. CONCLUSION Resting pressure of the anal canal, manometic anal canal length, and RAIR volume varies with the age. Normal values anorectal manometry at different age groups should be obtained to compare with pathological states of anorectum.
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Abstract
Anorectal malformations are common anomalies observed in neonates. Survival of these babies is currently achieved in most cases and improvements in operative technique, patient care, and better follow-up have led to improved functional results. A new, simplified classification system (Krickenbeck classification) and method of functional assessment has led to an improved understanding of these anomalies and has allowed for a better comparison of outcomes. Following successful anatomical repair and appropriate programs of bowel care, socially acceptable continence can be achieved in a majority of patients, especially those with an intact sacrum.
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Affiliation(s)
- Risto J Rintala
- Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland.
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Pratap A, Tiwari A, Kumar A, Adhikary S, Singh SN, Paudel BH, Bartaula R, Mishra B. Sphincter saving anorectoplasty (SSARP) for the reconstruction of Anorectal malformations. BMC Surg 2007; 7:20. [PMID: 17892560 PMCID: PMC2093923 DOI: 10.1186/1471-2482-7-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Accepted: 09/24/2007] [Indexed: 11/13/2022] Open
Abstract
Background This report describes a new technique of sphincter saving anorectoplasty (SSARP) for the repair of anorectal malformations (ARM). Methods Twenty six males with high ARM were treated with SSARP. Preoperative localization of the center of the muscle complex is facilitated using real time sonography and computed tomography. A soft guide wire is inserted under image control which serves as the route for final pull through of bowel. The operative technique consists of a subcoccygeal approach to dissect the blind rectal pouch. The separation of the rectum from the fistulous communication followed by pull through of the bowel is performed through the same incision. The skin or the levators in the midline posteriorly are not divided. Postoperative anorectal function as assessed by clinical Wingspread scoring was judged as excellent, good, fair and poor. Older patients were examined for sensations of touch, pain, heat and cold in the circumanal skin and the perineum. Electromyography (EMG) was done to assess preoperative and postoperative integrity of external anal sphincter (EAS). Results The patients were separated in 2 groups. The first group, Group I (n = 10), were newborns in whom SSARP was performed as a primary procedure. The second group, Group II (n = 16), were children who underwent an initial colostomy followed by delayed SSARP. There were no operative complications. The follow up ranged from 4 months to 18 months. Group I patients have symmetric anal contraction to stimulation and strong squeeze on digital rectal examination with an average number of bowel movements per day was 3–5. In group II the rate of excellent and good scores was 81% (13/16). All patients have an appropriate size anus and regular bowel actions. There has been no rectal prolapse, or anal stricture. EAS activity and perineal proprioception were preserved postoperatively. Follow up computed tomogram showed central placement the pull through bowel in between the muscle complex. Conclusion The technique of SSARP allows safe and anatomical reconstruction in a significant proportion of patients with ARM's without the need to divide the levator plate and muscle complex. It preserves all the components contributing to superior faecal continence, and avoids the potential complications associated with the open posterior sagittal approach.
