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PubMed1991

The anal sphincter force in the evaluation of postoperative imperforate anus.

Eight-four children, all of whom had imperforate anus, were evaluated by measuring the anal sphincter force (ASF). Sixty-three were boys, 46 of whom had a high imperforate anus and 17 of whom had the low anomaly. There were 7 girls with cloacal malformations, 7 girls with high type and 7 with low type of malformation. In all the boys with a high imperforate anus the ASF ranged from 50 to 300 g. Those boys with a low type had an average ASF of 513 g. Normal values vary from 480 to 600 g. Twenty-five of the boys with a high imperforate anus had undergone posterior sagittal anorectoplasty and none were clinically continent. Their ASF measurements were lower than in patients with spina bifida. Patients with a low anomaly, both boys and girls, were continent and had high ASF readings. The ASF is a simple, inexpensive, and objective measurement of fecal incontinence when this is the consequence of muscular inadequacy. A reproducible quantification is now available to compare results of different operations and different centres.

Adolescent↗

PubMed2006

Transanal endoscopic-assisted proctoplasty--a novel surgical approach for individual management of patients with imperforate anus without fistula.

BACKGROUND/AIM: Imperforate anus without fistula consists of a spectrum of defects with variable distance between the rectal pouch and the perineum. We have developed a novel surgical approach for individual management of these patients based on precise knowledge of the level of the anomaly. METHODS: All consecutive patients with imperforate anus without fistula between 2002 and 2004 had sigmoidostomy performed after having failed to pass meconium in the first 24 hours. The upper pouch was intraluminally visualized using retrograde endoscopy through the sigmoid mucous fistula. The distal termination of the rectum was clearly identified as by convergence of the anal columns. Bright translumination of the endoscope light from the rectum to the anal dimple within the external sphincter indicated a low malformation amenable to transanal proctoplasty. The rectum was incised from below under endoscopic visual control. Poor translumination indicated a higher defect, in which case, the operation was converted to standard posterior sagittal anorectoplasty. RESULTS: Seven patients (6 boys) were identified. Four patients (3 boys) completed transanal endoscopic-assisted proctoplasty. In all cases, the convergence of anal columns indicating rectal termination was right above the anal pit at the site of the maximal external sphincter squeeze. In 3 patients, the operation was converted to posterior sagittal anorectoplasty after verification of a higher anomaly by endoscopy. There were no operative complications. The median follow-up was 3 months (range, 1-26 months). All patients have an appropriate size anus and regular bowel actions. CONCLUSIONS: Transanal endoscopic-assisted proctoplasty allows safe and anatomical reconstruction of the anorectum, as well as contemporaneous closure of the sigmoidostomy in a significant proportion of patients with imperforate anus without fistula, avoiding the potential complications associated with the open posterior sagittal approach.

Anal Canal↗

PubMed1996

Does posterior sagittal anorectoplasty in patients with high imperforate anus provide superior fecal continence?

The posterior sagittal anorectoplasty (PSARP) has become the primary surgical procedure for patients with high imperforate anus. Very few careful long-term follow-up studies have established the superiority of the PSARP procedure over other surgical repair techniques. The authors' goal was to evaluate the operation and to identify the factors associated with improved continence. The medical records, operative reports, and radiographs of 53 patients (46 male, 7 female) who underwent PSARP for high imperforate anus at Children's Hospital and Medical Center (CHMC) between 1982 and 1990 were reviewed retrospectively. Subjective follow-up data were collected by telephone questionnaire, assessing habits indicative of stool continence, and a "fecal continence score" (FCS) was calculated for each patient. A prospective, 7-day diary assessing similar patterns of fecal continence was completed by each patient's family. The mean age of the patients studied was 8.0 years, and the mean follow-up period was 6.8 years. The telephone questionnaire was completed for 48 patients (94%). Toilet training for bowel continence was successful in 20 patients (42%) and occasionally successful in another 20 patients (42%), but 8 patients (16%) had no awareness of impending stool. Forty-five (94%) were physically active, but 16 (33%) reported social problems related to offending odor. The mean fecal continence score for all patients was 3.0 +/- 1.4 (5=excellent, completely continent), which was nearly identical to published scores for the other types of surgical repair. The FCS did not improve with age. The parents' responses to the telephone questionnaire matched the results obtained from the prospectively collected continence diary data. The authors' results for PSARP in patients with high imperforate anus do not differ substantially from those achieved by other repair techniques. Previously cited prognostic factors such as fistula anatomy and sacral anomalies did not appear to alter the functional results in the authors' series. Aggressive postoperative bowel management should be anticipated in all patients who have high imperforate anus and may benefit those who otherwise would achieve less satisfactory continence.

