Posterior Sagittal Anorectoplasty Group Research Articles

Current practice of diagnosis and treatment for rectourethral fistula in male patients with anorectal malformation: a multicenter questionnaire survey in Japan

PurposeSurgical procedures for anorectoplasty for anorectal malformations (ARMs), particularly rectourethral fistula (RUF), depend on the institution. We investigated the diagnosis and treatment of RUF in male patients with ARMs in Japan using a questionnaire survey.MethodsAn online survey inquiring about the diagnosis and treatment (diagnostic modalities, surgical approaches, fistula dissection devices, and fistula closure techniques) of each type of ARM in male patients was conducted among institutional members of the Japanese Study Group of Anorectal Anomalies. Fisher’s exact test was used to compare surgical methods between posterior sagittal anorectoplasty (PSARP) and laparoscopy-assisted anorectoplasty (LAARP).ResultsSixty-one institutions (100%) completed the survey. LAARP was the preferred approach for high-type ARM (75.4%). PSARP was preferred for intermediate-type ARM (59.0%). Monopolar devices were most commonly used (72.1%) for RUF dissection. Blunt dissection was more frequent in the PSARP group (PSARP vs. LAARP: 55.6 vs. 20.0%, p < 0.005). Cystoscopy/urethroscopy to confirm the extent of dissection was used more frequently in the LAARP group (70.0% vs. 25.0%, p < 0.005). Clips and staplers were used more frequently in the LAARP group (p < 0.05).ConclusionDistinct fistula management strategies for PSARP and LAARP were revealed. Further studies are needed to investigate the postoperative outcomes associated with these practices.

Comparison of postoperative urinary complications in laparoscopic-assisted anorectoplasty versus posterior sagittal anorectoplasty for anorectal malformation with rectourethral fistula.

Long-term urinary outcomes after anorectal malformation (ARM) repair are affected by surgical approach and sacral anomalies. This study aimed to compare laparoscopic-assisted anorectoplasty (LAARP) and posterior sagittal anorectoplasty (PSARP) in terms of urinary complications. Between 2001 and 2022, 45 patients were treated with LAARP or PSARP. The rectourethral fistula and inflow angle between the fistula and rectum was confirmed by preoperative colonography. The incidence of urinary complications and treatment were compared between the two groups. Four patients (14%) had remnant fistula and five patients (17%) had neurogenic bladder dysfunction in LAARP group, while three patients (18%) had urethral injury in PSARP group. All patients with remnant fistula were asymptomatic and followed without treatment. The incidence of remnant fistula improved between earlier decade and later decade. In all cases with urethral injury, suture repair was performed and no postoperative leakage was noted. All five patients with neurogenic bladder dysfunction had spine abnormalities that required clean intermittent catheterization (CIC) and two were free from CIC finally. It is important to check inflow angle preoperatively to prevent remnant fistula. For PSARP, meticulous dissection is required when separating fistula from urethra because they create common wall. The most contributing factor to neurogenic bladder is sacral anomalies. Preoperative evaluation and postoperative urinary drainage are important.

Analysis of postoperative complications in children treated for moderate to severe anal atresia with laparoscopic versus open surgery: A retrospective study

This study aimed to compare and analyze the postoperative complications and anal function after 3-stage laparoscopic-assisted anorectoplasty (LAARP) and conventional posterior sagittal anorectoplasty (PSARP) in the treatment of moderate to severe anal atresia in children. A total of 27 children with moderate to severe anal atresia who underwent conventional PSARP at the Dongguan Children Hospital between 2007 and 2011 were included in the control group, and 34 children with moderate to severe anal atresia who underwent 3-stage LAARP between 2012 and 2016 were included in the observation group. The incidence of postoperative complications and Kelly score of anal function in the 2 groups were statistically analyzed and the efficacy of the 2 procedures compared. The incidence of postoperative complications such as wound infection, anal stenosis, anastomotic leakage, fecal incontinence, and constipation in the LAARP group was lower as compared with the PSARP group, and there was a statistically significant difference (P &lt; .05). There was no significant difference in the incidence of postoperative complications such as rectal prolapse, diarrhea, and recurrent fistula between the LAARP group and the PSARP group (P &gt; .05). The Kelly score of anal function was higher in the LAARP group than in the PSARP group, and the difference was statistically significant (P &lt; .05). Compared to conventional PSARP, laparoscopic surgery for moderate to severe anal atresia in children has less complications, improved anal function, and a clear therapeutic impact.

