Bowel Function Following Posterior Saggital Repair Of Anorectal Malformations (a Ten-year Retrospective Study)

Abstract

Posterior sagittal repair was used to repair 352 patients with anorectal malformations· between 1st January 1990 and 31st December 1999. We evaluated 193 patients who were over 3 years of age and with an adaptation period of 6 months after the colostomy closure for bowel control. Males were 80 (41.5%) and females were 113 (58.5%), low anomalies were 86.5% and high anomalies were 13.5%, and while sacral defects were present in 14.0%. Colostomy was fashioned in 92.2% of the patients before definitive surgery, while only 7.8% were managed without a colostomy. More than half of the patients had their colostomies fashioned before the age of one month. Majority of males (97.1 %) had colostomy fashioned before the age of one month, while 66.7% of females had their colostomy fashioned after the age of one month. The overall mortality was 1.0%. The type of colostomies fashioned was divided sigmoid in 75.8% and transverse loop colostomy in 24.2% of the patients. Approximately 17.0% of these colostomies were revised. Transverse loop colostomy was revised in 58.1%of the patients compared to only 3.7% in divided sigmoid colostomy. Majority of the patients (90.5% of the patients) had to wait longer than 6 months for definitive surgery after colostomy fashioning. Majority of the patients in this series had PSARP in 76.7%of the patients, while 17.6% and 3.1% had anoplasty and a combined PSARP and abdominal approach respectively. By the age 5 years 93.3% of the patients have had definitive surgery while only 10.9% by age of6 months. Only 5.6% wait for less than 6 months colostomy closure after definitive surgery. Overall voluntary bowel movement (VBM) is achieved in 71.5% of the patients. Patients who had colostomy fashioned before the age of one month achieve VBM in 79.1% of the patients while those fashioned after one year in 61.1 %. Overall females achieve VBM in 77.0% of the patients compared to 63.8% in males. Patients with perineal fistula achieve VBM in 79.1% in males and 75.0% in females, 76.0% in rectovestibular fistula, 73.9% in rectourethralfistula, 56.0% in anorectal malformations without a fistula, 25.0% in vaginalfistula and 12.5% in rectovesical fistula. Overall where anoplasty was the definitive surgery VBM was achieved in 82.4% of the patients and 74.3% in PSARP of the patients. The patients who had definitive surgery before the age of 6 months achieved VBM in 81.1% compared to 61.5% when done after 5years.Overall patients with sacral defects achieve VBM in 25.9% compared to 78.9% in the patients with normal sacrum. The patients with low anomalies achieved VBM in 75.4%compared to 46.1% in high anomalies. Soiling was present in 21.2% of the patients. Patients with high anomalies and sacral defects e.g. rectovesical fistula and rectovaginal fistula have high incidence of soiling. Constipation is present in 7.3% of the patients and low (simple) anomalies have the highest incidence. In this series 24 (12.4%) of the 193 patients underwent secondary operations. Patients who had one redo operation were 21(87.5%) while 3(12.5%) of the patients had more than one redo operations. Indications for reoperations were severe fecal incontinence and severe constipation among others. All patients for redo operations due to severe constipation had normal sacrum. The patients with normal sacrum and low anomalies required one redo operation while some of the patients with high anomalies and sacral defects had more than one redo operations. All the patients who had one reoperation had good to fair results while all the patients who had more than one redo operations had fair to poor bowel control results. All patients with severe constipation had normal sacrum and had significant improvement after one redo operation. Sacral defects in the patients with severe fecal incontinence were present in 91.7% of the patients. Where severe fecal incontinence was the indication for redo operation, significant improvement was in 50.0% of the patients while 33.3% and 16.7% of the patients had fair and poor results respectively.