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Affiliation(s)
- Akshay Pratap
- Division of Pediatric Surgery, Department of Surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Awadhesh Tiwari
- Department of Radiology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Anand Kumar
- Division of Pediatric Surgery, Department of Surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Shailesh Adhikary
- Division of Pediatric Surgery, Department of Surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | | | - Bishnu Hari Paudel
- Department of Physiology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Rajiv Bartaula
- Division of Pediatric Surgery, Department of Surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Brijesh Mishra
- Division of Pediatric Surgery, Department of Surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
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Koch SM, Uludağ O, Rongen MJ, Baeten CG, van Gemert W. Dynamic graciloplasty in patients born with an anorectal malformation. Dis Colon Rectum 2004; 47:1711-9. [PMID: 15540304 DOI: 10.1007/s10350-004-0683-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of this study was to compare long-term results for patients born with an anorectal malformation and fecal incontinence treated with a dynamic graciloplasty with those for the total group of patients undergoing dynamic graciloplasty. METHODS Consecutive patients with fecal incontinence after surgical treatment of anorectal malformation and treated with dynamic graciloplasty were included in this study. Preoperative assessment was performed. Postoperative follow-up consisted of anorectal manometry and registration of defecation frequency, continence scores, and postponement time of defecation. RESULTS Twenty-eight patients with a median age of 25.5 years were included in the study. The median follow-up was 4 years. A high anorectal malformation was present in 89.3 percent of patients. Conventional graciloplasty had been previously performed in 36 percent. All patients were incontinent for stools. Median frequency of defecation was four times/day. Median postponement time of defecation was 0 minutes. Rectoanal inhibition reflex was present in 17 percent of patients. Median preoperative sensory threshold during balloon distention was 30 ml and median maximum urge threshold was 165 ml. Satisfactory continence was reached in 35 percent of patients, however, 7.1 percent of patients gained this continence score by additional bowel irrigation. Twenty-nine percent of patients were incontinent for loose stool, 36 percent were incontinent for formed stool. Satisfactory continence was achieved in only 18 percent of patients with a high anorectal malformation, compared with 100 percent in patients with a low anorectal malformation. In the total group of patients with dynamic graciloplasty, satisfactory continence was obtained in 76 percent. The sensitivity threshold in patients with a successful dynamic graciloplasty was lower than that in patients with a failing dynamic graciloplasty (45 vs. 24 ml, P = 0,06). When we compare median preoperative rectal sensitivity threshold in our study group with that in the total patient group with dynamic graciloplasty, statistical difference was established (P = 0.008). Postponement time (0 to 20 minutes) and anal squeeze pressure (81 to 120 mmHg) increased significantly after surgery. Patients with an anorectal malformation had significantly lower resting and stimulation pressure than that of the total group of patients, but the difference between resting and stimulation pressure in both groups was not significantly different (P = 0.33). The difference between resting and stimulation pressure was not significantly different between anorectal malformation patients with a failing dynamic graciloplasty and patients with a successful dynamic graciloplasty. Complications were noted in 57 percent of patients. Explantation of the dynamic graciloplasty was necessary in 32 percent of patients, mainly because of infection of the implant. CONCLUSIONS Results of dynamic graciloplasty for fecal incontinence are reasonable for this specific group of patients with limited treatment options. Despite functional dynamic graciloplasty, the results are worse than those for the total group of patients with dynamic graciloplasty. Rectal sensitivity and type of malformation are prognostic factors for outcome and can be used to select patients for treatment with dynamic graciloplasty, thereby improving treatment outcome.
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Affiliation(s)
- Sacha M Koch
- Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands
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Dewan PA, Elsworthy E, Mathew M, Poki O, Khaw SL, Roberts K, Catto-Smith A. Bowel imbrication in the management of anorectal anomalies. Pediatr Surg Int 2004; 20:708-13. [PMID: 15309467 DOI: 10.1007/s00383-002-0935-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2002] [Indexed: 10/26/2022]
Abstract
Four patients who had imbrication of their proximal rectum and distal sigmoid colon as part of the management of constipation following an anorectoplasty for an anorectal anomaly. Three children with an anorectal anomaly presented with constipation and marked dilation of the rectosigmoid portion of the large bowel; each had longitudinal imbrication of the dilated segment, via a left iliac fossa incision. The forth was born with a cloacal anomaly with associated colonic atresia. The small bowel was used to construct the anorectum following a redo anorectoplasty. Subsequently, the small bowel became ectatic, resulting in the patient developing persistent watery diarrhoea and severe perianal excoriation, which was managed with a 30 cm longitudinal imbrication of the distal bowel during an extensive laparotomy. All 4 have patients now have near normal bowel motions with minimal medication, after only a short hospital stay. Residual problematic dilatation of the rectosigmoid colon in patients with a high anorectal anomaly, in the presence of constipation, can be successfully managed by imbrication of the dilated segment, if carefully selected.
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Affiliation(s)
- P A Dewan
- Department of Surgery, Sunshine Hospital, 3021 St. Albans, Victoria, Australia.