Laparoscopic-assisted anorectoplasty for anorectal malformation with rectobulbar fistula: A two-center comparative study with posterior sagittal anorectoplasty.

Due to the controversy on the feasibility of laparoscopic-assisted anorectoplasty (LAARP) for the treatment of the anorectal malformation (ARM) with rectobulbar fistula (RBF), this study aimed to compare the outcomes of LAARP and posterior sagittal anorectoplasty (PSARP) for ARM with RBF. Demographic data, postoperative complications, and bowel function of RBF patients who underwent LAARP and PSARP at 2 medical centers from 2016-2018 were retrospectively reviewed. Eighty-eight children with RBF were enrolled, including 43 in the LAARP group and 45 in the PSARP group. There were no significant differences in the sacral ratio (P = .222) or sacral agenesis (P = .374). Thirty-seven and 38 patients in the LAARP and PSARP groups were followed up for a median of 4.14 years. The postoperative complications were comparable between the groups (P = .624), with no cases of urethral diverticulum. The urination of all cases was normal and no evidence of cyst formation was found on MCU or MRI during the follow-up period. The incidence of rectal prolapse was similar between the 2 groups (9.3% vs 17.8%, P = .247). The groups had equivalent Bowel Function Score (15.29 ± 2.36 vs 15.58 ± 2.88, P = .645), but the LAARP group had better voluntary bowel movement (94.6% vs 84.2%, P = .148) by Krickenbeck classification. The intermediate-term outcomes of LAARP show that the urethral diverticulum was rare by the intraluminal incision of the fistular and the bowel function was comparable to that of PSARP in ARM with rectobulbar fistula. However, LAARP was associated with smaller perineal wounds.

Comparison of clinical outcome and anal manometry following laparoscopic-assisted anorectoplasty and posterior sagittal anorectoplasty in patients with high and intermediate anorectal malformation: A randomised controlled trial.

Introduction:High and intermediate types of anorectal malformations (ARMs) may be managed by either open posterior sagittal anorectoplasty (PSARP) or by laparoscopic-assisted anorectoplasty (LAARP). Most of the literature favours one approach over the other based on retrospective analysis. We performed this study with the aim to compare the short-term outcomes of both procedures.Materials and Methods:All paediatric patients with high and intermediate ARM were enrolled and randomised into two groups: open PSARP group and LAARP group. Outcome parameters such as faecal continence using Kelly's scoring system, anal manometric parameters and post-operative complications were compared between the groups.Results:A total of 16 patients were included with equal distribution in the open PSARP and LAARP group. Patient's variables were comparable in both the groups. Five patients developed immediate post-operative complications, three in the LAARP and two in the open group. The mean Kelly's score was 3.63 ± 1.6 versus 2.57 ± 1.9 (P = 0.132) for LAARP and PSARP group, respectively. The mean resting pressure was 34.71 ± 6.26 cm of H2O and 35 ± 6.16 cm of H2O (P = 0.384) in LAARP and open group, respectively. Rectoanal inhibitory reflex was demonstrated in 6/7 patients in LAARP group and 5/7 patients in open group.Conclusion:Faecal continence in patients undergoing either of the procedure is comparable. However, wound-related complications are lesser in LAARP procedure.

Anorectal malformations and the impact of HIV on surgical outcome.

