Posterior Sagittal Anorectoplasty in Anorectal Malformations

14 Nishtar Medical Journal • Vol 1, No 1•January – March 2009

ORIGINAL ARTICLE

POSTERIOR SAGITTAL ANORECTOPLASTY IN ANORECTAL MALFORMATIONS

Aamir Hanif Khan, Mukhtar Hussain, Iram Uzma Khalid*, Haroon Khurshid Pasha

INTRODUCTION:

The malformations of anorectum are among the

commonest congenital anomalies1. The

description of this condition has come a long

way since the time of Soranus, while Paulus

Aegineta wrote the earliest surviving account of

surgery for imperforate anus2. Through ages

various surgeons have tried to restore these

patients to normality both anatomically and

physiologically3. Anatomical correction being

relatively easy to obtain, the main challenge

facing the surgeon today is to achieve

continence.

Most of low varieties are corrected surgically in

single stage at birth. Colostomy is performed in

cases of intermediate and high varieties,

followed by anorectoplasty at a later age and

then colostomy closure.

In 1982, Pena and deVries gave description of

posterior sagittal anorectoplasty4, which is a

landmark in surgery of Anorectal malformations.

This procedure is now time-tested but not free of

complication. Apart from different early and late

complications, continence is the major issue

related to the PSARP. There are various methods

of assessment of degree of continence after

PSARP5. Some of methods like McGill

5,

Kieswetter and Wingspread6 are used for

qualitative assessment and others like Tempelton

& Diteshiem7 and Kelly’s

5 are used for

quantitative assessment.

Department of Pediatric Surgery, Nishtar Medical College & Hospital, Multan. *Department of Paediatric Surgery Children Hospital Complex, Multan Correspondence: Dr. Muhammad Amir Hanif Khan Senior Registrar, Department of Pediatric Surgery

ABSTRACT OBJECTIVES: To assess the fecal continence after posterior sagittal anorectoplasty (PSARP) in patients of high variety of anorectal malformation and to describe complications of PSARP. DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: The study was conducted in the Department of Paediatric Surgery of Nishtar Medical College and Hospital, Multan. The duration of study was three years from 1

st May 2005 to 31

st

December 2007. PATIENTS AND METHODS: 30 patients of high variety anorectal malformation with sigmoid colostomy were inducted. The ages were 6 months or above. They were without any other gross anomaly. PSARP was performed according to Pena & deVries modification and the results were evaluated after colostomy closure. Kelly’s method was applied for assessment of grade of continence after 3 months, 6 months and one year of colostomy closure. Early and late complications of PSARP were also noted. RESULTS: Early complications were perianal excoriation (33.3%) bleeding (3.3%), retraction (6.7%) and wound infection (10%). Stenosis (16.7%) and mucosal ectropion (6.7%) were two major late complications. Grade of continence was good in 23.3% patients, fair in 46.6% and poor in 30.0% patients after 3 months of colostomy reversal. After one year the grade was good in 26.7%, fair in 53.3% and poor in 20.0% patients. CONCLUSION: Pena and deVries PSARP is a good procedure for high variety of anorectal malformations. It gives good results with minimal complications. Initial poor results should not discourage the surgeon as the condition of patient and grade of continence keeps on improving as child grows. KEY WORDS: Anorecal malformation, posterior sagittal anorectoplasty, Kelly’s method.

NMJ 2009; 1(1): 14-18 POSTERIOR SAGITTAL ANORECTOPLASTY IN ANORECTAL MALFORMATIONS

Nishtar Medical Journal • Vol 1, No 1•January – March 2009 15

A descriptive study was conducted to know the

different complications and results of PSARP in

a developing country using the Kelly’s method.

