Rectovaginal Fistulas: Comparative Analysis of Laparoscopic Assisted Pullthrough and Posterior Sagittal Anorectoplasty

AIM

Compare the laparoscopic treatment (LT) and the posterior sagittal anorectoplasty treatment (ST) of the rectovaginal fistulas (RvaF) in a single center. We have previously reported feasibility and results of LT in this rare variety of anorectal malformations (ARM) [1-3].

MATERIAL AND METHODS

19 patients were treated between February 2000 and November 2020. Nine underwent a LT and 10 a ST. Both surgical techniques were previously described. [2][4][5] The distal posterior wall of the vagina was kept intact in the LT. A technical change was introduced in the ST for that purpose. The fistula was treated from the inside of the rectum, avoiding the opening of the distal vagina as described for the treatment of a urethra rectal bulbar fistula in males. Age at operation, associated anomalies, sacral ratio index (SR), complications, urinary continence, presence of spontaneous intestinal movements, constipation, soiling and requirements of bowel management program (BMP) were analyzed.

RESULTS

Associated anomalies occurred in 17 patients (89.5 %), 63 % of which were urological. Five (26 %) had a SR below 0.4; 4 in the LT group and 1 in the ST group. The mean age at the time of operation was 23.2 (8-59) in ST and 17.6 months (4-32) in LT. Average operative time was 190.4 min for ST (120-334) and 195.8 min (90-270) for LT (p 0.13). One patient in the LT group presented a mild rectal prolapse and 2 a partial wound dehiscence after the ST. Only 15 patients were evaluable for functional results (8 in ST and 7 in LT). Mean follow up was 83 months (12-197). All patients are clean with a bowel management program. Five of the 7 patients undergoing a LT had a bad prognosis (SR < 0,4). Three (43 %) are clean with diet or any treatment, 3 (43 %) using laxatives or enemas and 1 (14 %) with a trans anal irrigation system. Only 1 of the 8 patients in the STgroup had a bad prognosis. Six (40 %) needed a diet; 4 (50 %) laxatives or enemas and 1 (10 %) a cecostomy button for antegrade enemas.

CONCLUSIONS

Patients with RvaF had a high index of associated anomalies. The difference of operative time was not statistically significative. No differences in functional results between both groups were observed. LT is a valid option to treat RvaF.

Reoperative Anorectal Procedures in Patients with Anorectal Malformations - Is Bladder Function Affected?

BACKGROUND

Anorectal malformations (ARM) are associated with neurogenic bladder. The traditional surgical ARM repair is a posterior sagittal anorectoplasty (PSARP), which is believed to have a minimal effect on bladder dynamics. However, little is known about the effects of reoperative PSARP (rPSARP) on bladder function. We hypothesized that a high rate of bladder dysfunction existed in this cohort.

METHODS

We performed a retrospective review of ARM patients undergoing rPSARP at a single institution from 2008 to 2015. Only patients with Urology follow-up were included in our analysis. Data was collected regarding original level of ARM, coexisting spinal anomalies and indications for reoperation. We assessed urodynamic variables and bladder management (voiding, CIC or diverted) before and after rPSARP.

RESULTS

A total of 172 patients were identified, of which 85 met inclusion criteria with a median follow-up of 23.9 months (IQR, 5.9-43.8 months). Thirty-six patients had spinal cord anomalies. Indications for rPSARP included mislocation (n = 42), posterior urethral diverticulum (PUD; n = 16), stricture (n = 19) and rectal prolapse (n = 8). Within 1 year following rPSARP, 11 patients (12.9%) had a negative change in bladder management, defined as need for beginning intermittent catheterization or undergoing urinary diversion, which increased to 16 patients (18.8%) at last follow-up. Postoperative bladder management changed in rPSARP patients with mislocation (p < 0.0001) and stricture (p 0.005) but not for rectal prolapse (p 0.143).

CONCLUSIONS

Patients who undergo rPSARP warrant especially close attention for bladder dysfunction as we observed a negative postoperative change in bladder management in 18.8% of our series.

LEVEL OF EVIDENCE

Level IV.

Surgical Simulation of Posterior Sagittal Anorectoplasty for Rectovestibular Fistula: Low-Cost High-Fidelity Animal-Tissue Model

PURPOSE

To provide a high-fidelity, animal tissue-based model for the advanced surgical simulation of a Posterior Sagittal Anorectoplasty (PSARP) for rectovestibular fistula in anorectal malformation (ARM).

MATERIALS AND METHODS

A chicken cadaver was used to assess the feasibility of simulating a PSARP for rectovestibular fistula in ARM. No modification was required to implement the surgical simulation.

RESULTS

A detailed description of the high-fidelity surgical simulation model is provided. The PSARP can be simulated while providing realistic anatomy (e.g. common wall between rectovestibular fistula and vagina), adequate rectal size, location and placement of the rectovestibular fistula, and proximity to the vagina. Haptic conditions of the tissue resemble human tissue and operative conditions as well.

DISCUSSION

Concerning the decreased exposure of index cases of pediatric surgical trainees and pediatric surgeons in practice, simulation-based training can provide means to acquire or maintain the necessary skills to perform complex surgical procedures [1-5] Surgical simulation models for ARM are limited. Few low-cost trainers are available with predominant artificial and mostly unrealistic tissue [6-8] Animal models have the advantage of realistic multilayer tissue haptic feedback [6].

CONCLUSION

We provide a low-cost, high-fidelity model for correcting a rectovestibular fistula in a child with ARM, a complex operative procedure with low incidence but high-stake outcomes. The described tissue model utilizing the chicken cloaca anatomy provides a high-fidelity model for operative correction of rectovestibular ARM. For simulation purposes in the treatment of ARM, this model appears to be promising in terms of providing realistic pathology and haptic feedback in pediatric dimensions.

LEVEL OF EVIDENCE

V.

Posterior sagittal anorecto-urethro-vagino-plasty in the late period was associated with the long-term bowel function in patients with persistent cloaca: results of a nationwide survey in Japan

PURPOSE

After conducting a nationwide survey of persistent cloaca (PC), we assessed whether or not the timing of definitive anorectoplasty affects the long-term bowel function of patients with PC.

