ORIGINAL ARTICLE

POSTERIOR SAGITTAL ANORECTOPLASTY IN ANORECTAL MALFORMATIONS

Aamir Hanif Khan, Mukhtar Hussain, Iram Uzma Khalid*, Haroon Khurshid Pasha
ABSTRACT
OBJECTIVES: To assess the fecal continence after posterior sagittal anorectoplasty (PSARP) in patients of high
variety of anorectal malformation and to describe complications of PSARP.
DESIGN: Descriptive study.
PLACE AND DURATION OF STUDY: The study was conducted in the Department of Paediatric Surgery of
st
st
Nishtar Medical College and Hospital, Multan. The duration of study was three years from 1 May 2005 to 31
December 2007.
PATIENTS AND METHODS: 30 patients of high variety anorectal malformation with sigmoid colostomy were
inducted. The ages were 6 months or above. They were without any other gross anomaly. PSARP was performed
according to Pena & deVries modification and the results were evaluated after colostomy closure. Kellys method
was applied for assessment of grade of continence after 3 months, 6 months and one year of colostomy closure.
Early and late complications of PSARP were also noted.
RESULTS:
Early complications were perianal excoriation (33.3%) bleeding (3.3%), retraction (6.7%) and
wound infection (10%). Stenosis (16.7%) and mucosal ectropion (6.7%) were two major late complications. Grade
of continence was good in 23.3% patients, fair in 46.6% and poor in 30.0% patients after 3 months of colostomy
reversal. After one year the grade was good in 26.7%, fair in 53.3% and poor in 20.0% patients.
CONCLUSION: Pena and deVries PSARP is a good procedure for high variety of anorectal malformations. It gives
good results with minimal complications. Initial poor results should not discourage the surgeon as the condition of
patient and grade of continence keeps on improving as child grows.
KEY WORDS: Anorecal malformation, posterior sagittal anorectoplasty, Kellys method.

INTRODUCTION:
The malformations of anorectum are among the
commonest
congenital
anomalies1.
The
description of this condition has come a long
way since the time of Soranus, while Paulus
Aegineta wrote the earliest surviving account of
surgery for imperforate anus2. Through ages
various surgeons have tried to restore these
patients to normality both anatomically and
physiologically3. Anatomical correction being
relatively easy to obtain, the main challenge
facing the surgeon today is to achieve
continence.
Department of Pediatric Surgery,
Nishtar Medical College & Hospital, Multan.
*Department of Paediatric Surgery Children
Hospital Complex, Multan
Correspondence:
Dr. Muhammad Amir Hanif Khan
Senior Registrar, Department of Pediatric Surgery
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Most of low varieties are corrected surgically in

single stage at birth. Colostomy is performed in
cases of intermediate and high varieties,
followed by anorectoplasty at a later age and
then colostomy closure.
In 1982, Pena and deVries gave description of
posterior sagittal anorectoplasty4, which is a
landmark in surgery of Anorectal malformations.
This procedure is now time-tested but not free of
complication. Apart from different early and late
complications, continence is the major issue
related to the PSARP. There are various methods
of assessment of degree of continence after
PSARP5. Some of methods like McGill5,
Kieswetter and Wingspread6 are used for
qualitative assessment and others like Tempelton
& Diteshiem7 and Kellys5 are used for
quantitative assessment.
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NMJ 2009; 1(1): 14-18

POSTERIOR SAGITTAL ANORECTOPLASTY IN ANORECTAL MALFORMATIONS

A descriptive study was conducted to know the

different complications and results of PSARP in
a developing country using the Kellys method.
Table I: Kellys method of fecal continence assessment (n=30)
Score
A Staining
No staining, always clean
2
Occasional staining
1
Always stained
0
B Occurrence of accidental defecation
Score
None
2
Occasional
accidents,
feces/flatus 1
escape
Constant
0
C Strength of sphincter squeeze on Score
digital examination
Strong and effective squeeze
2
Weak and partial squeeze
1
No contraction
0
D Total score (Range)
0-6 points
Good
5-6 points
Fair
3-4 points
Poor
2 points or less

PATENTS AND METHODS:

The study was carried out in the department of
Paediatric Surgery. Nishtar Hospital, Multan,
over a period of three years from 1st January,
2005 to 31st December, 2007. The patients of
high variety Anorectal malformation with
sigmoid colostomy performe at neonatal age
were inducted in the study. All patients were
admitted from out patient department. History
and examination were performed keeping in
mind the possibilities of associated urogenital,
skeletal, cardiac and respiratory anomalies.
Lumbosacral spine and chest tomograms were
taken to rule out any vertebral or cardiac
anomalies. Distal colostogram lateral view was
obtained to identify the fistula with urinary tract
and also to assess the length of blind rectal
pouch. Abdominal USG and IVU were used to
rule out abnormalities of urinary tract.
Echocardiography was performed in clinically
suspected cases of cardiac anomalies. Complete
blood count and urine analysis were done for
preparation of general anesthesia and to rule out
any acute infection.
Posterior sagittal anorectoplasty was performed
according to Pena and deVries8 by one of the

