Magnetic Resonance Evaluation of Anorectal Malformation Cases Treated by Posterior Sagittal Anorectoplasty

Abstract

OBJECTIVES:Pelvic MRI is a useful tool for assessing patients with anorectal malformations before and after operation. The images obtained after PSARP can be reviewed for quality and shape of the sphincter muscle, position of the rectum, shape of the sacrum, and associated pelvic abnormalities related to the initial operation. These were then correlated with the clinical status of the patient during follow-up after colostomy closure. MATERIALS AND METHODS: Twenty six male patients with intermediate or high anorectal malformation were included in the study between January 2012 to December 2013. The findings thus obtained in the MRI were correlated clinically with the Kelley's scoring system. RESULTS: A total of 26 post-PSARP patients were included in the study. Eighteen of them were also selected for clinical correlation after colostomy closure. According to MRI findings, 2 patients had good degree of development of the pelvic floor muscles, 11 of them had fair amount of muscles and the rest 13 of them had significantly thinned out muscles. Four patients showed well-developed external sphincter muscle, 15 of them were having fair degree of development and in the rest 7 of them it was poorly-developed. Our study also showed that only 3 patients were showing symmetrical development of the sphincter complex whereas in the rest 23 of them it was asymmetrical. Eighteen patients had centrally-placed pulled-through rectum, whereas in the rest 8 of them the colon was located away from the center of the sphincter complex. Sixteen patients had mesenteric fat inadvertently pulled along with the bowel during PSARP; and in this same study, 58% of our patients were also having associated anomalies detected by MRI. On clinical correlation, it was found that external sphincter muscle and fat interposition play an important role in the overall clinical status of the patients after colostomy closure. CONCLUSION: Pelvic MRI is a useful tool for assessment of anorectal malformation after PSARP. Our study shows that development of the external sphincter muscle and the presence of mesenteric fat interposition has significant impact on the overall clinical status of the patient; however, other factors like operative technique and muscle innervations may also play important role in the overall continence of the patients.

Pelvic Floor Muscles Contribution in Surgical Outcome of Children with High-type Anorectal Malformations

“…PSARP also underlined the role of the muscle complex as a functional prominent structure (Zaiem and Zaiem, 2017;Patel et al, 2018). Therefore, adequate placement of the neorectum not only through the puborectalis sling but also within the EAS is necessary for an adequate functional outcome (Bhuynan et al, 2015). In an attempt to give the muscle complex its due respect by keeping it intact and restored around the new pulled rectum, sphincter saving anorectoplasty (SSARP) and muscle complex saving posterior sagittal anorectoplasty (MCS-PSARP), have been described (Bhuynan et al, 2015).…”

“…The later introduced laparoscopically assisted anorectal pull-through (LAARP) technique for the high-type ARMs, aiming to reduce the amount of posterior dissection of the sphincter mechanism required for the accurate placement of the neorectum into the muscle complex under laparoscopic vision (Georgeson et al, 2000). The avoidance of division of the vertical muscle complex owed to the longitudinal cutting of the sphincter muscle complex with the PSARP technique, resulted in the minor disturbance of the muscle innervations (Bhuynan et al, 2015). The laparoscopic approach resulted in better sphincter symmetry, and lesser irregularity and perirectal fibrosis compared to PSARP (Bhatnagar, 2015c).…”

“…Except the musculature developmental status, appropriate placement of the rectal pull-through within the levator muscle, which is the most important factor of continence, and the EAS, is critical for optimal postoperative bowel continence (Bhatnagar, 2015b;Bhuynan et al, 2015). MRI is the optimal method for the evaluation of postoperative fecal incontinence, the study of complications, and the design of management in cases of consideration of potential reoperation (Podberesky et al, 2013;Bhatnagar, 2015c;Madhusmita et al, 2018).…”