METHODS

Patient information was obtained via questionnaire, and a total of 169 PC patients who underwent posterior sagittal anorectourethrovaginoplasty (PSARUVP) were enrolled in this study. Patients were classified into 2 groups based on their operative period, which was analyzed by the area under the receiver operating characteristic curve: the early group (EG) underwent anorectoplasty at ≤ 18 months old (n = 106), and the late group (LG) underwent anorectoplasty at > 18 months old (n = 63). The bowel function was evaluated using the evacuation score of the Japan Society of Anorectal Malformation Study Group. We also examined the postoperative results of vaginoplasty.

RESULTS

The total evacuation score was significantly higher in the EG than in the LG (5.2 ± 1.7 vs. 4.2 ± 1.8, p = 0.003). The frequency of bowel movement and the constipation scores were significantly higher in the EG than in the LG (1.4 ± 0.6 vs. 1.2 ± 0.7, p < 0.05, 2.4 ± 1.0 vs. 2.1 ± 1.0, p < 0.05, respectively). Postoperative vaginal stenosis was observed in 18 cases (10.7%), of which 16 could be reconstructed transperineally.

CONCLUSION

PSARUVP should be performed in early infancy and facilitate vaginal reconstruction.

Saving the perineal body-A modification of the posterior sagittal anorectoplasty

BACKGROUND

Wound dehiscence of the anocutaneous anastomosis and/or reconstructed perineal body is a feared perioperative complication after posterior sagittal anorectoplasty (PSARP). Dehiscence of the perineal body can have long-term negative implications for fecal continence, sexual intimacy, obstetrical outcomes, and the need for reoperative surgery. We describe a modification to the traditional PSARP for repair of an imperforate anus with a rectovestibular, perineal, or absent fistula by sparing the perineal body, eliminating postoperative perineal body dehiscence and potentially improving long-term functional outcomes.

METHODS

A retrospective review of female patients with a rectovestibular, perineal, or absent fistula who underwent PSARP with sparing of the perineal body was performed.

RESULTS

Six patients underwent PSARP with sparing of the perineal body between 2019 and 2022. There were no perioperative complications. At follow-up, all patients are having regular bowel function without difficulty and have an excellent appearance of their perineal body.

CONCLUSIONS

PSARP for a rectovestibular, perineal, or absent fistula can be safely performed with a more limited incision to avoid disruption of the perineal body. This eliminates the need for perineal body reconstruction during the procedure, thereby preventing wound dehiscence. Given the significant long-term adverse sequelae of wound dehiscence and resultant inadequate perineal body, we believe this modification to the PSARP warrants strong consideration.

Long-term outcomes of male imperforate anus with recto-urethral fistula: laparoscopy-assisted anorectoplasty versus posterior sagittal anorectoplasty

PURPOSE

A five-parameter fecal continence evaluation questionnaire (FCEQ) and incidence of complications were used for long-term assessment of laparoscopy-assisted anorectoplasty (LAARP) and posterior sagittal anorectoplasty (PSARP) for treating male imperforate anus (MIA) with rectobulbar (RB) or rectoprostatic (RP) fistulas.

METHODS

Subjects were 64 consecutive Japanese MIA patients with RB or RP fistulas treated at a single institution between 1995 and 2021. FCEQ data collected retrospectively were used to calculate a fecal continence evaluation (FCE) score (best = 10) and coefficient of variation for FCE (FCECV). The statistical significance threshold was defined at p < 0.05.

RESULTS

Fistulas were RB (n = 40; LAARP = 25/40, PSARP = 15/40) or RP (n = 24; LAARP = 17/24, PSARP = 7/24). Mean ages at surgery and status of the sacrum were similar (p = 0.06, 0.05 and 0.51). FCE scores in RP-LAARP were consistently higher with less FCECV but differences were only statistically significant from 7 years postoperatively (p < 0.05). While FCE scores for RB-LAARP and RB-PSARP were similar (p = 0.99), FCECV were lower for RB-LAARP compared with RB-PSARP. LAARP was associated with less-wound infections, but greater incidence of anal mucosal prolapse unrelated to preoperative status of the sacrum.

CONCLUSION

Long-term postoperative FCEQ assessment favored LAARP for treating MIA with either RB or RP fistulas.

Levator ani asymmetry and deviation in high-type anorectal malformation evaluated by magnetic resonance imaging

INTRODUCTION

The levator ani (LA) complex in high-type imperforate anus (H-IA), low-type imperforate anus (L-IA), and Hirschsprung's disease (HD) patients as controls were documented using magnetic resonance imaging (MRI) and compared for symmetry.

MATERIALS AND METHODS

Mean left:right LA thickness ratio (LA ratio), and deviation of the LA from the pubococcygeal line (PCL; LA angle) were calculated from thin-slice MRI images (axial 2 mm, coronal 2 mm, and sagittal 3 mm) of the puborectalis and pubococcygeus taken parallel to the PCL under sedation in H-IA (n=14), L-IA (n=16), and HD (n=9).

RESULTS

MRI scans were performed between January 2018 and June 2021. LA were significantly thinner in H-IA (1.78±0.46 mm) compared with L-IA (2.97±0.55 mm) and controls (2.87±0.32 mm), p<0.0001. LA ratio was significantly lower in H-IA (0.71±0.15) compared with L-IA (0.93±0.04), and controls (0.91±0.06), p<0.0001. Mean LA-angle was significantly different in H-IA, 10.8° (range 6°-19°), versus L-IA and controls, both zero degrees (range 0°-5°), p<0.0001, respectively.

CONCLUSIONS

LA was confirmed to be significantly asymmetric in H-IA. Because outcome of surgical repair involving a midline incision, such as posterior sagittal anorectoplasty could be impaired, pediatric surgeons are advised to plan surgical intervention for H-IA carefully and appropriately.

Single stage repair of anorectal malformation with rectovestibular fistula in adult

Anorectal malformations are a wide spectrum of disorders, affecting both genders and rare adult presentation as with increased knowledge and advancements, the majority of cases are diagnosed and rectified at birth. This case is a classic example of delayed presentation caused by illiteracy and a lack of adequate health care in rural locations and highlights the uniqueness of this disease, presentation in adult age group and its management and effect on patient psychology and mental health. Because all low anorectal abnormalities can be treated in a single stage, neonatal assessment at birth and early referral to advanced health care centres are critical, with anterior or posterior sagittal anorectoplasty performed by the age of six months. Concerning the anomaly, parent education is an important aspect of patient care.

