Rectal Pouch Research Articles

One stage operation through modified posterior sagittal approach preserving the sphincter intact for anal agenesis with rectovestibular fistula

PurposeTo describe the surgical technique and outcomes of an one stage operation through modified posterior sagittal approach (PSAP) preserving the sphincter intact for anal agenesia with rectovestibula fistula. Patients and methods57 patients suffering from anal agenesis with rectovestibular fistula were operated by a one-stage operation through a modified PSAP preserving the external sphincter intact from 2002 to 2010.The operation was performed in one-stage through a posterior sagittal approach with three modifications: The external sphincter complex was not opened on the posterior side, the dissection was carried out outside the rectal pouch, the rectal pouch was not tapered and was pulled through the center of the external sphincter identified by muscle stimulator. ResultsPatients age varied from 3days to 30days (mean: 21±9days). The mean operative time was 57±8min (range, 35–90 min). There were no intraoperative complications. There were no intraoperative or postoperative deaths. There were no early postoperative complications. Follow up from 40months to 140 was obtained in 52 (91.2%) patients. Constipation has seen in 3 patient, 46 patients (88.5%) had 1–2 defecations per day, 2 patients (3.85%) had 3–4 defecations per day, 1 patients (1.9%) had more than 4 defecations, and 3 patients(5.8%) had one defecation every 2–3 days. Rectal mucosal prolapse occurred in 7 patients who required a second operation. ConclusionOne stage operation through modified PSAP is feasible, is safe and provides good continence outcomes for anal agenesis with rectovestibular fistula.

Asociación de malformación anorrectal con duplicaciones anales y rectales

El objetivo de este trabajo es compartir la experiencia en el diagnóstico y tratamiento de casos de duplicaciones rectales y anales asociadas con malformación anorrectal. Se reportan dos casos con oclusión intestinal y diagnóstico tardío de la malformación anorrectal tratados inicialmente con laparotomía, anastomosis latero-lateral de la duplicación colónica proximal y co- lostomía y un caso con diagnóstico de malformación anorrectal con fístula recto-perineal al nacimiento al que, al realizarle colostomía, evidenció duplicaciones colónica y rectal relacionadas. En los tres casos se realizó, para su corrección quirúrgica definitiva, un abordaje abdominoperineal y anastomosis latero-lateral de la duplicación rectal, colocación del recto dentro del complejo muscular anorrectal y poste- rior cierre de la colostomía. En un cuarto paciente con malformación anorrectal sin fístula clínicamente evidente y colostomía al nacimiento, la electroestimulación perineal evidenció dos complejos musculares a los que se les realizó un abordaje sagital, observándose dos fondos de sacos ciegos rectales separados. Se realizó anastomosis termino-lateral del recto duplicado y se decidió utilizar el complejo con mayor acti- vidad contráctil para la colocación del neoano. Consideramos que el abordaje sagital posterior es la mejor opción quirúrgica para preservar el complejo muscular con mejor pronóstico para la continencia fecal.

Combined laparoscopic and modified posterior sagittal approach saving the external sphincter for rectourethral fistula: An easier and more physiologic approach

AimTo present surgical technique and results of combined laparoscopic and modified posterior sagittal approach (PSAP) saving the external sphincter in the management of rectourethral fistula. MethodsThe operation was started by a laparoscopic approach to dissect around the rectal pouch and separate the rectal pouch from the upper urethra. The PSAP saving the external sphincter was added to completely separate the rectal pouch from the urethra. The fistula was divided and closed. The rectal pouch was then pulled through a tunnel created at the center of the external sphincter and an anoplasty was performed. ResultsFrom September 2011 to September 2012, 19 patients were operated on using the same technique. Mean age of patients was 4.0±1.8months. Rectourethral fistula was located in the prostatic urethra in 15 patients and in the bulbar urethra in 4 patients. The mean operative time was 82±13min. There were no intraoperative complications. Postoperative perforation of the posterior wall of the rectum happened in one patient and required a second laparoscopic operation. Follow-up after closure of colostomy from 1month to 7months revealed all patients were able to pass stool spontaneously. All patients could urinate easily. No urethral fistula or diverticulum was detected on voiding cysto-urethrography. ConclusionsCombined laparoscopic and PSAP saving the external sphincter is the easier and more physiologic approach to manage rectourethral fistula with fewer complications.

