Surgical management of anorectal malformations: a unified concept

Abstract

Posterior sagittal anorectoplasty (PSARP) is a new approach for the treatment of anorectal malformations. It has allowed direct exposure of the anatomy of these defects, enabling the author to describe the spectrum of this malformation. It also permits patients to be grouped on the basis of their potential for continence and the correlation of operative findings with clinical results. Traditional anatomic concepts have proved very inaccurate. The new approach allows separation of rectum from genitourinary tract without damaging important structures. The rectum is located within the limits of the striated muscle structures in a precise manner. This approach has important implications for therapy, evaluation of results, classification, and terminology. All defects can be treated with PSARP. The size of the incision will vary according to the complexity of the malformation, from minimal PSARP in low malformations to full PSARP in higher defects. In addition, approximately 10% of all cases will require a laparotomy. Colostomy is recommended in most patients except for those with low malformations. A new classification is proposed based on practical therapeutic purposes. Patients are also grouped according to their common potential for continence, which is important for the evaluation and comparison of results. The decision to create a protective colostomy is based on clinical facts in 80%–90% of cases and on invertograms and other diagnostic tests in the remaining 10%–20%.