Commentary on can complex surgical interventions be standardized? Reaching international consensus on posterior sagittal anorectoplasty using a modified-Delphi method

This is a commentary on the manuscript entitled "Can Complex Surgical Interventions be Standardized? Reaching International Consensus on Posterior Sagittal Anorectoplasty Using a Modified-Delphi Method" by Hanke, R, Ponsky T, Garrison A, et al.

Can complex surgical interventions be standardized? Reaching international consensus on posterior sagittal anorectoplasty using a modified-Delphi method

BACKGROUND/PURPOSE

In an effort to standardize educational experience, address future physician shortages, and improve quality of care to patients, many surgical specialties are discussing how to maximize exposure to index cases. One solution being explored is telementoring, which requires a well-developed educational curriculum with intraoperative objectives. The American College of Surgery Telementoring Task Force selected anorectal malformation and posterior sagittal anorectoplasty (PSARP) for the repair of imperforate anus as the initial educational focus for this pilot. The purpose of this study was to obtain international consensus on intraoperative learning objectives for a complex surgical procedure.

METHODS

A multidisciplinary team of medical educators and pediatric surgery experts created an outline of essential curricular content and intraoperative learning objectives for PSARP in three clinical scenarios. Twelve international subject matter experts were identified meeting strict inclusion criteria. Intraoperative checklists were revised using the modified-Delphi process.

RESULTS

After five rounds of modifications to the intraoperative checklists, international consensus was achieved for three different clinical scenarios requiring a PSARP: perineal or vestibular fistula, low prostatic fistula, and bladder neck fistula.

CONCLUSIONS

A modified-Delphi approach was successful in generating guidelines for surgical techniques that can be used to standardize intraoperative teaching and expectations for trainees.

TYPE OF STUDY

Diagnostic study LEVEL OF EVIDENCE: Level V (expert opinion).

Adult residual rectourethral fistula and diverticulum presenting decades after imperforate anus repair: a case report

Background

This report describes a rare surgical case of an intraabdominal mass in a middle-aged patient 40 years after imperforate anus repair.

Case presentation

A 44-year-old Latino male with history of repaired anorectal malformation presented with recurrent urinary tract infections and rectal prolapse with bothersome bleeding and fecal incontinence. During his preoperative evaluation, he was initially diagnosed with a prostatic utricle cyst on the basis of magnetic resonance imaging findings, which demonstrated a cystic, thick-walled mass with low signal contents that extended inferiorly to insert into the distal prostatic urethra. However, at the time of surgical resection, the thick-walled structure contained an old, firm fecaloma. The final pathology report described findings consistent with colonic tissue, suggesting a retained remnant of the original fistula and diverticulum.

Conclusions

Although rare, persistent rectourethral fistula tracts and rectal diverticula after imperforate anus repair can cause symptoms decades later, requiring surgical intervention. This is an important diagnostic consideration for any adult patient with history of imperforate anus.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13256-021-02921-3.

Lessons learned from lower urinary tract complications of anorectoplasty for imperforate anus with rectourethral/rectovesical fistula: Laparoscopy-assisted versus posterior sagittal approaches

PURPOSE

To report the sequelae of and preventive strategies for selected lower urinary tract (LUT) complications, i.e., posterior urethral diverticulum (PUD), intraoperative LUT injuries, postoperative dysuria, and fistula recurrence in male imperforate anus (IA) with rectourethral/rectovesical (RU/RV) fistula after laparoscopy-assisted anorectoplasty (LAARP) or posterior sagittal anorectoplasty (PSARP).

METHODS

153 boys with IA and RU/RV fistula treated 1986-2019 by LAARP (n = 56) or PSARP (n = 97) at two unrelated institutes were studied retrospectively.

RESULTS

After mean follow-up of 17.0 years (range: 36.5 days-32.0 years), the overall incidences of LUT complications were: LAARP (6/56; 10.7%); PSARP (7/97; 7.2%); p = 0.55, comprising PUD: LAARP (n = 5), PSARP (n = 0); p = 0.006; injuries: LAARP (n = 0), PSARP (n = 5); p = 0.16; dysuria: LAARP (n = 1), PSARP (n = 1); p>0.999; and recurrence: LAARP (n = 0), PSARP (n = 1); p>0.999. Mean onset of PUD was 5.1 years (range: 1.0-15.1 years).

TREATMENT

PUD: surgery (n = 2/5), conservative (n = 3/5); injuries: intraoperative repair (n = 5/5); dysuria: conservative (n = 2/2), and recurrence: redo PSARP (n = 1/1).

CONCLUSIONS

Strategies devised to improve dissection accuracy resolved the specific technical issues causing LUT complications (remnant RU fistula dissection in LAARP and blind posterior access in PSARP). Currently, the incidence of new cases of PUD and LUT injuries is zero.

LEVEL OF EVIDENCE

Level III.

Vacuum-assisted closure (VAC) prevents wound dehiscence following posterior sagittal anorectoplasty (PSARP): An exploratory case-control study

BACKGROUND

Wound dehiscence (WD) of the anocutaneous anastomosis or perineal body after posterior sagittal anorectoplasty (PSARP) is common. We aimed to evaluate the efficacy of a perineal vacuum-assisted closure (VAC) for prevention of WD following repair of anorectal malformations (ARM) with rectoperineal and rectovestibular fistula.

METHODS

A retrospective dual-center case-control study of children undergoing PSARP without colostomy between 2011 and 2019 was performed. The VAC group received preoperative bowel preparation (PBP), postoperative application of a VAC, loperamide (only Location A), intravenous antibiotics (IA), and total parenteral nutrition (TPN). The non-VAC group underwent PBP, loperamide (Location A), IA, and TPN without VAC. Primary outcome was WD at the anocutaneous anastomosis or reconstructed perineal body within the first 14 days after surgery.

RESULTS

The study population included 18 patients (VAC group) and 20 children (non-VAG group) with rectoperineal and rectovestibular fistula. The incidence of WD in the VAC group was 0% compared to 25% in the non-VAC group (0/18 vs. 5/20, p = 0.04). No VAC related complications occurred.

CONCLUSION

Postoperative application of a VAC embedded in a perioperative treatment protocol has the potential to prevent wound dehiscence of the neoanus and reconstructed perineal body following PSARP.

TYPE OF STUDY

Case-control study.

LEVEL OF EVIDENCE

Level III.