Rectal Pouch Index: A Prognostic Indicator for Constipation after Surgery for High and Intermediate Anorectal Malformations

Constipation following posterior sagittal anorectoplasty (PSARP) is common. We correlated the dimensions of rectal pouch before PSARP with the postoperative bowel habit. Classical PSARP was modified with tapering of rectal pouch by plication of its walls thus preserving the internal sphincter because we believe that this preserves continence and lead to better results. It was observed that a distinct relationship exists between the preoperative size of the rectal pouch and constipation. The aim of this study is to correlate the dimensions of preoperative rectal pouch with postoperative constipation. PSARP was performed (n: 45) in anorectal malformations using an indigenous muscle stimulator. Before PSARP, a distal cologram via high sigmoid colostomy was performed. All the distal cologram were performed by a single senior radiologist and the pressure was kept constant between 15 and 20 cm of water while filling to rule out the confounding factor related to incomplete filling. Rectum index was calculated as follows: The maximum radiological diameter of the rectum within the pelvis in the sagittal plane was multiplied by the maximum diameter of the rectum in the frontal plane. The result of this calculation was divided by the product of multiplying the distance between the ischial spines and the distance between the posterior surface of the pubic symphysis and the anterior surface of the last sacral vertebrae. Symptomatic constipation requiring treatment developed in 25 patients (48%). None of these patients had anal stenosis or stricture. Constipation was managed by dietary measures and laxatives. Fifteen patients (60%) had grade 1 constipation and responded favorably. Eight and two patients had grades 2 and 3 constipation, respectively. Those patients who had a rectal pouch index of less than 0.8 had mild constipation grades 0 and 1, whereas those in whom the rectal pouch index was more than 0.8 had severe degrees of constipation (grades 2 and 3). Measuring the rectal pouch index can help in identifying the group which is likely to develop constipation after PSARP. These patients can be put on bowel training early on, after the colostomy closure, instead of waiting.

Comparison of MR and fluoroscopic mucous fistulography in the pre-operative evaluation of infants with anorectal malformation: a pilot study

Anorectal malformations are often associated with rectal pouch fistulas. Surgical correction requires accurate evaluation of the presence and position of such fistulas. Fluoroscopy is currently the chosen modality for the detection of fistulas. The role of MRI is unexplored. To compare the diagnostic accuracy of MR versus fluoroscopic fistulography in the pre-operative evaluation of infants with anorectal malformation. We conducted a pilot study of infants requiring defunctioning colostomy for initial management of anorectal malformation. Dynamic sagittal steady-state free-precession MRI of the pelvis was acquired during introduction of saline into the mucous fistulas. Findings were compared among MR fistulography, fluoroscopic fistulography and intraoperative inspection. Eight children were included. Median age at fistulography was 15 weeks, inter-quartile range 13-20 weeks; all were boys. There was full agreement among MR fistulography, fluoroscopic fistulography and surgical findings. The pilot data suggest that MR fistulography is promising in the pre-operative evaluation of children with anorectal malformation.

Anorectal Malformations: Finding the Pathway out of the Labyrinth

Anorectal malformations (ARMs) are a complex group of congenital anomalies involving the distal anus and rectum, as well as the urinary and genital tracts in a significant number of cases. Most ARMs result from abnormal development of the urorectal septum in early fetal life. In most cases, the anus is not perforated and the distal enteric component ends blindly (atresia) or as a fistula into the urinary tract, genital tract, or perineum. ARMs are also present in a great number of syndromes and associations of congenital anomalies. The classification of ARMs is mainly based on the position of the rectal pouch relative to the puborectal sling, the presence or absence of fistulas, and the types and locations of the fistulas. All of this information is crucial in determining the most appropriate surgical approach for each case. Imaging studies play a key role in evaluation and classification of ARMs. In neonates, clinical and radiologic examinations in the first 3 days of life help determine the type of ARM and the need for early colostomy. In older children, preoperative pelvic magnetic resonance imaging is the most efficient diagnostic method for evaluating the size, morphology, and grade of development of the sphincteric musculature.