Table I: Kelly’s method of fecal continence assessment (n=30)

A Staining Score

No staining, always clean 2

Occasional staining 1

Always stained 0

B Occurrence of accidental defecation Score

None 2

Occasional accidents, feces/flatus escape

1

Constant 0

C Strength of sphincter squeeze on digital examination

Score

Strong and effective squeeze 2

Weak and partial squeeze 1

No contraction 0

D Total score (Range) 0-6 points

Good 5-6 points

Fair 3-4 points

Poor 2 points or less

PATENTS AND METHODS:

The study was carried out in the department of

Paediatric Surgery. Nishtar Hospital, Multan,

over a period of three years from 1st January,

2005 to 31st December, 2007. The patients of

high variety Anorectal malformation with

sigmoid colostomy performe at neonatal age

were inducted in the study. All patients were

admitted from out patient department. History

and examination were performed keeping in

mind the possibilities of associated urogenital,

skeletal, cardiac and respiratory anomalies.

Lumbosacral spine and chest tomograms were

taken to rule out any vertebral or cardiac

anomalies. Distal colostogram lateral view was

obtained to identify the fistula with urinary tract

and also to assess the length of blind rectal

pouch. Abdominal USG and IVU were used to

rule out abnormalities of urinary tract.

Echocardiography was performed in clinically

suspected cases of cardiac anomalies. Complete

blood count and urine analysis were done for

preparation of general anesthesia and to rule out

any acute infection.

Posterior sagittal anorectoplasty was performed

according to Pena and deVries8 by one of the

consultants pediatric surgeons. Urethral catheter

was kept for ten days. Anal dilatation was started

two weeks after the procedure, with easily

passing Hager dilator at that time. Initially it was

done daily and the size of dilator was increased

up to twelve for patient below one year of age

and fourteen for patients above one year of age.

Colostomy was closed after about three months

of PSARP.

Patients were called for follow up initially

fortnightly for three months and then monthly

for one year. Grading of continence was done

following the Kelly’s method.

RESULTS:

Thirty cases were included in study. There were

22(73.3%) male patients and 8(26.7%) female

patients. Maximum number of patients

14(46.7%) were between 7-10 months of age,

followed by 8(26.7%) patients of 11-15 months.

6 (20%) were between 15-24 months and

2(6.6%) were of 24-30 months.

Among the early complication perianal

excoriation seen in 10(33.3%) patients, wound

infection in 3(10%), Retraction in 2(6.7%) and

bleeding in 1(3.4%). Anal stenosis (5 patients,

16.7%) and Mucosal ectropion (2 patients, 6.7%)

were two major late complications. Table II: Staining (n=30)

On grading of continence, according to Kelly’s

method, the first component is staining. There

was no staining in 7(23.3%) patients after 3

months, in 8(26.6%) patients after six months

and in 10(33.3%) patients after one year (Table-

II). Second component of Kelly’s method is

S/N Score After 3 months

After 6 months

After 12months

1 No 2.0

7(23.3%) 8(26.6%) 10(33.3%)

2 Occasional 1.0

17(56.7%) 16(53.3%) 16(53.3%)

3 Always 0.0

6(20.0%) 6(20.0%) 4(13.4%)

Total 30(100%) 30(100%) 30(100%)



accidental defecation. Constant accidental

defecation was seen in 4 patients (13.3%) after 3

months. This figure remained same even after

one year (Table-III). Third component is

Strength of sphincter squeeze on P/R

examination. It was weak in 16 (53.3%) patients

after three months. This figure rose to 18(60.0%)

after one year (Table-IV). Combining all, grade

of continence was good in 7(23.3%) patients

after three months and in 8(26.7%) patients after

one year. Table III: Accidental Defecation (n=30)


After 6 months

After 12 months

1 None (2.0) 8(26.7%) 9(30.0%) 10(33.3%)

2 Occasional (1.0) 18(60.0%) 17(56.7%) 16(53.3%)

3 Constant (0.0) 4(13.3%) 4(13.3%) 4(13.4%)

Total 30(100%) 30(100%) 30(100%)

DISCUSSION:

Anorectal malformation is a common congenital

anomaly with an average incidence of around 1

per 5000 live births2. It is more common in male

population12

. In our study there were 22(73.3%)

male patients and 8 (26%) were female patients.