An overview of opioid usage and regional anesthesia for patients undergoing repair of anorectal malformation

PURPOSE

The recent opioid crisis in the USA compelled us to evaluate our practice of opioid use for postoperative pain management and the influence of regional anesthesia on opioid requirement in patients undergoing repair of anorectal malformations.

METHODS

A retrospective chart review was performed evaluating patients who underwent posterior sagittal anorectoplasty (PSARP) and posterior sagittal anorecto-vagino-urethroplasty (PSARVUP), with or without laparotomy, between January 2016 and March 2020. Morphine milligram equivalents per kilogram (MME/kg) were calculated. IRB approval was obtained for this study.

RESULTS

A total of 105 surgical patients had either a PSARP (74 without laparotomy, 10 with laparotomy) or PSARVUP (13 without laparotomy, 8 with laparotomy). Regional anesthesia included epidurals, transversus abdominis plane block, caudal block or paravertebral catheters. Of the PSARP patients, 4 without laparotomy and 7 with laparotomy received regional anesthesia. For PSARVUP with laparotomy, 4/8 received regional. 44% of PSARP patients without laparotomy did not require opioids postoperatively. The MME/kg required exponentially increased for patients over the age of 5 who underwent PSARP.

CONCLUSIONS

Regional anesthesia is a useful modality for pain control for PSARP/PSARVUP with laparotomy, decreasing the opioid usage, but it is unnecessary for the already low opioid requirements, in patients younger than 5 years of age, without laparotomy.

Development of a posterior sagittal anorectal surgical teaching model

Background

An Anorectal Malformation (ARM) is a rare congenital malformation, which requires proper correction to ensure the best long-term prognosis. These procedures are relatively infrequent and complex, in which a structured approach is important. Therefore, training on an affordable model could be beneficial.

Methods

A low-cost ARM model was developed. The base was reusable and the perineal body disposable. Both expert pediatric surgeons (Experts) and residents/fellows (Target group) were recruited for this study. After testing the model, they completed a questionnaire regarding the realism and didactic value of the model, using a 5-point Likert scale.

Results

Forty-four participants were recruited (Target group n = 20, Experts n = 24). The model has high mean scores of 3.8–4.4 for the total group and even higher on several aspects by the Target group. The experts regarded the haptics and manipulation of the fistula less realistic than the Target group (3.7 versus 4.3, p = 0.021 and 4.2 versus 4.6, p = 0.047). It was considered to be a very good training tool (mean 4.3), without significant differences between the groups.

Conclusions

These results show general consensus that this model is a potent training tool for the component steps of the repair of an ARM with recto-perineal fistula by sagittal approach.

Assessing the previously repaired patient with an anorectal malformation who is not doing well

In this review, the care of children with a previously repaired anorectal malformation is explored. We know that the surgical care of children with anorectal malformations is complex; however, despite an increased understanding of the congenital anomaly and significant technical advances in the operative repair, many of these children continue to have poor functional outcomes. In this article we focus on the common surgical complications, discuss typical presentations, consider appropriate investigations, and review the risks and benefits of revisional surgery in those patients that are 'not doing well' following their primary reconstruction.

Single-incision laparoscopic-assisted anorectoplasty for treating children with intermediate-type anorectal malformations and rectobulbar fistula: a comparative study

PURPOSE

Single-incision laparoscopic-assisted anorectoplasty (SILAARP) was compared to posterior sagittal anorectoplasty (PSARP) for treating intermediate-type anorectal malformations (ARMs) with rectobulbar fistula.

METHODS

Between December 2011 and January 2016, 48 children with intermediate-type ARMS were treated with SILAARP (n = 34) or PSARP (n = 14) in our centre. Data including demographics, complications, and long-term outcomes were retrospectively compared.

RESULTS

No significant difference was observed between both groups in terms of median operative time and complications. The length of postoperative hospital stay was shorter in the SILAARP group than in the PSARP group (6.15 ± 1.10 vs 9.64 ± 4.13 days; p = 0.008). After a mean follow-up of 59.38 ± 13.68 months, the rates of voluntary bowel movements, soiling, and constipation were similar in both groups. Anorectal manometry was performed in 15 and 7 children from the SILAARP and PSARP groups, respectively. Although there were no significant differences in the presence of rectoanal relaxation reflex and high-pressure-zone length, anal canal resting pressure was higher in the SILAARP group than in the PSARP group (33.35 ± 12.95 vs 23.06 ± 8.40 mmHg; p = 0.039).

CONCLUSIONS

Both SILAARP and PSARP seemed feasible and effective for treating intermediate-type ARMs with rectobulbar fistula in children. However, SILAARP significantly reduced the length of postoperative hospital stay and improved anal canal resting pressure.

Primary Posterior Sagittal Anorectoplasty Outcomes for Rectovestibular and Perineal Fistulas Using an Accelerated Pathway: a Single Institution Study

BACKGROUND

Posterior sagittal anorectoplasty (PSARP) is the most common surgical treatment for patients with anorectal malformations. Such patients are often subjected to prolonged nil per os (NPO), antibiotic use, and use of parenteral nutrition. Our aim was to review our institutional experience with patients undergoing PSARP using an accelerated standardized postoperative pathway.

METHODS

Our hospital database was queried from 2004 to 2016 for patients diagnosed with imperforate anus who underwent a surgical procedure. Short term outcomes, hospital length of stay (LOS), and cost were evaluated.

RESULTS

Sixty-three patients were identified during the study period. Of these patients, 34 (54.0%) had a fistula to the urogenital tract or had no demonstrable fistula and one cloaca and 29 (46.0%) had a fistula in the perineum. Approximately half of patients underwent primary PSARP, including 8 patients with fistulas located in the vestibule and vagina in girls and two with no apparent fistulas (12.7% of total cohort). Only two postoperative complications occurred: one superficial surgical site infection and one perineal wound dehiscence. Among the whole cohort, median LOS was 3 days. Median time to PO intake was 2 days, and median cost was $11,532. No complications occurred among the subset of 8 patients undergoing primary PSARP.

CONCLUSION

Patients undergoing PSARP experienced similar outcomes compared to historical series, suggesting that the accelerated pathway for early refeeding and reduced use of antibiotics may be beneficial in appropriately selected patients.

TYPE OF STUDY

Case series with no comparison group Level of evidence Level IV.