Retained Rectum in a Patient Status Post Total Proctocolectomy for Ileocolonic Crohn’s Disease

A 28-year-old female with a twenty-year history of penetrating ileocolonic Crohn’s disease status post total proctocolectomy (TPC) presented to the inflammatory bowel disease clinic with 4 months of a draining perianal abscess. The discharge was serosanguineous mixed with mucoid tissue soiling 5 feminine pads daily. Three years prior to presentation she had an emergent subtotal colectomy with ileostomy for a colonic perforation while on adalimumab. Subsequent to her surgery, adalimumab was discontinued and she was maintained in clinical remission on mesalamine and azathioprine. One year later, a necrotic rectal stump precluded an attempt to restore continuity and underwent completion proctectomy through a perineal approach and maintained her permanent ileostomy. She remained on mesalamine and azathioprine with stable ostomy output and without any gastrointestinal symptoms until her current presentation. Her exam was significant for a 3 cm midline draining open wound at the level of her prior anus with surrounding erythema but no fluctuance. The site was exquisitely tender to palpation and blood mixed with pus was easily expressed. CT and magnetic resonance imaging of the pelvis revealed a perianal fistula communicating with a hyperintense lesion within the presacral fat and posterior to the uterus measuring 16 × 19 × 26 mm suggestive of a remnant rectal pouch. Additionally, there was evidence of a fistulous track from the rectal remnant to the perineum and a rectovaginal fistula. Initial therapy with oral metronidazole improved her perineal pain and drainage. She underwent a redo abdominoperineal resection where the remnant rectum was identified and completely resected. A rectovaginal fistula was identified in the posterior vaginal wall and excised. The histopathology of the specimen was significant for colonic tissue with chronic active colitis and transmural inflammation. After surgical excision of the active diseased colonic remnant tissue her fistulas healed and her perineal pain ceased. This is an unusual case of an unintentionally retained rectum in a patient status post proctocolectomy presenting as active perianal Crohn’s disease. Approximately 75% of all CD patients will require surgery during their lifetime, which can include a total colectomy in medically refractory Crohn’s colitis. Patients with rectal and perianal involvement of Crohn’s undergo TPC and end ileostomy given the high rates of complications in the excluded rectal stump. In patients with acute complications from Crohn’s colitis requiring urgent colonic resections, TPC is typically done in a two-step fashion, as was the intent with this patient. Routinely, due to the length of remaining distal rectum within the pelvic floor, an open abdominal approach is required to assure all colonic tissue is excised. The surgical perineal approach to removing the distal segment in this patient underestimated the length of the remaining colon within the pelvis leading to the retained rectum. Having completely removed the anal canal with adjacent rectal tissue and the proximal colon in the initial surgery, the patient was left with a “floating” segment of rectum within the pelvic floor, which maintained active CD. This case illustrates an unusual surgical complication of a completion proctectomy in Crohn’s.

Intraoperative colonoscopy facilitates safe dissection of the rectal pouch in a case of male imperforate anus

In an imperforate anus, colostography often fails to identify recto-urethral fistula (RUF). Thus, surgeons must always assume an RUF is present, despite colostography findings, and dissect the distal rectal pouch (RP) with caution. We report the usefulness of intraoperative colonoscopy (IOC) for excluding RUF and, thus, facilitating safe dissection of the RP. We used IOC in six cases of imperforate anus. All had right transverse colostomy initially after birth. Distal colostography excluded RUF in five cases and was inconclusive in one. Laparoscopy was used to free the RP carefully from the bladder neck in all cases. Near the prostate, a 4-mm fine, flexible colonoscope was inserted into the RP through the anterior rectal wall to observe the laparoscopic dissection of the RP, which was attached closely to the prostate/bulbar urethra intraluminally to prevent injury to the urethra. The mucosa of the distal end of the RP was mucosectomized or diathermied, and the colon was pulled-through. Mean age at surgery was 11 months. IOC excluded RUF under direct vision in all cases, which enabled the dissection of the RP to be monitored and to proceed smoothly. At follow-up (mean: 31 months), all cases were well. IOC can be used to exclude RUF and facilitate safe dissection of the RP in imperforate anus.