Anorectal malformations (ARMs) represent a significant surgical load in South African (SA) paediatric surgical centres. Surgical treatment of ARMs may be associated with postoperative complications owing to the nature of surgical procedures necessary in the neonatal and infant period. HIV and its effect on the immune response compound postoperative surgical complications. The impact of HIV exposure and its effect on the child's immune status, independent of the child's HIV status, has yet to be studied in the surgical population. To assess the incidence of complications in our population of ARM patients and to explore whether these were increased in HIV-exposed but serologically negative children compared with HIV-unexposed children. This was a prospective study of all patients presenting with ARMs to the paediatric surgery units attached to the University of the Witwatersrand, Johannesburg, SA. Specifically, exposure to an HIV-positive mother, patient HIV status and presence of surgical complications were documented. Data were analysed for the period August 2016 - September 2017. A total of 50 children were included (none were excluded); 19 (38%) were HIV-exposed but none were HIV-positive, and 28 (56%) were male and 22 (44%) female. Seventy-six operative procedures were performed, with 27 operative complications. In the HIV-exposed group, 68% of patients experienced operative complications, compared with 45% in the unexposed group (p=0.1); 50% of the HIV-exposed patients who had stoma formation experienced complications, compared with 20% in the unexposed group (p=0.08). The incidence of postoperative infectious complications in HIV-exposed patients was higher than in HIV-unexposed patients. The incidence of postoperative complications in HIV-unexposed patients parallels that in the international literature, except in the posterior sagittal anorectoplasty groups. It remains critically important to follow stringent perioperative protocols for infection prevention and aggressively treat any infection that arises, particularly in patients born to HIV-positive mothers, regardless of the patient's HIV status.

Assessing the long term manometric outcomes in patients with previous laparoscopic anorectoplasty (LARP) and posterior sagittal anorectoplasty (PSARP)

Background/purposeThe objective of this study is to compare the long term manometric outcomes in patients with previous laparoscopic anorectoplasty (LARP) and posterior sagittal anorectoplasty (PSARP). MethodsThis is a single-centered retrospective study and the participants were born with various types of anorectal malformation. Manometric assessment was carried out with high-resolution anorectomanometry performed as a day procedure. In addition, a seven-itemed bowel function score (BFS) was utilized to assess the functional outcomes. ResultsA total of 30 patients were included in this study (PSARP=14, LARP=16) and the median follow up periods were 15.5years and 9years in the PSARP and LARP groups respectively (p=0.06). The median value of BFS was significantly lower in the PSARP group (PSARP=12.5, range: 8–18; LARP=16, range: 10–20, p=0.03). The median value of sphincteric resting pressure was 20mmHg (range: 10–50mmHg) in the PSARP group and 40mmHg (range: 10–70mmHg) in the LARP group (p=0.05). There was no significant difference in following measurements: the percentage of patient having a normal sphincteric resting pressure (PSARP vs LARP=50% vs 75%, p=0.28); the median sphincteric squeeze pressure (PSARP vs LARP=30mmHg, range: 10–100 vs 50mmHg, range: 20–140mmHg, p=0.08); the incidence of rectoanal inhibitory reflex (RAIR) (PSARP vs LARP=42.9% vs 31.3%, p=0.14) and the median value for volume of air to elicit the first anal sensation (PSARP vs LARP=30ml, range: 20–60ml vs 40ml, range: 20–80ml, p=0.18). ConclusionAnorectomanometry is a useful follow up study after anorectoplasty and majority of the patients with previous LARP could retain a normal sphincteric resting pressure during long term follow up. Comparing the two surgical approaches, patients with previous LARP could achieve a higher bowel function score as well as sphincter resting pressure in manometric assessment. Level of evidenceLevel III.

Comparison of clinical outcomes in patients with congenital anorectal malformation treated with posterior sagittal anorectoplasty and laparoscopically assisted anorectal pull through