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Sangkhathat S, Patrapinyokul S, Osatakul N. Crucial Role of Rectoanal Inhibitory Reflex in Emptying Function After Anoplasty in Infants with Anorectal Malformations. Asian J Surg 2004; 27:125-9. [PMID: 15140664 DOI: 10.1016/s1015-9584(09)60325-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Constipation is a common problem after reconstructive surgery for anorectal malformations. The underlying pathophysiology of the constipation in these patients is unclear. The objective of this study was to compare manometric disturbance in infants with and without post-anoplasty constipation. Anorectal manometry studies were performed within 12 months of anoplasty, as a part of the follow-up protocol, in 24 infants aged less than 3 years who had anorectal malformations. The manometric profiles studied were mean resting anal pressure (ArP), mean resting rectal pressure (RrP), mean resting rectoanal pressure gradient (RRPG), peak squeeze pressure (PSP), and the presence of the rectoanal inhibitory reflex (RAIR). Eight of 24 infants (33%) experienced constipation during the examination period. There was no difference in pressure profiles between low and non-low anomalies. In the non-constipation group, RrP was 5.1 mmHg, ArP was 21.0 mmHg, RRPG was 16.0 mmHg, and PSP was 88.4 mmHg. In the constipation group, RrP was 7.3 mmHg (p = 0.37), ArP was 37.5 mmHg (p = 0.03), RRPG was 3.05 mmHg (p = 0.05), and PSP was 81.7 mmHg (p = 0.77). RAIR was present in 93.75% of cases without constipation and 12.5% of cases with constipation (p < 0.01). One patient who had clinical conversion from constipation to a good result also showed positive conversion of the RAIR. RAIR and anal resting tone play important roles in emptying function. As far as possible, these functions should be preserved during reconstruction.
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Affiliation(s)
- Surasak Sangkhathat
- Pediatric Surgery Unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand 90110.
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Yuan ZW, Lui VCH, Tam PKH. Deficient motor innervation of the sphincter mechanism in fetal rats with anorectal malformation: a quantitative study by fluorogold retrograde tracing. J Pediatr Surg 2003; 38:1383-8. [PMID: 14523825 DOI: 10.1016/s0022-3468(03)00401-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND/PURPOSE Deficiency of motoneuron innervation to the sphincter mechanism has been described in patients with anorectal malformation. Whether this event is primary or secondary remains unclear. METHODS The authors quantified the motoneuron innervation of the sphincter mechanism by Fluorogold (FG) retrograde tracing experiment in fetal rats with anorectal malformation. Anorectal malformation was induced in rat fetuses by ethylenethiourea (ETU). Serial longitudinal sections encompassing the whole width of lumbosacral spinal cord were examined. The number of FG-labelled motoneurons were scored and compared between male fetuses with or without malformation in the ETU-fed group and normal controls. RESULTS The number of FG-labelled motoneurons in the fetuses without defect, with imperforate anus (IA), with neural tube anomalies (NTA), with combined IA and NTA, and normal controls were determined to be (mean +/- SEM) 109.13 +/- 37.88, 55.05 +/- 25.85, 48.20 +/- 30.34, 54.43 +/- 28.55, and 135.22 +/- 28.78, respectively. FG-labelled motoneurons in the fetuses with IA, NTA, and combined IA and NTA are significantly fewer than that in fetuses without defects (P <.05) and in normal controls (P <.005). CONCLUSIONS These findings suggest that defective motoneuron innervation to the sphincter mechanism is a primary anomaly that coexists with the alimentary tract anomaly in anorectal malformation during fetal development. The intrinsic neural deficiency is an important factor likely to contribute to poor postoperative anorectal function despite surgical correction of anorectal malformation.
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Affiliation(s)
- Z W Yuan
- Division of Paediatric Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Pokfulam, Hong Kong SAR, China
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Abstract
Numerous laparoscopic operations have replaced the traditional open procedure in both adults and children. These new procedures have allowed access to body cavities without significantly traumatizing intervening tissue. The laparoscopically assisted anorectal pull-through (LAARP) for high anorectal malformations (ARM) uses fundamental concepts learned from decades of high ARM repair and incorporates modern technologic advancements in surgical instrumentation and techniques. This laparoscopic approach offers good visualization of an infant's deep pelvis with a reconstruction technique that minimizes trauma to important surrounding structures. The laparoscopic repair can be completed in one stage, 2 stages, or 3 stages. Currently, either the 2-stage or 3-stage operation is recommended. With the 3-stage approach, a temporary colostomy is created initially followed by LAARP in several weeks to months. The colostomy then is closed several months later.