Ileal Pouch Anal Anastomosis with Close Rectal Dissection Using Automated Vessel Sealers for Ulcerative Colitis: A Promising Alternative

Background: Despite decennia of experience, ileal pouch anal anastomosis for ulcerative colitis is still associated with high complication rates. The development of automatic vessel sealers has resulted in the revival of a promising surgical alternative to the conventional procedure: close rectal dissection. By preserving the mesorectal layer it is hypothesized that nerve-related and other postoperative complications can be reduced. Methods: All patients with ulcerative colitis with indication for restorative proctocolectomy at our institution during the pilot study underwent the close rectal pouch procedure with temporary diverting ileostomy. Standardized clinical history, anorectal physiology measurements, and endoscopic and histological examination were carried out before and after surgery. Results: The procedure was technically successful in all 10 patients, with a median age of 41 years and a median postoperative follow-up period of 16 months. There were no cases of pelvic sepsis and bladder or sexual dysfunction. The median daytime defecation frequency was 6.0. Endoscopic and histological examination showed no abnormalities. The anorectal physiology supported the good functional results. Conclusion: The preliminary results of the close rectal pouch procedure are promising, with good functional results and a low complication rate after 1 year.

Laparoscopic surgical technique to facilitate management of high anorectal malformations - report of seven cases.

Anorectal malformations (ARMs) occur in approximately 1 per 5000 live births. The most commonly used procedure for repair of high ARMs is posterior sagittal anorectoplasty (PSARP). This operation is performed entirely through a perineal approach. The first report of laparoscopically assisted anorectal pull-through (LAARP) for repair of ARMs was presented by Georgeson in 2000. The aim is presenting early experience with laparoscopically assisted anorectal pull-through technique in boys with high anorectal malformations. In the last 5 years 7 boys (9 months to 2 years old) with high ARMs were operated on using the LAARP technique. Laparoscopically the rectal pouch was exposed down to the urethral fistula, which was clipped and divided. Externally, the centre of the muscle complex was identified using an electrical stimulator. In the first 4 patients after a midline incision of 2 cm at the planned anoplasty site, a tunnel to the pelvis was created bluntly and dilated with Hegar probes under laparoscopic control. In the last 3 boys a minimal PSARP was done creating a channel into the pelvis. The separated rectum was pulled down and sutured to the perineum. Laparoscopic mobilization of the rectal pouch and fistula division was possible in all cases. There were no intraoperative complications except one ureteral injury. Patients were discharged home on post-operative day 5 to 7. The early results prove that LAARP, an alternative option to PSARP for treatment of imperforate anus, offers many advantages, including excellent visualization of the pelvic anatomical structures, accurate placement of the bowel into the muscle complex and a minimally invasive abdominal and perineal incision. It allows for shorter hospital stay and faster recovery. However, to compare the functional results against the standard procedure (PSARP), longer follow-up of all patients is necessary.

Re-operations for Hirschsprung’s Disease: Long-term Complications

In some patients with Hirschsprung's disease (HD), the initial surgical procedure fails, and the patients suffer from repeated or persistent symptoms. These patients complain of severe inflammation, intestinal obstruction, fecal or urinary incontinence, abdominal pain or dystrophy. However, little data has been published on the long-term follow-up results after re-operations for HD. We followed 8 cases between 2004 and 2006, of complicated HD requiring repeated surgery and recorded prior procedures, histological results, indications for re-operation, postoperative follow-up as well as long-term clinical outcomes including stool patterns, nutrition and micturition. The follow-up period ranged from 3.0 to 5.5 years (mean: 4.4 years). Indications for repeat procedures were as follows: blind rectal pouch after a Duhamel operation (n = 2), persistent aganglionosis (n = 4), long-segment stenosis (n = 1) after a Rehbein operation, and anal stenosis following TERPT (transanal endorectal pull-through) (n = 1). In one patient who had a Duhamel-Martin operation, extirpation of the rectum and a definitive terminal ileostomy was necessary. A Duhamel procedure was performed in five patients with a primary Rehbein and 1 patient with a primary Duhamel operation. Complete stool continence was achieved in 4 patients. Partial fecal incontinence persisted in one patient with associated trisomy 21. 1 patient with total colonic aganglionosis and 1 patient with a pelvic fistula and a previous subtotal colectomy reported soiling 1-2 times per week after a repeat operation. 4 patients in our series experienced postoperative complications following repeated surgery [perianal ulceration (n = 2), repeated botulinum toxin injection for sphincter achalasia (n = 1) and functionally impaired colonic transit without stenosis (n = 1)]. Micturition was normal in 7 patients, 1 patient with associated trisomy 21 was partially continent, and 1 patient reported infrequent urge incontinence. All patients improved after further surgical intervention. However, resolution of their symptoms was delayed and partial stool incontinence or soiling persisted in 3 patients. Most complications leading to repeat procedures are preventable, especially residual aganglionosis. Therefore, great efforts should be made to minimize complications when planning and performing the primary surgery.