Nishtar Medical Journal Vol 1, No 1January March 2009

consultants pediatric surgeons. Urethral catheter

was kept for ten days. Anal dilatation was started
two weeks after the procedure, with easily
passing Hager dilator at that time. Initially it was
done daily and the size of dilator was increased
up to twelve for patient below one year of age
and fourteen for patients above one year of age.
Colostomy was closed after about three months
of PSARP.
Patients were called for follow up initially
fortnightly for three months and then monthly
for one year. Grading of continence was done
following the Kellys method.
RESULTS:
Thirty cases were included in study. There were
22(73.3%) male patients and 8(26.7%) female
patients. Maximum number of patients
14(46.7%) were between 7-10 months of age,
followed by 8(26.7%) patients of 11-15 months.
6 (20%) were between 15-24 months and
2(6.6%) were of 24-30 months.
Among the early complication perianal
excoriation seen in 10(33.3%) patients, wound
infection in 3(10%), Retraction in 2(6.7%) and
bleeding in 1(3.4%). Anal stenosis (5 patients,
16.7%) and Mucosal ectropion (2 patients, 6.7%)
were two major late complications.
Table II: Staining (n=30)
S/N
Score
After
3 months
1
No
7(23.3%)
2.0
2
Occasional
17(56.7%)
1.0
3
Always
6(20.0%)
0.0
Total
30(100%)

After
6 months
8(26.6%)

After
12months
10(33.3%)

16(53.3%)

16(53.3%)

6(20.0%)

4(13.4%)

30(100%)

30(100%)

On grading of continence, according to Kellys

method, the first component is staining. There
was no staining in 7(23.3%) patients after 3
months, in 8(26.6%) patients after six months
and in 10(33.3%) patients after one year (TableII). Second component of Kellys method is

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NMJ 2009; 1(1): 14-18

POSTERIOR SAGITTAL ANORECTOPLASTY IN ANORECTAL MALFORMATIONS

accidental defecation. Constant accidental

defecation was seen in 4 patients (13.3%) after 3
months. This figure remained same even after
one year (Table-III). Third component is
Strength of sphincter squeeze on P/R
examination. It was weak in 16 (53.3%) patients
after three months. This figure rose to 18(60.0%)
after one year (Table-IV). Combining all, grade
of continence was good in 7(23.3%) patients
after three months and in 8(26.7%) patients after
one year.
Table III: Accidental Defecation (n=30)
S/N
Score
After
3 months
1
2
3

None (2.0)
Occasional (1.0)
Constant (0.0)
Total

8(26.7%)
18(60.0%)
4(13.3%)
30(100%)

After
6 months

After
12 months

9(30.0%)
17(56.7%)
4(13.3%)
30(100%)

10(33.3%)
16(53.3%)
4(13.4%)
30(100%)

DISCUSSION:
Anorectal malformation is a common congenital
anomaly with an average incidence of around 1
per 5000 live births2. It is more common in male
population12. In our study there were 22(73.3%)
male patients and 8 (26%) were female patients.
This figure is very close to 65% given in a series
by Pena2. The maximum number of patients (14
patients, 46.7%) in our study undergoing PSARP
were between 7-10 months of age, while
minimum (2 patients, 6.6%) were above 2 years
of age. The older age in our children is because
of poor nutrition and poor follow up.
PSARP was described by Pena and deVries in
19824. Since then it has become a procedure of
choice for management of high and intermediate
varieties as it is an easy, convenient and a
promising technique. Originally it was started as
a 2nd stage procedure in management of high and
intermediate cases of ARM but now a growing
number of authors are advocating for single
stage PSARP at neonatal age as Adeniran did in
his study9, 10. Even now Pena advocates that 3
months of age is more appropriate for PSARP11.