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Affiliation(s)
- Roman M Sydorak
- Department of Pediatric Surgery, University of California, San Francisco 94143, USA
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Tsuji H, Okada A, Nakai H, Azuma T, Yagi M, Kubota A. Follow-up studies of anorectal malformations after posterior sagittal anorectoplasty. J Pediatr Surg 2002; 37:1529-33. [PMID: 12407533 DOI: 10.1053/jpsu.2002.36178] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE There are few follow-up studies comparing posterior sagittal anorectoplasty (PSARP) with conventional procedures for patients with anorectal malformations (ARM). The authors have examined retrospectively postoperative anorectal function of patients with ARM treated with PSARP compared with those treated with conventional methods. METHODS Anorectal function in 23 patients with high and intermediate type anorectal malformations (PSARP group), who underwent PSARP more than 4 years previously, were assessed by Kelly's clinical scoring system and objective studies. These results were compared with those in 14 cases (5 high and 9 intermediate type cases; control group), who underwent other conventional surgical procedures. RESULTS Using Kelly's clinical scoring system, scores of the PSARP group compared with the control group were good in 48% versus 21%, fair in 48% versus 58%, and poor in 4% versus 21%, respectively. Barium enema studies suggested better anorectal sphincteric function in patients with high anorectal malformation in the PSARP group. Magnetic resonance imaging (MRI) studies showed more correct placement of the rectum through the striated muscle complex in the PSARP group at the I-line level. Manometric studies showed no difference in maximum resting pressure, anal canal length, and the incidence of anorectal reflex between the two groups. CONCLUSIONS The favorable results of MRI and barium enema studies can be explained by direct visualization of the striated muscle complex with the aid of electrical stimulation as well as no harmful effects of amputation of the sphincter muscle in PSARP. However, manometric studies suggest anorectal function in patients with high and intermediate anorectal malformations is limited even after PSARP. Long-term postoperative follow-up with adequate bowel management is required for all patients with high or intermediate anorectal malformation.
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Affiliation(s)
- Hisato Tsuji
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Suita, Osaka, Japan
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Heikenen JB, Werlin SL, Di Lorenzo C, Hyman PE, Cocjin J, Flores AF, Reddy SN. Colonic motility in children with repaired imperforate anus. Dig Dis Sci 1999; 44:1288-92. [PMID: 10489907 DOI: 10.1023/a:1026614726976] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Following surgical correction of imperforate anus, voluntary bowel control is frequently poor because of abnormal anorectal function. Using colonic manometry we investigated the role of colonic motility in the pathogenesis of fecal soiling in children following imperforate anus repair. Thirteen children with repaired imperforate anus and fecal soiling underwent motility testing 2-12 years after anoplasty. All had fecal incontinence unresponsive to conventional medical treatment. Colonic manometry was performed using water-perfused catheters. Anorectal manometry was undertaken in 10 patients. Motility study results, treatment and outcomes were compared. All patients had high-amplitude propagating contractions (HAPCs) with an average of 80% propagation into the neorectum. There was no correlation between HAPC number or morphology and any variable. Internal anal sphincter resting pressure was low in 6/10 patients. Relaxation of the internal anal sphincter was present in 6/10 children. Only 1 of 5 patients able to cooperate was capable of generating a normal maximal squeeze pressure. Therapeutic regimens were changed in 11 patients with clinical improvement in five. Fecal soiling in patients with repaired imperforate anus is a multifactorial problem including propagation of excessive numbers of HAPCs into the neorectum as well as internal anal sphincter dysfunction. Colonic manometry in conjunction with anorectal manometry aids in the understanding of the pathophysiology of fecal soiling and guides clinical management in children with repaired imperforate anus.