Anatomical alterations following the 'PSARP' procedure: Correlating MRI findings with continence scores

PURPOSE

To identify anatomical aberrations following PSARP procedure by using MRI, while correlating MRI findings to clinical outcome.

PATIENTS AND METHODS

Between January 2014 and December 2017, we conducted our study on male patients with rectourethral fistula who underwent PSARP. Postoperative pelvic MRI studies were performed and correlated to their clinical continence scores (Rintala, and Krickenbeck classification).

RESULTS

The study included 31 patients. Fourteen patients were retrieved from the hospital records and accepted to participate in the study; while the remaining 17 were collected from the fecal incontinence clinic. Their age ranged from 40 to 156 months (mean 83) We divided patients in the study into two groups according to their Rintala continence scores: (Group A) 15 patients with low scores (10 or less); and (Group B) 16 patients with higher scores (more than 10). We detected wider pelvic hiatus (hiatus/PC ratio) and more obtuse anorectal angle in group A than B.

CONCLUSION

Several anatomical alterations can be detected by MRI following the PSARP procedure that include abnormalities in the striated muscle sphincter (attenuation/deficiency), deviated neorectum, and presence of excessive perirectal fat. A widened pelvic hiatus and/or obtuse anorectal angle may correlate with poor fecal continence in these patients.

LEVEL OF EVIDENCE

This is a case control study (level III evidence).

Assessment of the Heineke-Mikulicz anoplasty for skin level postoperative anal strictures and congenital anal stenosis

INTRODUCTION

Acquired skin-level strictures following posterior sagittal anorectoplasty (PSARP) and some rare cases of congenital anal stenosis can be managed using a Heineke-Mikulicz like anoplasty (HMA). We hypothesized that this procedure was an effective, safe, and durable outpatient procedure in select patients.

METHODS

We retrospectively reviewed all patients who underwent HMA for skin level strictures following PSARP or for certain congenital anal stenoses from 2014 to 2017.

RESULTS

Twenty-eight patients (19 males, 9 females) with a mean age of 5.8 years (range 0.5-24.4) underwent HMA. Twenty-six had a prior PSARP, of which 18 were redo, and 8 were primary procedures. Two patients had congenital skin level anal stenosis. The mean follow up was 1.0 years (range 0.4-2.9). The average preprocedure anal size was Hegar 8, which after HMA increased 8 Hegar sizes to 16 (95% CI 7-9, p < 0.001). There were no operative complications. One patient restenosed and required a secondary procedure.

CONCLUSION

HMA is a safe procedure for skin-level anal strictures following PSARP (primary and redo) and can also be used in some rare cases of congenital anal stenosis. Long-term follow up to determine the restricture rate is ongoing. A plan to do an HMA if a stricture develops may offer an alternative to routine anal dilations, particularly after a redo PSARP in an older child.

TYPE OF STUDY

Case series.

LEVEL OF EVIDENCE

Level IV.

posterior sagittal anorectoplasty for high- and intermediate-type anorectal malformation

PURPOSE

Laparoscopic-assisted anorectoplasty (LAARP) is a minimally invasive procedure in which the levator ani muscle is left to potentially improve postoperative fecal continence. This study aimed to retrospectively evaluate postoperative complications and long-term outcomes of fecal continence after LAARP and compare them to those after posterior sagittal anorectoplasty (PSARP).

METHODS

Forty-five male patients with high and intermediate anorectal malformation (aged ≥ 4 years) who underwent LAARP or PSARP (LAARP 29, PSARP 16) from 1999 to 2013 were included. Postoperative complications and postoperative fecal continence were retrospectively evaluated and compared. Postoperative complications were also compared before and after introducing a urethroscope during fistula resection.

RESULTS

Complications after LAARP and PSARP were seen in 12 vs. 2 cases (p = 0.09) of mucosal prolapse and in 9 vs. 1 case (p = 0.07) of posterior urethral diverticulum (PUD), respectively. The incidence of PUD decreased after introduction of a urethroscopy from 40% in 8/20 cases to 11% in 1/9 cases. No significant difference was found in terms of fecal continence in both groups.

CONCLUSION

Through our study, greater improvement of postoperative fecal continence after LAARP has not been shown. LAARP was at higher risk for mucosal prolapse and PUD. However, precise dissection of the urethral fistula could be performed after the introduction of urethroscopy.

Posterior sagittal anorectoplasty in vestibular fistula: with or without colostomy

PURPOSE

The aim of this study is to compare the results and complications of one- and three-stage repairs in females with vestibular fistula (VF) and make contribution to the discussion of whether the disadvantages outweigh the protective effect of a colostomy from wound infection and wound dehiscence following posterior sagittal anorectoplasty (PSARP).

METHODS

Patients with a diagnosis of VF who underwent PSARP between October 2009 and November 2015 were retrospectively reviewed. The patients were divided into two groups: Group 1-patients treated by one-stage procedure (n = 30); Group 2-patients treated by three-stage procedure (n = 16).

RESULTS

There were no statistically significant differences between the groups with respect to wound infection, recurrence of fistula and rectal mucosal prolapse. Minor wound dehiscence occurred slightly more common in Group 1, even if p value is not significant. No wound dehiscence has been observed since we switched to the protocol of keeping the child nil per oral for 5 postoperative days and loperamide (0.1 mg/kg) administration for 7 postoperative days. The mean time before resuming oral intake was 2.87 ± 1.7 and 1.19 ± 0.4 days in Group 1 and Group 2, respectively (p = 0.001). None developed major wound disruption or anal stenosis in either group. There were no statistical differences between the groups in terms of voluntary bowel movements, soiling and constipation.

CONCLUSIONS

PSARP performed without a protective colostomy in patients with VF has low morbidity, good continence rates and obvious advantages for both the patients and their parents.

Muscle complex saving posterior sagittal anorectoplasty

INTRODUCTION

Posterior sagittal anorectoplasty (PSARP) published by DeVries and Peña in 1982 had become the preferred surgical technique for the management of anorectal malformations (ARM). The original technique is based upon complete exposure of the anorectal region by means of a median sagittal incision that runs from the sacrum to the anal dimple, cutting through all muscle structures behind the rectum by dividing the levator muscle and the muscle complex. Then, the rectum is located in front of the levator and within the limits of the muscle complex. In this review, we described Muscle Complex Saving-Posterior Sagittal Anorectoplasty (MCS-PSARP), which is a less invasive technique that consists of keeping this funnel-shaped muscle complex completely intact and not divided, and pulling the rectum through this funnel, toward fixing the new anus to the skin. This technique aimed both to respect the lower part of the sphincter mechanism consisting of the muscle complex, and to avoid the disturbance of this important structure by dividing and resuturing it.

