Anorectal malformation (ARM) is one of the commonest anomalies in pediatric surgical practice. The specific cause of anorectal malformation is unknown. The overall incidence of ARM worldwide is 1 in 5000 live births. A slight male predominance exists [1]. There have been many different surgical techniques to treat anorectal malformations such as anterior and posterior perineal approaches and many different types of anoplasties. Most pediatric surgeons now use the posterior sagittal approach with or without laparotomy or laparoscopy to repair these malformations [1]. In the case of high and intermediate varieties, staged operations are performed. In PSARP, complete exposure of the anorectal region by median sagittal incision from the sacrum to the anal dimple, cutting through the sphincter mechanism [2]. The benefit of complete exposure is a visualization of the anatomy of the area such as there is a strong funnel-like muscle that forms the sphincter mechanism, the upper portion of the funnel formed by the levator muscle that is arranged horizontally and the lower portion of this funnel is made mainly of vertical fibres that are called muscle complex [2]. There are several complications of PSARP such as constipation, perianal soiling, faecal incontinence, rectal prolapse, urologic injury and neurogenic bladder. The most common functional disorder is constipation after PSARP [3,4]. Muscle complex is formed by the puborectalis muscle and external anal sphincter and is a functionally important structure for continence. Placement  of   neoanus  within  the  center  of  the  muscle complex during definitive repair has an important impact on future faecal continence [2,3]. In muscle complex saving posterior sagittal anorectoplasty, proper identification of muscle complex with muscle stimulator, saving the muscle complex and placement of distal pouch within the muscle complex, so less chance of complication than without muscle complex saving posterior sagittal anorectoplasty [5].

This prospective, interventional study was carried out in the faculty of pediatric surgery, Bangladesh Shishu Hospital and Institute, Sher-e-Bangla Nagar, Dhaka. The aim of this study was the evaluation of the early postoperative outcome of muscle complex-saving posterior sagittal anorectoplasty for high and intermediate variety anorectal malformation. This study was a hospital-based quasi-experimental study (Single group clinical trial) and was conducted from March 2020 to February 2022. A total of 23 participants were included in this study, among them, 17(73.9%) patients were intermediate variety and 6 (26.1%) patients were high variety anorectal malformation. 19(82.6%) had rectourinary fistula and 4(17.4%) had no fistula. All male patients had a fistula and all female patients had no fistula.

Operative Technique for Muscle Complex Saving Posterior Sagittal Anorectoplasty

The urinary catheter was inserted after general anaesthesia and then the patients were placed in the prone position. The site of the neoanus was located using a muscle stimulator. A sagittal skin incision was made starting from the lower portion of the back of the sacrum to the anterior margin of the neoanus. The parasagittal fibres were divided in the midline. Starting at the tip of the coccyx, the upper portion of the sphincter, the levator muscle, was divided in the midline; this muscle division was arrested at the level of the upper limit of the muscle complex which joins the levator muscle with a nearly 90° angle. The deep pelvic fascia was opened exposing the rectal pouch. Two silk sutures were placed in the posterior rectal wall, and the rectal pouch was opened longitudinally between both sutures. Once the fistula was visualized, separation of the rectal pouch from the urethra was performed and the rectal blind pouch was mobilized upwards above the level of the muscle complex, which can be demonstrated clearly; preoperatively using the muscle stimulator. The fistula was closed in two layers. The lower part of the funnel formed by the muscle complex was once again defined by a muscle stimulator. A tunnel was created through the center of the funnel, starting from the lower part of the muscle complex and pushed through the center of the muscle complex funnel and at this point, an electrostimulation test proves the contraction of the muscle complex. The created pathway was serially dilated until it accommodates the proper Hegar dilators. The tapered new rectum was pulled down through the tunnel, and then fixed proximally at the upper ring of the muscle complex funnel and to the levator plate by several sutures. Finally, a standard eight-suture anorectoplasty was performed.

Follow-up visits were

Follow up were taken every month after colostomy closure and continued up to 6 months.

On each Follow-Up, the Following were Checked

• Frequency of bowel movement - Grade 1 - 1-5 per day, Grade 2-Very often (>5 /day), Grade 3

• Every alternative day or less than 3 per week.

• Soiling Yes/no, Grade 1- Occasionally (once or twice per week), Grade 2 - Every day, no social problem, Grade 3 - Constant, social problem.

• Constipation Yes/no, Grade 1- Manageable by changes in diet, Grade 2 - Requires laxative, Grade 3 - Resistant to laxatives and diet.

Data Analysis

Statistical analysis was carried out using the Statistical Package for Social Sciences version 26.0 for Windows (SPSS Inc., Chicago, Illinois, USA). The quantitative data were indicated by frequencies and percentages.

Ethical Issues

Ethical clearance was taken from the Ethical committee of Bangladesh Shishu hospital and Institute. Permission was also taken from other concerned departments. Informed written consent was taken from all the parents or legal guardians of patients. They were assured of the protection of patient autonomy, privacy, and confidentiality.