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Affiliation(s)
- J B Heikenen
- Department of Pediatrics, The Medical College of Wisconsin, Milwaukee 53226, USA
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Albanese CT, Jennings RW, Lopoo JB, Bratton BJ, Harrison MR. One-stage correction of high imperforate anus in the male neonate. J Pediatr Surg 1999; 34:834-6. [PMID: 10359190 DOI: 10.1016/s0022-3468(99)90382-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE The aim of this study was to examine the feasibility, safety, and short-term outcome of complete one-stage repair of high imperforate anus in the newborn boy. METHODS A retrospective review was conducted of five full-term male infants who underwent posterior sagittal anorectoplasty without a colostomy within the first 48 hours of birth. Preoperative imaging was performed to assess associated anomalies. All infants underwent cystoscopy before the perineal operation to determine the level of the urinary tract fistula, if present. After completion of the anoplasty, all were turned supine and the colon irrigated free of meconium. Follow-up ranged from 10 to 24 months. RESULTS Laparotomy was not required for any patient. Three patients had a rectoprostatic urethral fistula, one a rectovesical fistula, and one no fistula (common wall at level of prostate). Tapering rectoplasty was required for only the one patient with a rectovesical fistula. There were no intraoperative complications. All patients passed stool within 12 hours after operation and took full feeding by 48 hours. The average hospital stay was 7 days. Postoperative and stenosis occurred in one patient secondary to parental noncompliance with the postoperative dilation regimen. There were no perineal wound complications. All patients have a strong urinary stream and defecate spontaneously without the aid of oral medication or rectal stimulation or enemas. CONCLUSIONS One-stage repair of high imperforate anus in the male neonate is feasible without short-term genitourinary or gastrointestinal morbidity. Whether it is preferable compared with a delayed (two or three stage) repair depends on ultimate long-term anorectal function, which cannot be assessed for several years.
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Affiliation(s)
- C T Albanese
- Department of Surgery, The Fetal Treatment Center, University of California, San Francisco 94143-0570, USA
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Rintala RJ, Lindahl HG. Posterior sagittal anorectoplasty is superior to sacroperineal-sacroabdominoperineal pull-through: a long-term follow-up study in boys with high anorectal anomalies. J Pediatr Surg 1999; 34:334-7. [PMID: 10052817 DOI: 10.1016/s0022-3468(99)90203-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND/PURPOSE It is unclear which surgical method offers best long-term functional results in patients with high anorectal anomalies. The purpose of this study was to compare the long-term outcome of sacroperineal-sacroabdominoperineal pull-through (SP-SAP) to that of posterior sagittal anorectoplasty (PSARP). METHODS Only boys with high anorectal anomalies (rectourethral fistula) were included in the study to get fully comparable patient groups. From 1975 to 1987, 36 consecutive patients underwent anorectal reconstruction: 19 had SP-SAP (1975 to 1983) and 17 PSARP (12 with internal sphincter-sparing technique, 1983 to 1987). The late bowel function (age at follow up, SP-SAP, 19 years; range, 15 to 22; PSARP, 13 years; range, 10 to 19) was evaluated by clinical interview and examination, and anorectal manometry. RESULTS Six (35%) of the PSARP patients and one (5%) of the SP-SAP patients (P < .04) were always clean without any adjunctive measures. Three PSARP patients and two SP-SAP patients stayed clean with daily enemas. In the PSARP patients with soiling, the median frequency of soiling episodes in a month was four (range, 1 to 16), in the SP-SAP patients, 20 (range, 2 to 28, P < .001). None of the SP-SAP patients but 8 of 17 of the PSARP patients had constipation requiring diet or oral medication. Two PSARP patients and four SP-SAP patients had occasional faecal accidents. The median daily bowel movements in the PSARP group was one (range, one to four) and in the SP-SAP group, three (range, one to five, P < .001). The PSARP patients had significantly higher anorectal resting and squeeze pressures and voluntary sphincter force (cm/H2O, PSARP: mean resting, 47+/-9; mean squeeze, 106+/-29; mean voluntary sphincter force, 60+/-22; SP/SAP: mean resting, 27+/-10; mean squeeze, 68+/-22; mean voluntary sphincter force, 41+/-17; P < .01). Thirteen (76%) of the 17 PSARP patients and none of SP-SAP patients had positive rectoanal reflex indicating functional internal sphincter. CONCLUSIONS In boys with high anorectal anomalies, PSARP clearly is superior to sacroperineal and sacroabdominoperineal pull-through in terms of long-term bowel function and faecal continence.
