Anorectal malformations--update 1998.

Anorectal malformation is a common congenital anomaly. Its correction still challenges the wisdom and expertise of the pediatric surgeon. From 1977 through 1997, approximately 400 cases of this anomaly were treated at this institution. Prior to 1985, cut-back anoplasty and translocation anoplasty were the treatments of choice for the low anomalies, and abdominoperineal pull-through anoplasty or sacroperineal anoplasty (and their modifications) preferred for the intermediate or high defects. Since 1985, posterior sagittal anorectoplasty (PSARP) has been adopted exclusively as the operative procedure for the correction of the entire spectrum of anorectal malformations. Two hundred patients have undergone this procedure either primarily (N = 166) or secondarily (N = 34). PSARP is a procedure which enables the surgeon to repair the pelvic anatomy under direct vision, maximally utilizing all the existing continence muscles and hence resulting in better fecal continence. With minimal, limited or maximal division of the continence muscles under one same skin incision, the entire spectrum of this defect can be repaired. The result of cosmesis is generally regarded as better, and the immediate postoperative complications are fewer. In spite of all efforts, 10 to 30% of patients still suffer from total fecal incontinence which is intractable to all kinds of medications and enemas. A bowel management program with large volume enemas, either through the anus or a Malone appendicostomy, retrogradely or antegradely, to wash out stool in the colon and rectum may be necessary to keep the patient clean and more socially acceptable. Biofeedback therapy offers another alternative to improve continence with the development of better computer systems and manometry equipment. This review provides a new concept of the fecal continence mechanism and an operative procedure for constructing a new anorectum based on this concept for the treatment of patients with anorectal malformations.