16

There are also trials to do PSARP with the help

of Laprocsope12.
Among the early complications, perianal
excoriation was most frequent, seen in 10
patients (33.3%). Bleeding was encountered in 1
(3.3%), retraction of rectal loop in 2 (6.7%) and
wound infection in 3 (10.0%) patients. This
percentage is higher than 0.45% given by Pena
in a series2. Nakayama also described wound
dehiscence or infection as a major
complication13. Although we did not encounter
but Nakayama also described retraction as
another major complication. In his point of view
retraction occurred as a consequence of
inadequate length of neo-rectum or poor blood
supply. Among the late complications, stenosis
of anal canal occurred in 5 (16.7%) patients.
Mucosal ectropion found in 2 (6.7%) patients.
No urinary fistula was persistent after repair.
Nixon reported anal stenosis in 30 % patients of
his series14. He also described mucosal prolapse
in 23% of his operated cases.
There are various methods of assessment of
degree of continence and results of PSARP4.
McGill, Kiesswetter5, Kelly and some others
described methods of quantitative and qualitative
assessment. In this study we have applied
Kellys criteria for assessment of continence. It
is by far the simplest of all scoring systems and
the easiest to apply even in the office settings4.
The results were judged on the basis of staining,
accidental defecation and strength of sphincter
squeeze on per rectal examination.
Table IV: Strength of Sphincter Squeeze Onper Rectal Examination
(n=30)
S/N
Score
After
After
After
3 months
6 months
12 months
1
Strong Squeeze 2.0
6(20.0%)
7(23.3%)
7(23.3%)
2

Weak squeeze 1.0

16(53.3%)

16(53.3%)

18(60.0%)

No contraction 0.0

8(26.7%)

7(23.4%)

5(16.7%)

Total

30(100%)

30(100%)

30(100%)

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NMJ 2009; 1(1): 14-18

POSTERIOR SAGITTAL ANORECTOPLASTY IN ANORECTAL MALFORMATIONS

In this study we have compiled results on the

basis of observations and examination made
after 3, 6 and 12 months of colostomy closure.
At the end of one year almost half of the patients
were around 3 years of age which is appropriate
age for assessment of continence level. Staining
was occasional in 16(53.3%) patients after one
year. This figure is almost equal to that of Pena2,
who found soiling in 57% of his patients.
Similarly Nixon mentioned 40% of patients with
occasional soiling14. All these results are quite
different from Rintala15, who showed occasional
staining in 14% of his patients. There was
occasional accidental defecation in 16(53.3%)
patients after one year. Although Chen16
reported only 3% of his cases with accidental
defecation, while Nixon reported 20% of cases
with same problem14. Rintala gave a figure of
22% for the patients having accidental
defecation15.
The sphincter squeeze was assessed on per rectal
examination after three months, six months and
one year. Strong squeeze was seen in 23.3% of
our cases which is quite low than that of Kubota,
who showed good squeeze in 55% of patients
undergoing PSARP17. Yuan also concluded that
45% of his patients had strong squeeze of
puborectalis after PSARP18. Low percentage of
sphincter squeeze in our study is probably due to
poor muscle complex as all cases of our series
were of high variety.
Table V: Grade Of Continence (n=30)
S/N
Grade
After
After
3 months
6 months
1
2
3

Good 5-6
Fair 3-4
Poor <3
total

7(23.3%)
14(46.6%)
9(30.0%)
30(100%)

8(26.7%)
15(50.0%)
7(23.3%)
30(100%)

After
12 months
8(26.7%)
16(53.3%)
6(20.0%)
30(100%)

Normal level of continence, which includes the

differentiation between flatus and faeces is very
difficult to achieve in high variety of anorectal
malformation19. As normally developed anus has
normal level of proprioception, which is
essential for this sense of differentiation, so it
Nishtar Medical Journal Vol 1, No 1January March 2009

does not remain intact in cases of high variety of

ARM20. In our study 10 (33.3%) patients showed
good results after one year. Nixon mentioned
good results in 40% of patients14, while Tsuji
showed good results in 48% of patients. After
one year 53.3% patients were fairly continent in
our study. This is almost equal to 48% of Tsuji21
but very low than a figure of 97% reported by
Chen16. In our series 5 patients (16.7%) were
poorly continent after one year. This is slightly
higher than Tsuji21 and Liem22. Both of their
series showed only 4% of patients with poor
results. But our result is same to that of Nixon14
who mentioned poor results in 20% of his
patients. During study it was noted that grade of
continence kept on improving as the child grew
up i.e. after one year the patients were more
continent than they were after three months.
Rintala also observed the same point23.
CONCLUSION:
1. To achieve good results and avoid
complications, Pena and de Vries PSARP is
a good procedure for high variety of
Anorectal malformation.
2. Initial poor results should not discourage the
surgeon as the condition of patients and
grade of continence keep on improving as
child grows.
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malformation. In: Aschcraft KW, Holcomb GW,
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2. Pena A, Marc AL. Anorectal malformation. In:
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(edi). Paediatric Surgery. Philadelphia. Mosby;
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3. Holschneider AM, Jesch NK, Stragholz E,
Pfrommer W. Surgical Methods for anorectal
malformations from Rehbein to Pena critical
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Nishtar Medical Journal Vol 1, No 1January March 2009