Adolescent↗

PubMed1998

Immediate and long-term results of surgical management of low imperforate anus in girls.

BACKGROUND: The majority of girls with imperforate anus are reported to have a malformation of the low variety. Despite this, much of the literature has focused on the more complex, high lesions. METHODS: This study reviews our experience with 44 girls with low imperforate anus from a 22-year period. RESULTS: The incidence of associated anomalies was 61%, which is higher than generally reported. All patients in the study had anal fistulae. Fifty-seven percent had perineal fistulae, 23% had fourchette fistulae, and 20% had vestibular fistulae. Cutback anoplasty was performed in 55%, Potts transfer anoplasty was used in 27%, and 18% of patients were treated with either limited posterior sagittal anorectoplasty or anterior sagittal anorectoplasty. Surgical complications were uncommon. Long-term follow-up was carried out by telephone survey. This showed 89% of the girls to be successfully toilet trained. However, 47% of patients experience at least occasional soilage or episodic fecal incontinence. CONCLUSIONS: Low imperforate anus can be successfully treated using a variety of procedures without colostomy. Most girls with low imperforate anus are successfully toilet trained, but problems with continence persist in a significant number of these patients.

Anus, Imperforate↗

PubMed1996

Associated urologic anomalies in low imperforate anus are capable of causing significant morbidity: a 15-year experience.

OBJECTIVES: To determine the incidence and morbidity caused by urologic anomalies in patients with low imperforate anus. METHODS: The case records and imaging studies of 95 patients who underwent surgery for low imperforate anus over a 15-year period were retrospectively reviewed. Follow-up ranged from 2 to 18 years (mean 5.4). RESULTS: Genitourinary abnormalities were seen in 29 patients (31%), whereas 10 (11%) had lumbosacral abnormalities. A micturating cystourethrogram was performed in 48 patients, 18 of whom were shown to have vesicoureteric reflux and 2 of whom required surgical correction. Three additional patients required bilateral ureteric reimplantation: 2 had megaureters whereas 1 had bilateral ectopic ureters. Four patients had evidence of chronic renal failure; these included 1 patient with reflux nephropathy, 2 with bilateral dysplastic kidneys, and 1 with neurogenic bladder. The patient with reflux nephropathy underwent renal transplantation at the age of 18 years. Two patients had proximal hypospadias and 4 had undescended testes. A neurogenic bladder was documented in 5 children, 4 of whom had lumbosacral abnormalities. One of these had a spinal lipoma and required excision of the lipoma and untethering of the spinal cord. CONCLUSIONS: We conclude that 30% of patients with low imperforate anus would have associated urologic anomalies, several of which are capable of causing significant morbidity. Thus, all patients with imperforate anus, whether high or low, need to be screened for associated urologic anomalies.

Abnormalities, Multiple↗

PubMed1999

Primary adenocarcinoma of the anus: a retrospective analysis.

PURPOSE: To report the clinical features and outcome of patients with primary adenocarcinoma of the anus following radiotherapy with or without chemotherapy. METHODS AND MATERIALS: A retrospective analysis was performed on 15 patients referred to Peter MacCallum Cancer Institute between 1981 to 1998 with primary adenocarcinoma of the anus. The median follow-up was 7.5 years. Six patients underwent treatment with curative intent-either chemoradiation or radiotherapy alone. Surgery was mainly limited to either incisional or excisional biopsy. The remaining nine patients were treated with palliative intent because of advanced age, advanced disease, or poor medical status. The biological equivalent doses were calculated for all patients and correlated with time to progression. RESULTS: None of the curative group had relapsed after a median follow-up of 6.6 years. All except one were alive and well. No patient developed any serious long-term toxicity and all patients avoided colostomy. All patients managed with palliative intent died with persistent locoregional disease with a median survival of 0.8 year. CONCLUSION: Primary adenocarcinoma of the anus is a very rare disease that precludes a rigorous analysis. This study demonstrates that radiation and in particular chemoradiation are effective therapies consistent with other recent series and analogous to squamous cell carcinomas of the anus. It also emphasizes the poor prognosis of patients treated with palliative intent.

Adenocarcinoma↗

PubMed2000

Posterior sagittal anorectoplasty for failed imperforate anus surgery: lessons learned from secondary repairs.