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Affiliation(s)
- R J Rintala
- Children's Hospital, University of Helsinki, Finland
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NIKOLAEV V, BIZHANOVA D. HIGH POSTTRAUMATIC VAGINAL STRICTURE COMBINED WITH URETHROVAGINAL FISTULA AND URETHRAL STRICTURE IN GIRLS: RECONSTRUCTION USING A POSTERIOR SAGITTAL PARARECTAL APPROACH. J Urol 1998. [DOI: 10.1016/s0022-5347(01)62293-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- V.V. NIKOLAEV
- From the Departments of Pediatric Surgery, and Obstetrics and Gynecology, Russian State Medical University, and Departments of Urology and Gynecology, Russian Children's Clinical Hospital, Moscow, Russia
| | - D.A. BIZHANOVA
- From the Departments of Pediatric Surgery, and Obstetrics and Gynecology, Russian State Medical University, and Departments of Urology and Gynecology, Russian Children's Clinical Hospital, Moscow, Russia
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Nikolaev VV, Bizhanova DA. High posttraumatic vaginal stricture combined with urethrovaginal fistula and urethral stricture in girls: reconstruction using a posterior sagittal pararectal approach. J Urol 1998; 160:2194-6. [PMID: 9817367 DOI: 10.1097/00005392-199812010-00083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE High vaginal stricture is a rare abnormality of traumatic origin, which in most cases is associated with urethral injury. Because to our knowledge there are no previous reports of surgical management of this condition, we describe our experience with plastic surgery performed via a posterior sagittal approach using local tissue in girls with posttraumatic vaginal stricture. MATERIALS AND METHODS We performed vaginoplasty using a posterior sagittal pararectal approach in 6 girls 5 to 14 years old with posttraumatic high vaginal stricture. Five patients had urethral stricture and urethrovaginal fistula. In 5 cases bladder neck closure and the Mitrofanoff procedure were done. RESULTS There were no complications in any patients during the immediate postoperative period. Followup studies 1 to 3 years later in all girls revealed a fully patent vaginal anastomosis. CONCLUSIONS Principles of reconstruction that must be followed if a positive result is to be obtained include concurrent vaginoplasty and suture of the urethrovaginal fistula with separation of the suture line, complete excision of scars in the segments being joined, use of meeting flaps to lengthen the anastomotic line as much as possible, and prevention of ischemia and inflammation in the anastomotic region.
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Affiliation(s)
- V V Nikolaev
- Department of Pediatric Surgery, Russian State Medical University, Russian Children's Clinical Hospital, Moscow
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Abstract
BACKGROUND There is no general agreement about how patients who have short-segment Hirschsprung's disease should be treated. METHODS Ten patients with Hirschsprung's disease, seven with rectal and three with rectosigmoidal aganglionosis, were operated on through a posterior sagittal incision. In nine patients, a primary rectal resection and coloanal anastomosis was performed. In one patient, a longitudinal posterior myectomy of the rectum was performed as a primary procedure, but the procedure was eventually converted to a rectal resection and coloanal anastomosis through the same incision. RESULTS One early and one late anastomotic complication occurred. Both were successfully treated with a temporary fecal diversion (left-sided colostomy for 6 to 8 weeks). The functional results as evaluated with anorectal manometry were similar to a group of Hirschsprung's patients treated with transabdominal pull-through resection and coloanal anastomosis. CONCLUSION This approach might prove to be a useful alternative both to the transabdominal resection and the posterior longitudinal rectal myectomy in Hirschsprung's disease with rectal aganglionosis.
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Abstract
Rectal atresia (RA) with a normal anus is a rare anomaly mostly described as part of a series of anorectal malformations. Most authors believe it to be an acquired lesion with a vascular genesis. One of the arguments quoted is the lack of other congenital anomalies. Several operative procedures are recommended for this lesion. We describe four patients with RA who had other significant congenital anomalies; two other cases were found in the literature. A lack of other congenital anomalies in patients with RA does not seem to be a strong argument for an acquired lesion. All four patients were treated by a posterior sagittal approach with good functional results.