Aim: To compare the complications and outcomes of laparoscopic-assisted anorectoplasty (LAARP) for anorectal malformation (ARM) with that of posterior sagittal anorectoplasty (PSARP) using Kelly’s score. Materials and Methods: This was a single-center study conducted over a period of 4-year. A total of 95 male ARM patients were included in the study, of which 25 patients underwent LAARP, whereas 70 patients underwent PSARP. Result: Superficial wound infection was seen in 2 (2.85%) cases of the PSARP group while in 1 (4%) case in LAARP group. 12 (17.14%) cases of PSARP group had wound dehiscence at the neo-anal site, of which 6 (8.57%) had complete wound dehiscence and the remaining 6 (8.57%) had partial dehiscence, whereas 4 (16%) cases had wounddehiscence in LAARP group of which 3 (12%) had partial and 1 (4%) had complete dehiscence. Retraction of the neo-anus was seen in 6 (8.57%) cases of PSARP group while in 2 (8%) cases of LAARP group. Ectopically placed neo-anus was seen in 3 (4.28%) patients of PSARP group while in none of the cases in LAARP group. None of the patients in LAARP group had anal stenosis, whereas 2 (2.85%) patients underwent redoanoplasty in PSARP group for anal stenosis. Mucosal prolapse was seen in 8 (11.42%) cases of PSARP group, as compared to 3 (12%) patients of LAARP group. The net average Kelly’s score in LAARP group was 4.56, whereas, in PSARP group, it was 4.10. Conclusion: This study emphasizes the emerging laparoscopic technique for the managementof ARMs. Using this approach, it is possible to achieve better continence rates as the extent of perineal dissection is minimal.

Evaluation of postoperative anal functions using endoanal ultrasonography and anorectal manometry in children with congenital anorectal malformations

PurposeThe aim of this study was to assess the postoperative anorectal anatomy and function in children with congenital anorectal malformations (ARM) using endoanal ultrasonography (EUS) and anorectal manometry. MethodsThis study included 47 children who had undergone posterior sagittal anorectoplasty (PSARP) or transperineal anorectoplasty for the repair of an ARM. Children were grouped according to symptoms of defecation disorder, including normal defecation, fecal soiling, fecal incontinence, and constipation. Ten children with no history of anal or rectal diseases served as healthy controls. A well-established scoring system was used for the evaluation of anal function and defecation disorder. ResultsEUS showed significant differences in the thickness of the interior sphincter between the ARM patients and the healthy controls (P<0.05). However, no significant difference was found in the thickness of the interior sphincters between the PSARP group and transperineal anorectoplasty group (P>0.05). Anorectal manometry showed that the balloon volumes were significantly different between the surgical group and the control group (P<0.01), and between the low defect group and the intermediate-high defect group (P=0.022). Balloon volume was significantly correlated with anal function scores (r=−0.30, P<0.05). ConclusionsEUS and anorectal manometry can provide objective assessment of postoperative anorectal anatomy and function in children with ARM.

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

Background/purposeThe 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. MethodsTwenty-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. ResultsThe 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). ConclusionsPSARP results in superior bowel function and better quality of life in adulthood compared with AP procedures for the repair of anorectal malformations

Long term outcomes of laparoscopic-assisted anorectoplasty: A comparison study with posterior sagittal anorectoplasty

PurposeThe aim of this study is to compare the long term outcomes between laparoscopic-assisted anorectoplasty (LAARP) and posterior sagittal anorectoplasty (PSARP) for children with rectobladderneck and rectoprostatic fistula anorectal malformations (ARM). MethodsThirty-two ARM children with rectobladderneck and rectoprostatic fistula who underwent LAARP between October 2001 and March 2012 were reviewed. The outcomes were compared with those of 34 ARM children who underwent PSARP between August 1992 and September 2001. The sacral ratio (SR), age at operation, operative time, postoperative hospital stay and complications were evaluated. Bowel functions were assessed using the Krickenbeck classification. ResultsThe mean operative time of the LAARP was significantly shorter than that of PSARP group (1.62±0.40 vs 2.13±0.30h). The postoperative hospital stay was significantly shorter in the LAARP group (5.8±0.65 vs 8.4±0.67h). The wound infections (11.8% vs 0%) and recurrent fistula (11.8% vs 0%) were more common in PSARP patients. The overall morbidity rate of PSARP group was significantly higher than that of the LAARP group (35.3% vs 12.5%, p<0.05). However, 7.5% of the LAARP patients developed rectal prolapse. Twenty-four of 32 patients were followed up for more than 3years in LAARP group. The median follow up period was 7.5years (range 4–11) in LAARP patients and 15.5years (range 11–20) in PSARP patients. The rates of voluntary bowel movement, soiling (grade 1, 2 & 3) were similar in both groups. More patients from PSARP group developed grade 2 or 3 constipation (22.5% vs 0%, P<0.01). ConclusionsCompared to PSARP, LAARP is a less invasive procedure. The long term functional outcomes after LAARP were equivalent if not better than those of PSARP.