PURPOSE: The aim of this study was to evaluate secondary operations using a posterior sagittal approach in patients with fecal incontinence and impaction after primary repair of anorectal malformations. METHODS: Twenty patients (14 boys, 6 girls) who had previous failed surgery for imperforate anus underwent secondary operations. The indications for surgery included fecal incontinence (n = 16) and fecal impaction (n = 4). Patients ranged in age from 2 to 30 years (mean, 11 years), with 4 over the age of 20 years. The primary procedures included abdominosacroperineal (n = 7), sacroperineal (n = 10), and perineal (n = 3) pull-throughs. At surgery, none of the patients underwent a diverting colostomy. The rectum was mobilized from the surrounding structures through a posterior sagittal approach. The surgical findings included anteriorly displaced anus (n = 17), laterally displaced anus (n = 3), mesenteric fat surrounding the rectum (n = 4), mega-rectosigmoid (n = 2), and others (n = 3). The rectum underwent reconstruction, which involved relocation of the rectum and anus to surround them with the muscle complex. RESULTS: Patients underwent follow-up for periods ranging from 8 months to 6 years after surgery (mean, 3 years). To evaluate the functional results, fecal continence scores (Templeton and Ditesheim) were calculated for incontinent patients. Of the 16 incontinent patients, 12 achieved continence and 4 some improvement. Of the 4 patients with fecal impaction, 2 achieved daily voluntary bowel movement, whereas the other 2 have mild constipation and need occasional enemas. CONCLUSIONS: Our study suggests that (1) a secondary operation through a posterior sagittal approach can restore fecal continence and is efficacious even in adolescents and adults and (2) a posterior sagittal procedure can be safely performed without a diverting colostomy.

Adolescent↗

PubMed1982

[Urodynamic investigations of bladder disturbances in imperforate anus and Hirschsprung's disease) (author's transl)].

104 children with imperforate anus and 68 children with megacolon congenitum were subjected to careful analysis in respect of postoperative incontinence of urine. This was observed in 20 patients with imperforate anus (19.2%) and 15 patients with Hirschsprung's disease (22%). In children with imperforate anus urine incontinence showed a slight tendency only to spontaneous cure. For example, 19.1% of the children with imperforate anus still showed signs of incontinence 11 years after the first operation. On the other hand, there was often a spontaneous cure of incontinence of urine in children with Hirschsprung's disease, so that 5.8% only of the patients had incontinence after the same period. The causes of incontinence are of a multifactorial nature. Rectourethral fistulas, which can damage the sphincter vesicae externus, play an important part. This is likewise true of sequel operations in the pelvis minor with iatrogenic lesions of the sacral nerve fibres; of associate malformations of the urogenital tract and of the vertebral column; and of chronic relapsing infections of the urinary tract caused by an accompanying encopresis (incontinence of faeces).

Anus, Imperforate↗

PubMed1982

Laser versus electrical cautery in the treatment of condylomata acuminata of the anus.

Thirty-eight patients with condylomata acuminata of the anus, requiring surgical therapy, had the left half of the anus treated with conventional electrical cautery, while the right half of the anus was treated with the carbon dioxide laser at the same time. Patients were questioned about the amount of pain on both sides and were studied for evidence of recurrence. The laser was associated with either more pain or the same amount of pain when compared with that of electrical cautery. Recurrences were first seen more often on the laser side. The cost of the laser treatment to the patient was higher by $50. it is concluded that the laser offers no advantage and may, indeed, be less effective than the conventional electrical cautery in the treatment of condylomata acuminata of the anus.

Anus Neoplasms↗

PubMed1977

Imperforate Anus: a five to thirty year follow-up perspective.

A twenty-five year experience with 284 patients with imperforate anus has been reviewed, with a 5 to 30 year assessment after surgical intervention. The following conclusions seem to be suggested by the study: 1. There was a 20% mortality overall, with the greatest number of these occurring in the Type III high lesions. Eighty per cent of the deaths were unrelated to imperforate anus and resulted from associated anomalies. 2. Eighty-eight per cent of the overall series achieved socially acceptable continence. Four out of five poor results occurred in the Type III high lesions. 3. Functional results achieved in imperforate anus surgery seem more closely related to the anatomy presented to the surgeon than by his choice of operative procedure. 4. Continence is more slowly achieved in an imperforate anus patient than in a normal child. It is an evolutionary process which seems to improve with age, being especially influenced by the social motivation that comes with puberty. 5. An appreciable number of patients with poor musculature for continence remain clean by promptly heeding the defection signals, by avoiding laxative foods, and by enforced constipation. 6. Secondary surgery when the levator sling muscles have been missed or partially bypassed seems to improve continence in a high percentage of patients.