The majority of the patients belonged to the age group 13 -24 months with a mean age was 19.61±8.08 months. 19(82.6%) patients had 1-5 bowel movement per day, among them high variety were 5(26.32%) and the intermediate variety was 14(73.69%). No patient had > 5 bowel movements per day. 4(17.4%) patients had grade 3 (Every alternative day or < 3 per week) among them high variety were 3(75%) and intermediate variety were 1(25%). The majority of 15(65.2%) patients had no perianal soiling among them high variety were 2(13.34%) and the intermediate variety was 13(86.67%). 8(34.80%) patients had occasionally perianal soiling among them high variety were 4(50%) and intermediate variety were 4(50%). 19 (82.6%) patients had no constipation among them high variety were 2(10.52%) and the intermediate variety was 17(89.47%). 04(17.4%) high variety ARM patient had constipation among them 02(8.7%) manageable by changes in diet and 02(8.7%) requires laxative.

In the present study, no patients had wound infection or wound dehiscence and also no patients had anal stricture or stenosis. Emre and Orkan reported that short-term postoperative complications following PSARP were wound infection (7-24%), wound dehiscence (7.5-10.6%) and anal stricture or stenosis (16-38%)[6]. Maqtadir et al. reported that wound dehiscence was 14.8% and the wound infection rate was 13% [7]. Tofft et al. reported that wound dehiscence was 31%. In our study, no patients had wound infection or dehiscence due to colostomy [8]. In the present study, 19(82.6%) patients had 1-5 bowel movements per day. Akshay et al. reported that the average number of bowel movements was 3-5 per day [10]. This finding was similar to the present study. In the previous study, 75% of patients had voluntary bowel movements after PSARP [3, 9]. Sejdi et al. reported that 62.7% had voluntary bowel movements after PSARP [11]. But the present study, voluntary bowel movement could not be assessed due to the short follow-up period. In the present study, 15(65.2%) patients had no soiling and 8(34.80%) patients had occasional (once or twice per week) soiling. In the previous study, 75% of patients had voluntary bowel movements but half of these patients (37.5%) still soil their underwear occasionally after PSARP [3, 9]. Sejdi et al. reported that 36.36% of patients had occasional perianal soiling after PSARP [11]. In the present study, 19(82.6%) patients had no constipation and 4(17.4%) patients had constipation. Among the constipation patient, half of them were managed by changing their diet and half of them were managed by laxatives. Pena and Hong reported that 48% had constipation [9]. Sejdi et al. reported that 52.38% had constipation [11]. Emre and Orkan reported that 30-80 % had constipation after PSARP [6]. In the present study, soiling and constipation were less than in the previous study due to proper identification of the muscle complex with a muscle stimulator, preserving it and placement of the rectum within the muscle complex.

Muscle complex saving posterior sagittal anorectoplasty is a good operative procedure for high and intermediate variety anorectal malformation in terms of soiling and constipation.

Conflict of Interest

None declared

Funding

No funding sources

1. Levitt, M.A. and A. Peña. Imperforate Anus and Cloacal Malformations. In Ashcraft’s Pediatric Surgery, edited by G.W. Holcomb III, P. Murphy and D.J. Ostile, 6th ed., Elsevier, 2014, pp. 492–514.

2. Peña, A. and P.A. De Vries. "Posterior Sagittal Anorectoplasty: Important Technical Considerations and New Applications." Journal of Pediatric Surgery, vol. 17, 1982, pp. 796–811.

3. Levitt, M.A. and A. Peña. "Anorectal Malformations." Orphanet Journal of Rare Diseases, vol. 2, no. 1, 2007, pp. 33–42.

4. Levitt, M.A. and A. Peña. "Pediatric Fecal Incontinence: A Surgeon’s Perspective." Pediatrics in Review, vol. 31, no. 3, 2010, pp. 90–99.

5. Maher, Z. and Z. Feras. "Muscle Complex Saving Posterior Sagittal Anorectoplasty." Journal of Pediatric Surgery, vol. 52, 2016, pp. 889–892.

6. Emre, D. and E. Orkan. "General Complications after Surgery for Anorectal Malformations." Pediatric Surgery International, 2020, pp. 1–15.

7. Maqtadir, A.M.A. et al. "Anorectal Malformations Management and Outcome: An Observational Study." International Journal of Anatomy, Radiology and Surgery, vol. 7, no. 3, 2018, pp. 11–14.

8. Tofft, L. et al. "Wound Dehiscence after Posterior Sagittal Anorectoplasty in Children with Anorectal Malformation." BioMed Research International, 2018, pp. 1–6.

9. Peña, A. and A. Hong. "Advances in the Management of Anorectal Malformations." American Journal of Surgery, vol. 180, 2000, pp. 370–376.

10. Akshay, P. et al. "Sphincter Saving Anorectoplasty for the Reconstruction of Anorectal Malformations." BMC Surgery, vol. 7, no. 20, 2007, pp. 1–10.

11. Sejdi, S. et al. "Treatment of Children with Anorectal Malformations—10-Year Review." Open Access Library Journal, vol. 2, 2015, pp. 1–8.