Anterior sagittal anorectoplasty: An alternative to posterior approach in management of congenital vestibular fistula

Better exposure, possibility of extension if needed and precise placement of the anal canal within the external sphincter complex have made the posterior and anterior sagittal approaches more popular and established for the correction of anovestibular fistula. The mini posterior sagittal anorectoplasty (PSARP) was the procedure of choice for female ARM at our center till date. As an alternative surgical option, we performed anterior sagittal anorectoplasty (ASARP) in 15 cases of anovestibular fistula and compared them with 12 cases of vestibular fistula operated by PSARP technique. Fifteen female infants with vestibular fistula who had anterior sagittal anorectoplasty (ASARP) procedure were reviewed. The procedure and its outcome were evaluated. The manoeuvering during anesthesia and operative access were quite easier in ASARP compared to PSARP. Delineation of plane in ASARP between rectum and vagina was easier and clearer in comparison to PSARP. Rent occurred in the posterior vaginal wall in three cases of ASARP and two cases of PSARP. There were two cases of wound infection in each group. Three cases of PSARP group developed anal stenosis and constipation while one in the ASARP group developed constipation. Anesthesia and access in ASARP makes it an easier alternative option to PSARP in the management of anovestibular fistula in girls.

Comparison of clinical outcomes and anorectal manometry in patients with congenital anorectal malformations treated with posterior sagittal anorectoplasty and laparoscopically assisted anorectal pull through

Purpose The objective of this study is to analyze the clinical outcomes and anorectal manometry (AM) in infants with congenital high anorectal malformations treated with posterior sagittal anorectoplasty (PSARP) and laparoscopically assisted anorectal pull through (LAARP). Materials and Methods From August 2005 to December 2008, 23 patients with congenital high anorectal malformations were randomly distributed into PSARP and LAARP groups. All of them underwent LAARP (11 cases) or PSARP (12 cases) at 2 or 3 months old. Clinical outcomes and results of anorectal manometry were compared between patients at the age of 17.4 ± 4.9 and 19.3 ± 6.2 months ( P = .4270), respectively. Results Kelly's clinical score for patients in LAARP and PSARP groups was 3.91 ± 1.14 and 3.83 ± 1.40 ( P = .8827), respectively. Anal canal resting pressure and high-pressure zone length were 29.4 ± 7.2 vs 23.4 ± 6.5 mm Hg ( P = .0479) and 14.9 ± 3.0 vs 13.9 ± 3.1 mm ( P = .4414), respectively. Rectal anal inhibitory reflex was observed in 81.8% (9/11) and 83.3% (10/12) patients ( P = 1.0000), respectively. The mean length of stay during the second hospitalization was 10.6 ± 0.9 and 14.3 ± 1.4 days ( P < .0001), respectively. Conclusions Although no significant difference can be noted in clinical scoring between both groups, the results of anorectal manometry indicate that LAARP can significantly improve anal canal resting pressure and reduce the length of stay.