Adolescent↗

PubMed1992

Congenital urethral fistula with normal anus: a report of two cases.

Congenital rectourethral or anourethral fistulae without imperforate anus in males are rare, representing less than 1% of anorectal malformations. We report our experience with two males with "N type" urethral fistulae. One, a 5-year-old boy, presented with recurrent urinary tract infections (UTIs) and passage of urine per anus. Investigations included a voiding cystourethrogram (VCUG), which demonstrated a fistula from the urethra to the anus. On physical examination, a small perianal opening was noted just outside the anus, which drained a small amount of urine after voiding. The fistula was excised via a perineal approach. The second patient is a 5-year-old boy with a long history of recurrent UTI requiring multiple hospitalizations since the newborn period. Chronic renal failure developed as a complication of repeated urinary tract infections. Investigations showed a single hydronephrotic pelvic kidney and a small bladder. He underwent numerous diagnostic and reconstructive procedures including cystoscopy and augmentation cystoplasty. Recurrent infections continued and an N type anourethral fistula was eventually diagnosed. The fistula was located between the anal canal and the membranous urethra. An anterior perineal approach was also used. Both fistulae were easily located, and reconstructive surgery of the urethra was not required. Postoperative VCUGs in both patients were normal. They have been free of infection with normal urinary continence since resection of the fistula. Congenital N type anourethral fistulae are rare, but should be considered in cases of recurrent urinary tract infections. The diagnosis may be missed by endoscopic procedures, but VCUG should demonstrate the fistulous tract.

Child, Preschool↗

PubMed2002

Evaluation of the location of the anus by a modified technique in the neonate.

PURPOSE: The aim of the current study was to bring to notice the anterior displacement of the anus and to recommend the measurement of anal position index in the neonate by a modified method. METHODS: Sixty newborns (34 girls and 26 boys) were taken into study, and the anal position index (API), which is the ratio of anus-fourchette (scrotum) distance to coccyx fourchette (scrotum) distance, was measured. To obtain the measurement, a transparent adhesive tape was placed along the midline on the long axis, covering the anus. The upper and lower tips and the center of the anal circle was marked and measured using a caliber. RESULTS: API was found as 0.46 (SD +/- 0.08) and 0.53 (SD +/- 0.05) in female and male neonates, respectively. Because an index of 0.34 in girls and 0.46 in boys are considered abnormal, the 3 female babies in the study group with API indices of 0.18, 0.28, and 0.33 were subjected to further examination. The abnormality was seen not to be rare in the Aegean region. CONCLUSIONS: An abnormal index alone cannot be the sole cause of constipation mentioned in the literature and therefore not an indication for operation. Anal position index in the neonates could be measured more accurately by the current modified method. If an anterior location of the anus is found early in infancy the baby should undergo follow-up accordingly.

Anal Canal↗

PubMed1994

Ectopic anus in childhood.

The treatment of ten cases of ectopic anus is presented in this paper. The association of constipation with perineal anus due to alignment disturbance of the external sphincter triple loop system during evacuation has been described by Hendren (1978), Leape and Ramenofsky (1978), Upadhyaya (1984) et al. Hendren, Leape and Ramenofsky described two valid surgical techniques for this association. In this paper we describe the effect of non-invasive treatment in patients affected by symptomatic "primary" perineal anus. We also describe the effect of posterior anal transplant via the perineum in six infants and children with vulvar anus. This approach gave good results within three months without having to perform more complex operative techniques (Peña for example). Posterior anal transplant leads not only to an esthetic improvement but also to an improvement in fecal continence, which is sometimes deficient due to reduced anorectal angulation. It appears to us that an adequate perineal spur plays an important complementary role in the complex mechanism which controls fecal continence.

Adolescent↗

PubMed2000

[Reconstruction of anus in low rectum cancer operation].

OBJECTIVE: While low rectum cancer being resected with Mile's operation, the anus was reconstructed in situ simultaneously. METHODS: Thirty cases of artificial anus were perfectly reconstructed in situ with transferring of the gracilis and invaginating of the end of the sigmoid for the outer and inner sphincter of the anus. The artificial rectum valve was used for the rectum angle. RESULTS: The rate of excellent and good operative results reached 90.63%. CONCLUSION: The results show that this method is suitable for radical operation of low rectum cancer and functional incapacitation of the anus from other diseases as well.

Adenocarcinoma, Mucinous↗

PubMed2002

[Externalized anus in patients with advanced ovarian cancer].

