Long-term functional evaluation of fecal continence after laparoscopic-assisted pull-through for high anorectal malformations.

BACKGROUND: The use of laparoscopy while performing an abdominal dissection for the mobilization of rectovesical fistula should have an impact on anorectal function, as compared to the original posterior sagittal anorectoplasty, where muscle complex was not cut and the rectum was pulled in a way similar to the old techniques for the abdominoperineal pull-through. This necessitates a functional reevaluation.

MATERIALS AND METHODS: A prospective case study included 15 patients treated with a laparoscopic-assisted pull-through for high anorectal malformation. Laparoscopy was used for abdominal dissection and ligation of the fistula, with the pull-through completed by a small perineal incision centered over the external sphincter. Nine of them are now older than 3 years for fecal continence evaluation. After the approval of the Ethical Committee for Medical Research in the Department of Surgery at Ain Sams University (Cairo, Egypt) and obtaining an informed consent from the parents, they were subjected to a full clinical history and a checklist about motions and soiling to be filled in over 1 month, a barium enema to check for any dilatation, anorectal manometry to evaluate resting pressure, maximum squeezing pressure, and sphincter relaxation, and MRI (magnetic resonance imaging) to evaluate the central situation of the rectum within the sphincter and the degree of development of the sphincter. Their degree of continence was graded according to the Kelly score.

RESULTS: Six of 9 patients are clean without any attacks of fecal soiling or incontinence, and they evacuate spontaneously but need the application of a rectal suppository for evacuation from time to time. The remaining 3 patients had variable degrees of fecal incontinence. One of them had mucosal prolapse and was excised with good cleanliness postoperatively. The remaining 2 patients are managed by medical control and they are clean with minimal soiling when stools are loose. MRI and barium enema showed a centrally placed rectum in the muscle complex without dilatation in all cases. Manometry showed a high resting pressure that decreased on straining in the 7 clean patients and low in 2. The resting pressure did not increase on squeezing and all showed weak rectoanal inhibitory reflex (RAIR). One patient developed dysurea and constipation 1 year after surgery, as diagnosed by VCUG (voiding cystourethrogram) to have a diverticulum at the site of excised fistula causing rectal and urethral obstruction treated by a transabdominal excision with a good functional result.

CONCLUSION: The state of continence with the laparoscopic technique in high anorectal malformations in this study showed acceptable results but needs bigger series with longer follow-up for a proper evaluation of this technique.