P-449 Intraoperative colonoscopy facilitates safe dissection of the distal rectal pouch in male high/intermediate type imperforate anus patients without rectourethral fistula

P-449 Intraoperative colonoscopy facilitates safe dissection of the distal rectal pouch in male high/intermediate type imperforate anus patients without rectourethral fistula

Obstructed Defecation after Stapled Hemorrhoidopexy: A Report of Four Cases

Stapled hemorrhoidopexy or Procedure for Prolapse and Hemorrhoids (PPH) has become an accepted alternative to excisional hemorrhoidectomy for treating prolapsing hemorrhoids. Although rare, severe complications have been reported after this procedure. We report a series of four male patients with the unusual but debilitating symptoms of obstructed defecation (OD) after PPH. Presenting symptoms included evacuation difficulty, rectal pain, and urgency. All had scarring and stenosis at their PPH anastomotic staple line with a resultant ball-valve effect in three patients as the mobile, excessive, proximal rectal mucosa prolapsed past this relatively immobile area. The fourth patient had an anterior rectal mucosal pouch distal to the PPH staple line. In three of the four patients the anastomosis was below the dentate line or on an oblique angle. Corrective operative intervention largely relieved OD symptoms. One patient, more refractory to successful revision, was eventually diagnosed and treated successfully for pudendal neuropathy. Avoidance of the complication of OD is possible through careful patient selection, proper operative technique, and consideration of nonsurgical etiologies. These complications are complex in nature but most patients will respond to an individualized treatment plan that combines surgical and medical interventions.

A Can of V8® Vegetable Juice Per Rectal Route

Purpose: Rectal foreign bodies can be a difficult diagnostic dilemma especially due to the reluctance with which patients disclose history pertaining to them. Presentation is usually delayed because of the perceived stigma associated with rectal problems. A 78-year old gentleman presented with a three-day history of vomiting, abdominal bloating and fecal incontinence symptoms. The vomiting occurred with every meal and consisted of undigested food. He had history of two weeks of chronic diarrhea but stool studies had been negative. Abdominal exam was significant for generalized tenderness and distension, without rebound or peritoneal signs. Digital rectal examination revealed a rock-hard but smooth surfaced mass deep in the rectal vault. A computed tomography scan revealed a distended rectum with “massive amounts of fecal material” and a “cylindrical object in the rectal pouch with an air-fluid level within the object”. Fecal disimpaction with digital manipulation was unsuccessful. The patient was re-interviewed but denied inserting any foreign body through his anus. Patient was taken to the operating theatre where the object was extracted under general anesthesia and found to be a 12 oz Can of V8® vegetable juice. The patient did not suffer any complications of perforation and his gastrointestinal symptoms resolved within the next 48 hrs. He was offered psychological support post-op which he accepted. This case serves to illustrate that very few people with anorectal foreign bodies will freely admit to trans-anal introduction.(1) In the referenced case, a digital rectal examination and radiological evaluation proved invaluable in clinching the diagnosis. As with our patient, offering psychological support without passing judgment is an important part of the post-extraction management.(2)Figure. V8: ® vegetable can in rectum.

