Advances in the management of anorectal malformations.

BACKGROUND: Anorectal malformations represent a continuing challenge for the pediatric surgeon. A significant number of these children suffer from fecal incontinence, urinary incontinence, and sexual inadequacy. However, major advances in the management of these children have occurred during the last 10 years. The posterior sagittal approach has led to a better understanding of the internal anatomy of these defects, and in turn, a more rational way to manage the patients. We present here our experience with the long-term follow-up of a large series of these patients operated on by us.

METHODS: Clinical information from our database of patients with anorectal malformations was retrospectively reviewed. A total of 1, 192 patients operated on by the authors and observed for the last 19 years are included in the database. We searched for type of malformation, associated defects, results in terms of voluntary bowel movements, soiling, constipation, and urinary control.

RESULTS: Globally, 75% of all patients have voluntary bowel movements. Half of this group still soils their underwear occasionally. Therefore, about 37.5% of all cases are considered totally continent. Constipation was the most common sequelae. Urinary incontinence was relatively common after the repair of cloacas. Male patients rarely suffered from urinary incontinence. Twenty-five percent of all cases suffered from fecal incontinence but they significantly improved their quality of life when subjected to a bowel management program. An operation called "continent appendicostomy" further improved their quality of life.

CONCLUSION: All patients born with anorectal malformations can be kept clean of stool and dry of urine, either because they achieve bowel control or because they are subjected to a bowel management program.