METHODS

We presented six cases of male patients who were born with anorectal malformation (ARM) and underwent MCS-PSARP. The surgical technique proved to be feasible to achieve the dissection of the rectal pouch and the division of the rectourethral fistula in all patients, by opening only the upper part of the sphincter mechanism, the levator muscle, and keeping the lower part consisting of intact muscle complex.

RESULTS

The early results in our series are encouraging; however, long-term functional outcomes of these patients are awaited. The surgical tips were also discussed.

CONCLUSIONS

This proposed approach in the management of anorectal malformation cases provides an opportunity to maximize preservation of the existing continence mechanisms. It preserves the muscle complex components of the levator muscle intact, allowing a better function of the continence mechanism.

Usefulness of posterior sagittal anorectoplasty for redo pull-through in complicated and recurrent Hirschsprung disease: Experience with a single surgical group

AIM

To retrospectively examine 12 patients with Hirschsprung disease (HD) who underwent posterior sagittal anorectoplasty (PSARP) for various complications.

METHODS

This study included patients with HD who underwent redo pull-through (PT) via PSARP at our institute between 2005 and 2014. The type of initial procedure, clinical presentations, indications, and functional results were analyzed. Postoperative excretory function was assessed using the Krickenbeck classification.

RESULTS

The study group comprised 9 boys and 3 girls (total, 12). Five patients were diagnosed with rectosigmoid aganglionosis, 5 with long segment aganglionosis, and 2 with total colonic aganglionosis. The primary operations performed on these patients included the Soave, Duhamel, Swenson, Rehbein, and Ikeda-Soper procedures. The interval between the primary operations and reoperation ranged from 5months to 8years (median, 3years). The indications for PSARP were rectocutaneous fistulae (6 cases), frozen pelvis (5 cases), severe anastomotic stricture (3 cases), rectovaginal fistulae (2 cases), and hemorrhagic proctitis with an inflammatory polyp (1 case). All fistulae were repaired using PSARP; only one rectocutaneous fistula recurred and required two additional surgeries. Stricture and hemorrhagic proctitis were cured in all involved cases. Nine patients were followed up for 8months to 10years after PSARP surgery (average, 5.1years). All 9 patients had voluntary bowel movements within 6months after the last PSARP and stoma closure: 3 had normal bowel movement, while 6 had varying degrees of soiling, depending on the length of residual colon. None complained of constipation.

CONCLUSION

PSARP is useful for treating severe complications of failed PT in HD. Complex and recurrent rectocutaneous fistulae and frozen pelvis are the main indications for PSARP, while soiling is the most common surgical complication.

Correlation between magnetic resonance imaging findings after posterior sagittal anorectoplasty for anorectal malformations and the clinical outcome: Preliminary report

BACKGROUND/PURPOSE

To assess the anatomical results after posterior sagittal anorectoplasty (PSARP) by magnetic resonance imaging (MRI) and to evaluate the correlation of these findings with clinical outcomes.

METHODS

Patients followed-up at our center after PSARP, being at least 6year old, with neither evidence of sacral abnormalities nor spinal dysraphisms were prospectively included. Complex ARMs were excluded. MRI was performed on a 1.5T unit. T1- and T2-weighted sequences were acquired, in orthogonal planes, according to the anal canal orientation. The degree of anorectal centering in the muscle complex (DARC), the pelvic floor symmetry, the rectal maximum diameter, the fat tissue interposition, and the presence of fibrosis were evaluated. A clinical questionnaire (Rintala score) was filled in by the parents. MRI findings were compared to the clinical outcomes assessed by the Rintala score. For statistical analysis the Spearman rho correlation coefficient was calculated and the Wilcoxon rank-sum test was performed.

RESULTS

We recruited 11 patients (mean age 12years, range 6-19) with MRI. DARC (range 252-360°) was strongly correlated with the degree of fecal incontinence (rho=0.70), mildly with the ability to hold back defecation (rho=0.58), constipation (rho=0.46) and total Rintala score (rho=0.41). Pelvic floor symmetry correlated with the frequency of defecation (rho=0.58). Rectal maximum diameter negatively correlated with the ability to feel the urge to defecate (rho=-0.60). Patients with fibrosis were slightly more constipated (p=0.056) and presented more social impairment (p=0.04). Fat tissue interposition had no correlation with the clinical outcome.

CONCLUSIONS

Thanks to soft tissue definition, multiplanar imaging, and lack of ionizing radiation, MRI is a valuable tool in the postoperative anatomical evaluation of patients with ARM. Our preliminary results show that abnormal anatomical findings can correlate to a nonoptimal functional outcome, thus helping in understanding the clinical course. The degree of anorectal centering in the muscle complex (DARC) seems to have the better correlation with the outcome, especially in terms of fecal continence.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

level IV.

Vaginal agenesis and rectovestibular fistula. Experience utilizing distal ileum for the vaginal replacement in these patients, preserving the natural fecal reservoir

BACKGROUND

The association of rectovestibular fistula (RVF) and vaginal agenesis (VA) presents a diagnostic and management challenge. The vaginal replacement is usually performed with rectum or sigmoid, which are the natural fecal reservoirs; thus, the fecal control could be affected. We present our experience utilizing ileum to preserve the rectum and sigmoid.

METHODS

We performed a retrospective study of eight patients with RVF and VA treated from May 2011 to June 2015 at two colorectal centers, at Pittsburgh and Mexico. We recorded the age at diagnosis of VA, treatment, presence of other associated malformations and outcome.

RESULTS

Eight of forty-nine girls with RVF had an associated VA (16.3%). Three patients had a timely diagnosis and five a delayed diagnosis. Six patients were submitted to a vaginal replacement with ileum and achieved fecal control. Two are waiting for surgery.

CONCLUSIONS

A high index of suspicion of vaginal agenesis helps in a timely diagnosis in girls with RVF. The use of ileum allows for preservation of the fecal reservoirs, thus optimizing the chance for fecal control in patients with anorectal malformations.