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Holschneider AM, Ure BM, Pfrommer W, Meier-Ruge W. Innervation patterns of the rectal pouch and fistula in anorectal malformations: a preliminary report. J Pediatr Surg 1996; 31:357-62. [PMID: 8708903 DOI: 10.1016/s0022-3468(96)90738-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The innervation patterns of the rectal pouch and fistula of 52 children with anorectal malformations were investigated. Posterior sagittal anorectoplasty was used for intermediate and high anomalies; for the latter it was combined with an abdominal approach. Perineoproctoplasty was performed for low anomalies. The specimens were investigated by acetylcholinesterase staining, lactate dehydrogenase, and succinyldehydrogenase reaction. They consisted of fistula material only in 23 patients and of parts of the rectal pouch in 29. Fourty-four patients (84.6%) had follow-up, and information of bowel movements and continence was obtained after a mean of 3.3 years. Abnormal innervation patterns were found in 96% of the specimens. All fistulas were found to be aganglionic, including the adjacent part of the rectum involving the internal sphincter equivalent. Classical aganglionosis was found in 31% of the rectal pouch specimens, hypoganglionosis in 38%, neuronal intestinal dysplasia (NID) type B in 14%, and dysganglionosis in 10%. All patients with severe constipation or soiling at the time of follow-up had some histopathological correlation. Of the 25 patients for whom the specimens had consisted of rectal pouch material, nine (31%) had severe constipation. All four patients with a low-type malformation who had follow-up and pathological innervation patterns in the rectal pouch suffered from severe constipation; this was true of only five of the 19 children with intermediate or high malformations (P < .05). However, numerous pathological innervation patterns had been identified in patients who had normal bowel function at the time of follow-up. It is concluded that partial denervation of the rectum may not be the only cause in the pathogenesis of constipation after posterior sagittal anorectoplasty and perineoproctoplasty. The high frequency of neuronal intestinal malformations in the rectal pouch may be related to the higher frequency of bowel disturbances in patients with low malformations, in whom the resection was less radical. However, the clinical course is not necessarily related to specific histopathological findings. In the authors' opinion, the recommendation to use the distal rectal pouch and parts of the fistula in the reconstruction of anorectal malformations should be reconsidered.
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Affiliation(s)
- A M Holschneider
- Department of Pediatric Surgery, Children's Hospital of Cologne, Germany
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Yoo SY, Bae KS, Kang SJ, Kim SY, Hwang EH. How important is the role of the internal anal sphincter in fecal continence? An experimental study in dogs. J Pediatr Surg 1995; 30:687-91. [PMID: 7623229 DOI: 10.1016/0022-3468(95)90691-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
It is a generalized concept that the internal anal sphincter (IAS) plays a significant role in fecal continence by generating high pressure in the anal canal at rest and relaxation during rectal distention. Agreement also exists on the importance of internal sphincter-saving anoplasty on anorectal malformations in establishing anal continence. Twelve dogs were divided into four groups. Group 1, a control group, was subjected to a perirectal dissection only. Group 2 underwent the same perirectal dissection plus a 2-cm resection of the anal canal. Group 3 underwent the perirectal dissection plus a 4-cm resection of the anal canal, and group 4 underwent perirectal dissection and transposition of the anus to the posterolateral portion of the voluntary muscle mass. Clinical continence was evaluated, and manometric results were compared with preoperative measurements. All dogs in groups 1, 2, and 3 were clinically continent without soiling except one in group 3, and also manometric results showed minimal change between preoperative and postoperative anal pressure profiles. The transposed anus of group 4 showed continuous fecal soiling. The anal resting pressure (ARP) was also decreased but still existed in this group. This experimental study showed that the IAS contributes to the anal resting tone. However, resection of the IAS did not completely interfere with fecal continence. The smooth muscle of pulled-through rectum seemed to partly take over the function of the IAS.
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Affiliation(s)
- S Y Yoo
- Department of Surgery, Yonsei University, Wonju College of Medicine, South Korea
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Dickson JA. The Surgery of Ano-Rectal Anomalies. Med Chir Trans 1994; 87:646-7. [PMID: 7837179 PMCID: PMC1294924 DOI: 10.1177/014107689408701102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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