Patients with Anorectal Malformation and Hirschsprung's Disease

Dysganglionosis and aganglionosis have been frequently described in biopsies of the distal bowel in patients with anorectal malformation (ARM). They are interpreted as a developmental disorder of the anorectum. The true association of total colonic aganglionosis and anorectal malformation has not been reported before. The aim of this study was to explore the true association of anorectal malformation and Hirschsprung's disease with or without trisomy 21. A retrospective study of all patients diagnosed with anorectal malformation in our institute from 1986-2008 was performed. All patients with anorectal malformation and Hirschsprung's disease were included in the study. Rectal biopsies were taken from multiple sites, including the rectum, left, transverse, right colon and appendix. The diagnosis of aganglionosis was proven histopathologically by the absence of ganglion cells with or without acetylcholinesterase staining. Specimens were examined by at least two experienced consultant pathologists. Aganglionosis was confirmed in three patients out of 53 patients with anorectal malformation. Two had Down's syndrome. All were males and presented with high anorectal malformation without fistula. The clinical presentation was intestinal obstruction, necrotizing enterocolitis and failure to thrive. The level of aganglionosis was up to the left colon in two and total colonic with ileal involvement in one. One of the children with Down's syndrome and total colonic aganglionosis died. Another had correction of a congenital heart disease, colostomy and is awaiting definitive surgery. The third case is continent at the age of 22 years with a Malone stoma after pull-through of ARM and a subsequent Duhamel procedure. The association between ARM and intestinal dysganglionosis is not rare. We recommend not using the distal rectal pouch and parts of the fistula in the reconstruction of anorectal malformations as this may solve the constipation if the pathology is limited. In cases of aganglionosis beyond the rectal pouch and fistula, surgical intervention is needed. Delay in diagnosis may lead to morbidity or even mortality.

Imperforate Anus: Determination of Type Using Transperineal Ultrasonography

ObjectiveThis study was designed to assess the usefulness of transperineal ultrasonography (US) for the determination of imperforate anus (IA) type.Materials and MethodsFrom January 2000 to December 2004, 46 of 193 patients with an IA underwent transperineal US prior to corrective surgery. Sonographic findings were reviewed to identify the presence of internal fistulas and to determine "distal rectal pouch to perineum (P-P)" distances. IA types were determined based on the sonographic findings, and the diagnostic accuracy of transperineal US was evaluated based on surgical findings.ResultsOf the 46 patients, 17 patients were surgically confirmed as having a high-type IA, three patients were confirmed as having an intermediate-type IA and 26 patients were confirmed as having a low-type IA. The IA type was correctly diagnosed by the use of transperineal US in 39 of the 46 patients (85%). In 14 of the 17 patients with a high-type IA, internal fistulas were correctly identified. All cases with a P-P distance > 16 mm were high-type IAs and all cases with a P-P distance < 5 mm were low-type IAs.ConclusionTransperineal US is a good diagnostic modality for the identification of internal fistulas in cases of high-type IA and for defining the IA level.

Histology of the Terminal End of the Distal Rectal Pouch and Fistula Region in Anorectal Malformations

Until recently, surgeons have been posed with a dilemma---whether or not they should preserve the terminal end of the distal rectal pouch and the fistula region in anorectal malformations (ARMs). A detailed histological study of this region was conducted to establish a consensus for preserving or excising this region for reconstruction of ARMs. Histopathological examination using haematoxylin and eosin-stained sections of the terminal portion of the distal rectal pouch and proximal portion of the rectourogenital or rectoperineal connection was performed in 60 cases of high, intermediate and low ARMs. Distorted internal sphincter was present in 93.3% of high, 90% of intermediate and 100% of low ARMs. The proximal fistula region was lined by transitional epithelium in 50% of cases, and anal glands were present in 83.3% and anal crypts in 68.3% of cases. The rectal pouch in the region of the internal sphincter and fistula was aganglionic in all cases. This study shows that the terminal end of the distal rectal pouch and proximal fistula region possess distorted anal features with aganglionosis, and contradicts the recommendation that this region should be reconstructed in patients with malformations.