Surgical management of recto-prostatic and recto-bulbar anorectal malformations

PURPOSE

Laparoscopically assisted anorectoplasty (LAARP) was compared to posterior sagittal anorectoplasty (PSARP) in the treatment of male imperforate anus associated with either recto-prostatic fistula (RPF) or recto-bulbar fistula (RBF).

METHOD

19 RPF patients (12 treated by LAARP and 7 by PSARP) and 26 RBF patients (14 treated by LAARP and 12 by PSARP) between 1995 and 2014 were retrospectively assessed using a fecal continence evaluation questionnaire (FCE) (with a maximum score of 10), an FCE score coefficient variation, as well patients' MRI scores, anorectal angle values (AA), and incidence of postoperative complications. Statistical significance was determined at p < 0.05.

RESULTS

Both groups were similar in mean age and mean weight at repair, as well as sacral status. Postoperatively, mean MRI scores, mean AA, and biochemistry were also similar (p = NS). All cases treated with LAARP showed consistently higher and less variable FCES values, fewer wound infection incidence, but greater rectal mucosal prolapse unrelated with sacrum status. Significantly lower doses of postoperative analgesia were needed in all LAARP cases (p < 0.05).

CONCLUSION

Technical outcomes appear to be similar based on imaging studies, but FCES-assessed functional outcomes appear to favor LAARP for treatment of both RPF and RBF.

Can we expect a favorable outcome after surgical treatment for an anorectal malformation?

BACKGROUND

The aim of this study was to retrospectively review the classification, surgical experience, and the functional outcome of anorectal malformations (ARMs) according the type of ARM.

METHODS

A total of 311 children (M:F=200:111) who underwent surgical treatment for ARM between 1990 and 2011 were reviewed. Functional outcomes were evaluated using the Krickenbeck classification. The mean follow-up period was 112.2 ± 76.7months (range: 36.8-414.9months).

RESULTS

In the male patients, 90 (45%) had perineal fistulas, 60 (30%) had urethral fistulas, and 7 (3.5%) had rectovesical fistulas. There were 17 cases of ARM without a fistula (8.5%), and we could not determine the type of fistula in 26 boys (13%) because of follow-up losses and death. In the female patients, 34 (30.6%) had perineal fistulas, 71 (64%) had rectovestibular fistulas, and 2 (1.8%) had rectovaginal fistulas. Four patients did not have a fistula (3.6%). For 264 patients, we did anoplasty (121 cases), fistula transposition (14 cases), and posterior sagittal anorectoplasty (PSARP, 129 cases). We found that 224 (84.8%) patients showed voluntary bowel movements. The overall rate for constipation was 30.7% and for soiling was 6.5%. The continence outcome was good for 82.2% of children, fair for 2.7%, and poor for 15.2%. For rectovestibular fistulas, constipation was higher in the perineal operation group, but the continence outcome was similar.

CONCLUSION

Through a review of 20years' experience, an accurate diagnosis based on the Krickenbeck classification and operations following the principles of PSARP are crucial to achieve a good functional outcome in children with an ARM.

OUTCOMES OF POSTERIOR SAGITTAL ANORECTOPLASTY FOR HIGH ANORECTAL MALFORMATION IN BENIN CITY, NIGERIA

BACKGROUND

Surgical treatment for high anorectal malformations has evolved over the years with introduction of posterior sagittal anorectoplasty in the early 80s. Posterior sagittal anorectoplasty is being perfomed in many centres which necessitates a review of its outcomes in Benin City, Nigeria.

AIM

To report a 10-year outcome and experience gained with posterior saggital anorectoplasty for children diagnosed with high anorectal malformation.

METHODS

A retrospective analyses of the records of all children with high anorectal malformation and managed with posterior sagittal anorectoplasty between April 2006 and March 2016 at the University of Benin Teaching Hospital.

RESULTS

A total of 96 children were managed for anorectal malformation during the period. High anorectal malformation accounted for 33 (34.4%) cases, the intermediate 15 (15.6%) and the low types were 48 (50%). The 33 radiologically confirmed high type were19 males and 14 females with a male/female ratio of 1.3: 1. They were aged between 2 days and 4 years with a mean of 6.8 ± 3 months. A child each had additional prune belly syndrome, multiple limbs anomalies and unilateral undescended testis. Recto-bladder neck/recto-prostatic and recto-vaginal fistulae were recorded in 31 (94%) children. Five (15%) clinically stable neonates had primary posterior sagittal anorectoplasty without colostomy which was well tolerated. The majority, 28 (85%), had conventional posterior sagittal anorectoplasty that involves initial colostomy. Minor postoperative morbidities recorded in 10 (30.3%) children included superficial wound infection in 3 (9%), anal stenosis in 3 (9%) and fecal incontinence in 2 (6%) children which resolved on conservative treatment while 2 (6%) with rectal mucosal prolapse required refashioning. The functional clinical anal outcomes of posterior sagittal anorectoplasty recorded showed that the majority 18 (54.5%) of children were continent while 4 (12.1%) had voluntary bowel controls corresponding with their ages. Anal stenosis in the 3 and incontinence in the 2 children were the common anal dysfunctions recorded. The child with prune belly syndrome had breakdown of colostomy closure which resulted in the one (3%) death recorded.

CONCLUSION

Anorectal malformation was common in this setting during this study with a large proportion of the children diagnosed with the high type and were managed with good outcome using posterior sagittal anorectoplasty.

Posterior sagittal anorectoplasty results in better bowel function and quality of life in adulthood than pull-through procedures

BACKGROUND/PURPOSE

The short-term outcome of posterior sagittal anorectoplasty (PSARP) procedure has been reported to be better than after abdominoperineal or abdominosacroperineal (AP) procedures. This study aimed to investigate the long-term functional outcome and quality of life after PSARP in adulthood and compare with the outcome after AP procedures.

METHODS

Twenty-four patients operated with PSARP at the Department of Pediatric Surgery, Uppsala, Sweden, from 1984 to 1993 were identified. They were compared with 20 patients that underwent AP pull-through procedures from 1974 to 1983. The patients were sent validated bowel function and quality of life (SF-36) questionnaires. Sixteen PSARP (median age 21, five females) patients and fourteen AP patients (seven abdominosacroperineal and seven abdominoperineal pull-throughs, median age 32, seven females) responded and were included in the study.