This figure is very close to 65% given in a series

by Pena2. The maximum number of patients (14

patients, 46.7%) in our study undergoing PSARP

were between 7-10 months of age, while

minimum (2 patients, 6.6%) were above 2 years

of age. The older age in our children is because

of poor nutrition and poor follow up.

PSARP was described by Pena and deVries in

19824. Since then it has become a procedure of

choice for management of high and intermediate

varieties as it is an easy, convenient and a

promising technique. Originally it was started as

a 2nd

stage procedure in management of high and

intermediate cases of ARM but now a growing

number of authors are advocating for single

stage PSARP at neonatal age as Adeniran did in

his study9, 10

. Even now Pena advocates that 3

months of age is more appropriate for PSARP11

.

There are also trials to do PSARP with the help

of Laprocsope12

.

Among the early complications, perianal

excoriation was most frequent, seen in 10

patients (33.3%). Bleeding was encountered in 1

(3.3%), retraction of rectal loop in 2 (6.7%) and

wound infection in 3 (10.0%) patients. This

percentage is higher than 0.45% given by Pena

in a series2. Nakayama also described wound

dehiscence or infection as a major

complication13

. Although we did not encounter

but Nakayama also described retraction as

another major complication. In his point of view

retraction occurred as a consequence of

inadequate length of neo-rectum or poor blood

supply. Among the late complications, stenosis

of anal canal occurred in 5 (16.7%) patients.

Mucosal ectropion found in 2 (6.7%) patients.

No urinary fistula was persistent after repair.

Nixon reported anal stenosis in 30 % patients of

his series14

. He also described mucosal prolapse

in 23% of his operated cases.

There are various methods of assessment of

degree of continence and results of PSARP4.

McGill, Kiesswetter5, Kelly and some others

described methods of quantitative and qualitative

assessment. In this study we have applied

Kelly’s criteria for assessment of continence. It

is by far the simplest of all scoring systems and

the easiest to apply even in the office settings4.

The results were judged on the basis of staining,

accidental defecation and strength of sphincter

squeeze on per rectal examination. Table IV: Strength of Sphincter Squeeze Onper Rectal Examination

(n=30)


After 6 months

After 12 months

1 Strong Squeeze 2.0 6(20.0%) 7(23.3%) 7(23.3%)

2 Weak squeeze 1.0 16(53.3%) 16(53.3%) 18(60.0%)

3 No contraction 0.0 8(26.7%) 7(23.4%) 5(16.7%)

Total 30(100%) 30(100%) 30(100%)


Nishtar Medical Journal • Vol 1, No 1•January – March 2009 17

In this study we have compiled results on the

basis of observations and examination made

after 3, 6 and 12 months of colostomy closure.

At the end of one year almost half of the patients

were around 3 years of age which is appropriate

age for assessment of continence level. Staining

was occasional in 16(53.3%) patients after one

year. This figure is almost equal to that of Pena2,

who found soiling in 57% of his patients.

Similarly Nixon mentioned 40% of patients with

occasional soiling14

. All these results are quite

different from Rintala15

, who showed occasional

staining in 14% of his patients. There was

occasional accidental defecation in 16(53.3%)

patients after one year. Although Chen16

reported only 3% of his cases with accidental

defecation, while Nixon reported 20% of cases

with same problem14

. Rintala gave a figure of

22% for the patients having accidental

defecation15

.

The sphincter squeeze was assessed on per rectal

examination after three months, six months and

one year. Strong squeeze was seen in 23.3% of

our cases which is quite low than that of Kubota,

who showed good squeeze in 55% of patients

undergoing PSARP17

. Yuan also concluded that

45% of his patients had strong squeeze of

puborectalis after PSARP18

. Low percentage of

sphincter squeeze in our study is probably due to

poor muscle complex as all cases of our series

were of high variety. Table V: Grade Of Continence (n=30)