Prospective long-term functional and cosmetic results of ASARP versus PASRP in treatment of intermediate anorectal malformations in girls

Prospective randomized comparison of the functional and cosmetic results of anterior sagittal anorectoplasty (ASARP) and posterior sagittal anorectoplasty (PSARP) in the management of intermediate anorectal malformations (ARMs) in girls was performed. Thirty-eight girls with intermediate ARMs were randomly allocated to group A treated by ASARP technique and group B treated by PSARP technique: 14 girls from each group passed 30-month age for early functional assessment by Templeton and Holschneider scores, 18 cases passed 55 months for late functional evaluation. Results were compared statistically where P value < or = 0.05 was considered significant. Cosmetic satisfaction was higher in ASARP group with a median score of 3 compared to 2 in PSARP group. Functional results were assessed early at median of 33.5 months post-repair where Templeton score was 4 versus 3.75 and Holschneider score was 11 versus 11. Late functional assessment was done for 8 cases from each group where Templeton score was 4 versus 4, while Holschneider score was 12 versus 11. ASARP is an optimal technique for treatment of intermediate ARM in girls. Cosmetic results were superior to PSARP. Despite the observations that functional results give higher scores in ASARP group versus PSARP group, no statistical significance could be reached.

Functional outcome in correction of perineal fistula in boys with anoplasty versus posterior sagittal anorectoplasty

Optimal surgical therapy for low anorectal anomalies remains controversial. We compared functional outcome after correction of perineal fistula in boys with either anoplasty (AP) or limited posterior sagittal anorectoplasty (PSARP). Thirty-nine boys from two centres treated for perineal fistula with either AP (n = 24) or PSARP (n = 15) from 1996 to 2001 underwent prospective follow-up for functional outcome. In order to minimize heterogeneity of the study groups, only boys with perineal fistula were included. Functional outcome was assessed using a validated bowel function score (maximum score 20). Day and night time wetting as well as the age at potty training were also recorded. An independent nurse specialist interviewed caregivers. AP and PSARP groups were comparable regarding age, associated malformations and frequency of sacral dysplasia. No significant differences between the groups were observed in the overall median bowel function score, AP 18 (11-20) versus PSARP 18 (11-20), or in the age at potty training, AP 32 (14-66) versus PSARP 36 (18-60). Covering colostomy was employed significantly (P < 0.05) more often with PSARP (10/15) than with AP (1/24). Surgery for local complications was carried out significantly (P < 0.05) more often after PSARP (5/15) than after AP (2/24). Two patients in both groups required a temporary salvage colostomy. Overall functional outcome is comparable after AP and PSARP for perineal fistula in boys. As a more straightforward procedure AP is safer and less prone to complications avoiding the need for covering colostomy.

Midterm follow-up study of high-type imperforate anus after laparoscopically assisted anorectoplasty

Purpose The aim of this study was to evaluate postoperative anal function of high-type imperforate anus after laparoscopically assisted anorectoplasty (LAARP). Methods Between 2000 and 2002, LAARP was performed in 13 patients with high-type imperforate anus. Clinical data of the LAARP group were compared with the posterior sagittal anorectoplasty (PSARP) group (n = 7) operated before 2000. All patients were treated with initial colostomy in the newborn period. After anorectoplasty, daily glycerin enemas were given for postoperative bowel management. Anorectal function of these patients was evaluated using the Kelly score and manometry at the age of 3 to 5 years (LAARP) and 5 to 6 years (PSARP). Results Age at evaluation in the LAARP group was younger than that in the PSARP group (51 ± 10 vs 73 ± 12 months, P < .01). Kelly score was 3.8 ± 1.3 vs 3.4 ± 0.8, respectively. Resting pressure of internal sphincter was 31 ± 11 vs 33 ± 10 cm H 2O, respectively. Relaxation reflex of the internal anal sphincter was observed in 62% (8/13) and 29% (2/7), respectively. Conclusions Midterm follow-up study revealed that satisfactory fecal continence can be achieved in patients with high-type imperforate anus after LAARP. Laparoscopically assisted anorectoplasty may be a good alternative in this patient population. However, long-term follow-up is necessary to compare the benefits of LAARP against PSARP.

Follow-up studies of anorectal malformations after posterior sagittal anorectoplasty

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. J Pediatr Surg 37:1529-1533. Copyright 2002, Elsevier Science (USA). All rights reserved.

Posterior sagittal anorectoplasty is superior to sacroperineal-sacroabdominoperineal pull-through: A long-term follow-up study in boys with high anorectal anomalies

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/H 2O, 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.