RESULTS

The median Miller incontinence score was 1 (range 0-13) in the PSARP group and 10 (range 3-16) in the pull-through group (P=0.0042). The use of underwear protection and oral loperamide was significantly less frequent in the PSARP group (P=0.0096 and 0.0021 respectively). The SF-36 scores of Vitality, Mental health and Mental Cluster Scale were higher in the PSARP group (P=0.0291, 0.0500, 0.0421 respectively).

CONCLUSIONS

PSARP results in superior bowel function and better quality of life in adulthood compared with AP procedures for the repair of anorectal malformations.

Can we expect a favorable outcome after surgical treatment for an anorectal malformation? J Pediatr Surg. 2016;51:421-424. [PMID: 26572852 DOI: 10.1016/j.jpeds urg.2015.08.048]

BACKGROUND

The aim of this study was to retrospectively review the classification, surgical experience, and the functional outcome of anorectal malformations (ARMs) according the type of ARM.

METHODS

A total of 311 children (M:F=200:111) who underwent surgical treatment for ARM between 1990 and 2011 were reviewed. Functional outcomes were evaluated using the Krickenbeck classification. The mean follow-up period was 112.2 ± 76.7months (range: 36.8-414.9months).

RESULTS

In the male patients, 90 (45%) had perineal fistulas, 60 (30%) had urethral fistulas, and 7 (3.5%) had rectovesical fistulas. There were 17 cases of ARM without a fistula (8.5%), and we could not determine the type of fistula in 26 boys (13%) because of follow-up losses and death. In the female patients, 34 (30.6%) had perineal fistulas, 71 (64%) had rectovestibular fistulas, and 2 (1.8%) had rectovaginal fistulas. Four patients did not have a fistula (3.6%). For 264 patients, we did anoplasty (121 cases), fistula transposition (14 cases), and posterior sagittal anorectoplasty (PSARP, 129 cases). We found that 224 (84.8%) patients showed voluntary bowel movements. The overall rate for constipation was 30.7% and for soiling was 6.5%. The continence outcome was good for 82.2% of children, fair for 2.7%, and poor for 15.2%. For rectovestibular fistulas, constipation was higher in the perineal operation group, but the continence outcome was similar.

CONCLUSION

Through a review of 20years' experience, an accurate diagnosis based on the Krickenbeck classification and operations following the principles of PSARP are crucial to achieve a good functional outcome in children with an ARM.

Comparison of outcomes between laparoscopy-assisted and posterior sagittal anorectoplasties for male imperforate anus with recto-bulbar fistula

PURPOSE

All reports comparing laparoscopy-assisted anorectoplasty (LAARP) with posterior sagittal anorectoplasty (PSARP) in male high-type imperforate anus include a mix of recto-vesical, recto-prostatic, recto-bulbar, and absent fistula cases without focusing on recto-bulbar fistula (RBF), the most challenging type to treat laparoscopically. We compared LAARP with PSARP for treating only RBF.

METHOD

We used our fecal continence evaluation questionnaire (FCE; maximum score=10), scoring of magnetic resonance imaging (MRI) findings (MRI scores), and the angle between the rectum and the anal canal (RAA) to assess 20 RBF cases (LAARP=12, PSARP=8) treated from 2000 to 2013 prospectively.

RESULTS

Mean ages at surgery, MRI scores, mean RAA, and duration of raised C-reactive protein (6.6 vs. 6.7days; p=NS) were similar. In all cases, postoperative MRI showed no residual fistula and normal urination. LAARP had consistently higher FCE (7.9 vs. 7.8 at 3years; 8.6 vs. 8.3 at 5years; 8.9 vs 8.6 at 7years; p=NS, respectively), less wound infections (0 vs. 37.5%; p<0.05), higher incidence of rectal mucosal prolapse (50.0 vs. 0%; p<0.05), and required less analgesia (p<0.05).

CONCLUSION

Although LAARP and PSARP are comparable for treating RBF, LAARP is associated with less wound infections and higher incidence of rectal mucosal prolapse.

Long-term bowel functional outcomes in rectourethral fistula treated with PSARP: controlled results after 4-29 years of follow-up: a single-institution, cross-sectional study

BACKGROUND/PURPOSE

Posterior sagittal anorectoplasty (PSARP) has become the standard surgical treatment for males rectourethral fistula (RUF) at most surgical centers worldwide. We aimed to define the long-term bowel functional outcomes following PSARP for RUF at our institution between 1983 and 2006, with comparison to age- and gender-matched controls.

METHODS

Patients were invited to answer a detailed, previously validated Bowel Function Score (BFS) questionnaire by post. Respondents were matched by age and gender to three controls from the general population who had answered identical questionnaires. Case records were reviewed retrospectively for operative details. Ethical approval was obtained. Social continence was defined as soiling or fecal accidents <1/week and no requirement for changes of underwear or protective aids.

RESULTS

Of 34 (79%) respondents (median age 19 (range, 4-29) years), 74% had voluntary bowel movements (VBMs), 24% were reliant on anterograde continence enema (ACE) washouts, and 1 patient had a colostomy. Impairment of bowel function was significantly higher in all aspects of fecal control among patients than controls (p<0.001). A statistically significant decline in fecal accidents and soiling was observed with age (p ≤ 0.03). Thirty-one percent of patients with VBMs had constipation managed with diet or laxatives (vs 2% of controls, p=0.0002). Of patients with VBMs followed up for > 12 years (n=20), 50% were completely continent (vs 73% of controls; p=NS). Overall, 76% of respondents were socially continent with or without artificial means in the form of ACE washouts. By BFS score, 39% had a good functional outcome, 27% had a moderate outcome, 9% had a clearly poor score and 24% were living with an ACE.

CONCLUSIONS

Our results suggest that in the long-term, functional symptoms remain highly prevalent among patients treated for RUF with PSARP. However, the majority can be expected to achieve social continence, although for some this will require intervention with ACE bowel management. Approximately one third may report VBMs and complete continence.

Spontaneous intravesical knotting of urethral catheter

Infant feeding tubes (IFT) have been universally used as urethral catheters in neonates and children for several decades. Though generally a safe procedure, it may cause significant morbidity if the catheter spontaneously knots inside the bladder. We report this complication in three children including a neonate.

Fecal Incontinence after Posterior Sagittal Anorectoplasty - Follow up of 2 years

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.