S/N Grade After 3 months

After 6 months

After 12 months

1 Good 5-6 7(23.3%) 8(26.7%) 8(26.7%)

2 Fair 3-4 14(46.6%) 15(50.0%) 16(53.3%)

3 Poor <3 9(30.0%) 7(23.3%) 6(20.0%)

total 30(100%) 30(100%) 30(100%)

Normal level of continence, which includes the

differentiation between flatus and faeces is very

difficult to achieve in high variety of anorectal

malformation19

. As normally developed anus has

normal level of proprioception, which is

essential for this sense of differentiation, so it

does not remain intact in cases of high variety of

ARM20

. In our study 10 (33.3%) patients showed

good results after one year. Nixon mentioned

good results in 40% of patients14

, while Tsuji

showed good results in 48% of patients. After

one year 53.3% patients were fairly continent in

our study. This is almost equal to 48% of Tsuji21

but very low than a figure of 97% reported by

Chen16

. In our series 5 patients (16.7%) were

poorly continent after one year. This is slightly

higher than Tsuji21

and Liem22

. Both of their

series showed only 4% of patients with poor

results. But our result is same to that of Nixon14

who mentioned poor results in 20% of his

patients. During study it was noted that grade of

continence kept on improving as the child grew

up i.e. after one year the patients were more

continent than they were after three months.

Rintala also observed the same point23

.

CONCLUSION:

1. To achieve good results and avoid

complications, Pena and de Vries PSARP is

a good procedure for high variety of

Anorectal malformation.

2. Initial poor results should not discourage the

surgeon as the condition of patients and

grade of continence keep on improving as

child grows.

REFERENCES: 1. Pena A, Marc AL. Imperforate Anus and Cloacal

malformation. In: Aschcraft KW, Holcomb GW, Murphy JP (edi). Text Book of Paediatric Surgery. Philadelphia. Elsevier; 2005:496-517.

2. Pena A, Marc AL. Anorectal malformation. In: Grofeld JL, O’Neil JA, Coran AG, Fonkalsurd EW (edi). Paediatric Surgery. Philadelphia. Mosby; 2006:1566-89.

3. Holschneider AM, Jesch NK, Stragholz E, Pfrommer W. Surgical Methods for anorectal malformations from Rehbein to Pena – critical assessment of score system and proposal of a new classification. Eur J Pediatr Surg 2002; 12:73-82.



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6. Langemeijer RA, Molenaar JC. Continence after posterior sagittal anorectoplasty. J Pediatr Surg 1991; 26(5):587-90.

7. Templeton JM, Ditesheim JA. High imperforate anus: Quantitative result of long term fecal continence. J Pediatr Surg 1985; 20:645-52.

8. Pena A. Anorectal malformation. In: Ziegler MM, Azizkhan RG, Weber TR (edi). Operative paediatric surgery. New York. McGraw-Hill; 2003:739-62.

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14. Nixon HH, Puri P. The results of anorectal anomalies: A thirteen to twenty years follow up. J Pediatr Surg 1998; 96:505-9.

15. Rintala R, Lindahl H, Louhi I. Anorectal malformation. Result of treatment and long term follow up in 208 patients. Pediatr Surg Int 1991; 6:36-9.

16. Chen CJ. The treatment of imperforate anus: experience with 108 patients. J Pediatr Surg 1999; 34(11):1728-32.

17. Kubota M, Suita S. Assessment of sphincter muscle function before and after PSARP using a magnetic spiral stimulator technique. J Pediatr Surg 2002; 37(4):617-22.

18. Yuan Z, Bai Y, Zhang Z, Ji S, Li Z, Wang W. Newer electrophysiological studies on the external anal sphincter in children with anorectal malformation. J Pediatr Surg 2000; 35(7): 1057-7.

19. Rintala RJ, Lindahl H. Is normal bowel function possible after repair of intermediate & high anorectal malformations? J Pediatr Surg. 1995; 30(3):491-4.

20. Meierragge WA, Holschneider AM. Histopathological observation of Anorectal malformation in anal atresia. Pediatr Surg Int 2000; 16(1-2):2-7.

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Posterior Sagittal Anorectoplasty in Anorectal Malformations

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