Kifayat Khan.
Modified posterior sagittal anorectoplasty for the treatment of patients with anorectal malformations.
J Surg Pak Jan ;11(3):100-3.

Objectives: The aim of the study was to assess the results of modification in the posterior sagittal anorectoplasty (PSARP) as devised by Alberto Pena for in patients with anorectal malformations (ARM). Design of Study: Interventional study. Place and duration of study: This study was carried out at the Department of Paediatric Surgery, Postgraduate Medical Institute Lady Reading Hospital Peshawar, form January 2003 to December 2004. Patients and Methods: Forty patients were studied who underwent a modified PSARP. The following technique was adopted. Incision starting from the tip of the coccyx up to the margin of the external anal sphincter muscle complex without cutting it. Levator ani muscle was split preserving the external anal sphincter complex, which was identified by electrical stimulation. Genital or urethral fistula dissected from outside without opening the rectal pouch and divided between the clamps. Fistula was transfixed or repaired with polyglycolic sutures. Rectum was then mobilized to an adequate length. Center of the external anal sphincter complex was identified with a muscle stimulator. Cruciate skin incision was made and cutaneous flaps raised at the proposed anal area. A tunnel was made in the center of the sphincter muscle complex through which the mobilized rectum brought down and stitched with the anal skin to make the neoanus. Rest of the management was similar to the classical PSARP. Patients were followed up in the out patient department and faecal continence was assessed for an average period of 2 years. Results: A total of 40 patients with ARM were studied. There were 25 males and 15 female infants. Age ranged from 6-12 months. Isolated modified PSARP was performed in 35 infants while in 5 patients this procedure was combined with abdominal approach. Post-operative course was uneventful except one death and one burst abdomen. The shape, size and location of the anus were acceptable in all patients. Anal stenosis resulted in 3(7.5%) patients, rectal mucosal prolapse in 4(10%), faecal soiling, and incontinence of faeces in 17(43.58%) and 07(17.05%) patients respectively. Faecal continence was good in 15(38.46%), fair in 17(43.58%) and poor in 07(17.94%) patients respectively. Conclusions: This modification in PSARP allows the surgeon to accurately identify and preserve the anatomic structures that are relevant for faecal continence. Our results of the present series suggest that this procedure is a valuable alternative to classical PSARP for the treatment of anorectal malformations.

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