Anorectal function and endopelvic dissection in patients with repaired imperforate anus

Abstract

Fifty-eight patients with anorectal malformations were closely followed up for postoperative anorectal function. Constipation was noted shortly after anorectoplasty in 10 of 28 low anomalies (35.7%) treated with limited sagittal anorectoplasty (LSARP), in 18 of 25 high or intermediate anomalies (72.0%) treated with posterior sagittal anorectoplasty (PSARP), but in none of 5 high or intermediate anomalies treated with Rehbein's mucosa-stripping endorectal pull-through and anterior sagittal perineal anorectoplasty (R-ASAP). The constipation resolved mostly within 1-2 years after repair under conservative management, but persisted beyond 2 years after repair in 3/25 children with LSARP and 10/25 with PSARP. Anal soiling was noted in 1/23 (4.3%) LSARP and 6/22 (27.3%) PSARP patients, but normal anorectal function was attained in 20/23 LSARP (86.9%) and 11/12 PSARP patients (50.0%) by the time of toilet training. Manometric studies disclosed that the resting rectal pressure (RRP) was lower and the anorectal pressure gradient (ARPG) higher in the constipated than the non-constipated children, while the RRP was higher and the ARPG lower in the soiled than the non-soiled patients. The ARPG after R-ASPA was close to that of non-constipated and in between that of the constipated and soiled patients. The rectoanal sphincter inhibitory reflex was not related to defecation status or surgical procedures, but showed a tendency toward positive conversion with time or after exclusion of esctatic terminal bowel in the severely constipated. It is concluded that anorectal function in patients with repaired imperforate anus seems to be more affected by the extent of endopelvic dissection than by preservation of the terminal bowel or sphincter muscles.

Earlier appearance and higher incidence of the rectoanal relaxation reflex in patients with imperforate anus repaired with laparoscopically assisted anorectoplasty

“…One of the factors affecting the presentation of resting rectal pressure in patients with repaired imperforate anus is the severity of perirectal scarring caused by rectal dissection for pull-through procedures [1]. Consistent with the observation that LAR patients had an earlier appearance and a higher incidence of RARs, we postulate that the higher resting rectal pressure in PSARP patients may indicate the presence of more severe surgical damage to their pelvic or perirectal tissues.…”

“…The reflex also appeared earlier in LAR than in PSARP patients (Table 2). In a report of a post-PSARP anorectal continence study, it was suggested that the extent of intrapelvic dissection in PSARP may affect the anorectal continence more significantly than the mere preservation of the terminal bowel or the sphincter muscles [1]. The detrimental effect of pelvic dissection on anorectal function also has been well documented in both humans and experimental animals [10,15].…”

“…However, long-term continence after PSARP is less than ideal [1,6,8]. For example, only about 25% of boys with a rectoprostatic fistula have normal continence, and significant soiling occurred in more than half of this patient population [6].…”

Posterior sagittal anorectoplasty in anorectal anomalies: clinical, manometric and profilometric evaluation

“…On the other hand, patients with large rectal volumes, abnormal pressure curves of high intensity and large amplitudes, led us to a diagnosis of hypertonic sphincter, with fecal retention and fecal escapes at inappropriate moments, thus characterizing a condition of pseudo-incontinence. [37][38][39][40] Posterior sagittal anorectoplasty has been shown to be an excellent technique for treating anorectal anomalies, and good results without greatly compromised neuromuscular structures have been achieved. Nonetheless, many patients may continue to present functional problems following surgery, reflected through varying degrees of fecal escape and constipation.…”

Laparoscopic Assisted Anorectoplasty: A New Definitive Repair of High Imperforate Anus

“…Chronic constipation occurred with a rate of 55.5% in cases of bulbar fistulae but in the higher anorectal malformations with prostatic or bladder neck fistulae the rate was 41.4% and 18.2% respectively. In a study by Chen et al (21) , constipation was noted shortly after anorectoplasty in 18 of 25 (72%) high and intermediate anomalies treated with PSARP, but in none of 5 high and intermediate anomalies treated with Rehbein's mucosa-stripping endorectal pull-through. It was concluded that anorectal function in patients with repaired imperforate anus seems to be more affected by the extent of endo-pelvic dissection.…”