OBJECTIVE: Intestinal operations in advanced ovarian carcinoma due to intestinal obstruction are still controversial. DESIGN: The aim of study was to analyse the efficacy of intestinal operation and making anus praeter in the patient with advanced ovarian carcinoma. MATERIAL AND METHODS: A total of 497 patient with ovarian carcinoma were operated in II Department of Obstetrics and Gynecology in 1990-2001. 66 patients with advanced ovarian cancer were analysed with a view to interventions for intestinal obstruction and making the anus praeter. RESULTS: In the group of 497 patients with ovarian carcinoma there were a operations of making anus praeter in 66 cases (13.28%). It was performed during first operation in 40.9%, during SLO in 22.72%, TLO in 16.67% and following operations in 19.70%. In 5 cases (7.58%) there was a liquidatio of anus praeter after an average 8.8 months after intestinal operation. CONCLUSION: Surgical intervention can be of value in removing life-threatening intestinal obstruction and to achieving longer survival with a possibility of receiving a further antineoplastic therapy.

Adult↗

PubMed2005

[Bowel control of elderly low rectal cancer patients after anus-retained operation].

BACKGROUND & OBJECTIVE: Though anus-retained operation has became the first choice in radical cure operation for rectal cancer, most surgeons whom fear of dissatisfied bowel control after operation recommend permanent bowel stoma in abdomen for elderly low rectal cancer patients rather than anus-retained operation. This study was to evaluate the bowel control of elderly low rectal cancer patients after anus-retained operation. METHODS: A total of 80 elderly low rectal cancer patients were divided into > or =75-year old group (39 patients) and 60-74-year old group (41 patients). Clinical data and follow-up data of the 80 patients were analyzed; bowel function and continence of the 2 groups were compared. RESULTS: The postoperative 18-month survival rate of all patients was 98.8%. The bowel control statuses of 76 patients were evaluable, of which 36 were in > or =75-year old group, 40 were in 60-74-year old group. Three months after operation, the bowel function was significantly poorer in > or =75-year old group than in 60-74-year old group (P<0.05), but the difference dissolved 6 months after operation (P>0.05). The time of recovering normal defecation frequency was slightly longer in > or =75-year old group than in 60-74-year old group (P>0.05). The prevalence of grade I incontinence 6 months after operation was significantly higher in > or =75-year old group than in 60-74-year old group (36.1% vs. 12.5%, P<0.05), but all symptoms of incontinence were relieved after treatment. CONCLUSIONS: Most elderly low rectal cancer patients could maintain bowel control after anus-retained operation. Age alone should not be a contraindication to a restorative resection for low rectal cancer.

Adenocarcinoma↗

PubMedDate not supplied

[Duplication of the anus and rectum in an adult. Report of 1 case].

It is reported a case of duplication of the anus and rectum. A 48 year old man, had two functioning rectae, one ending in its normal anatomical topography and the functioning but nor functional supernumerary rectum exteriorized in the left gluteal region trough a rudimentary anus. Histological studys demonstrated a rudimentary sphincter in the ectopic anus, and focal carcinamotous transformation of one of the four adenomatous polyps, encountered protruding through the normally located anus. The anal anomaly was associated with partial agenesis of the sacrum, absence of coccyx, sacral anterior meningomyelocele and hypoplasia of the twelve right rib. The frequency of the anomaly, its histology and embriology, as well as its classification within the malformations of the terminal gut, were revised in the medical bibliography. It is concluded that this type of anomaly has not been classified or describe, before.

Abnormalities, Multiple↗

PubMed1989

Conservative management of Bowen's disease of the anus.

Bowen's disease of the anus is usually treated by wide local excision including macroscopic normal areas if random biopsies show dysplasia. Skin grafting will often be necessary, since areas of microscopic dysplasia may be found at a considerable distance from the gross affected site. In this study of 11 patients with Bowen's disease of the anus we report the results of a more conservative approach. All patients were treated by local excision of the gross affected areas only, and none of the patients required skin grafting. Seven patients were followed for a median of 34 months without macroscopic recurrence, including 3 patients with histologically proven dysplasia in the resection margins. Two patients, one with and one without dysplasia in the resection margins, developed recurrence within a year. One patient with an area of invasive carcinoma was first treated by local excision, but required an abdominoperineal excision 3 months later. One patient lost to follow-up had invasive carcinoma after 3 years. It is concluded that a conservative surgical approach in Bowen's disease of the anus is justified, provided the patients are followed closely.

Adult↗