Transperineal Sonography for Determination of the Type of Imperforate Anus

The purpose of this study was to assess whether transperineal sonography is valid and accurate for discriminating the low (translevator) type of imperforate anus from the intermediate and high (supralevator) types. The distinction is critical in determination of the surgical approach. Fifty-six consecutively enrolled infants (0-90 days old) with imperforate anus underwent transperineal gray-scale sonography with a 12-MHz linear array transducer. The distance between the distal rectal pouch and the perineum was measured, and a cutoff distance for differentiating types of imperforate anus was identified. The sonographic findings were compared with the final diagnosis reached with radiographic and surgical findings. Transperineal sonography was feasible in all children without specific preparation. The mean distance between the distal rectal pouch and the perineum in the 22 infants with low imperforate anus was 10 +/- 4 (SD) mm compared with a mean of 24 +/- 6 mm in the 34 infants with intermediate or high anomalies (p < 0.001). The sensitivity of transperineal sonography was 100%; all 34 cases of intermediate or high imperforate anus were identified with a cutoff distance between the distal rectal pouch and the perineum of 15 mm. The specificity of sonography was 86% and the accuracy, 95%. Transperineal sonography is a valid and accurate noninvasive imaging technique for differentiating low and intermediate or high imperforate anus.

Sphincter saving anorectoplasty (SSARP) for the reconstruction of Anorectal malformations

BackgroundThis report describes a new technique of sphincter saving anorectoplasty (SSARP) for the repair of anorectal malformations (ARM).MethodsTwenty six males with high ARM were treated with SSARP. Preoperative localization of the center of the muscle complex is facilitated using real time sonography and computed tomography. A soft guide wire is inserted under image control which serves as the route for final pull through of bowel. The operative technique consists of a subcoccygeal approach to dissect the blind rectal pouch. The separation of the rectum from the fistulous communication followed by pull through of the bowel is performed through the same incision. The skin or the levators in the midline posteriorly are not divided. Postoperative anorectal function as assessed by clinical Wingspread scoring was judged as excellent, good, fair and poor. Older patients were examined for sensations of touch, pain, heat and cold in the circumanal skin and the perineum. Electromyography (EMG) was done to assess preoperative and postoperative integrity of external anal sphincter (EAS).ResultsThe patients were separated in 2 groups. The first group, Group I (n = 10), were newborns in whom SSARP was performed as a primary procedure. The second group, Group II (n = 16), were children who underwent an initial colostomy followed by delayed SSARP. There were no operative complications. The follow up ranged from 4 months to 18 months. Group I patients have symmetric anal contraction to stimulation and strong squeeze on digital rectal examination with an average number of bowel movements per day was 3–5. In group II the rate of excellent and good scores was 81% (13/16). All patients have an appropriate size anus and regular bowel actions. There has been no rectal prolapse, or anal stricture. EAS activity and perineal proprioception were preserved postoperatively. Follow up computed tomogram showed central placement the pull through bowel in between the muscle complex.ConclusionThe technique of SSARP allows safe and anatomical reconstruction in a significant proportion of patients with ARM's without the need to divide the levator plate and muscle complex. It preserves all the components contributing to superior faecal continence, and avoids the potential complications associated with the open posterior sagittal approach.

Ureterorectostomy as a continent urinary diversion for complicated bladder exstrophy in children by using a modified Duhamel procedure: A case series

Introduction Whatever the method and timing of surgery, a high proportion of children with bladder exstrophy will continue to suffer from urinary incontinence. They face the options of urinary diversion to an external stoma or construction of a neobladder from bowel. This study describes a modified Duhamel's rectal pouch with a ureterorectostomy was carried out on 11 children who had a failed repair of bladder exstrophy. Materials and methods Ten boys and one girl, aged from 4 to 7 years (mean 5.5), had several unsuccessful operations for bladder exstrophy. All selected to have good renal function and no other anomalies, but were incontinent of urine and had a small contracted or prolapsed bladder. They underwent urinary diversion to the rectum using the Duhamel pullthrough technique, where the sigmoid colon was opened into the back of the anal canal above the dentate line, creating a rectal bladder and making use of the anal sphincter to control urine and stool. All were followed up for 24 months (18–27 months). Results In this selected group of patients there were no major operative or postoperative complications. Follow-up for 2 years revealed no deterioration in renal function, or electrolytes disturbance. They can hold up to 300 ml of urine and all patients are continent during the daytime with an emptying frequency of 3–5 times. Nocturnal wetting occur some 4–8 times per month with significant decrease with time. Two cases developed pyelonephritis but this was controlled with medical treatment. Conclusion Eleven children achieved effective urinary continence by ureteric diversion to the rectum using a modified Duhamel pullthrough technique. Two years follow up showed no complications, except bed wetting, but long term assessment is warranted.