Colorectal Quiz: Episode 2

Many patients are seen on laxatives with an anus in the wrong place, and many patients have had cecostomy with perfect anatomy.

Families care whether the anoplasty will work and whether the child will be clean and in normal underwear, not how technically elegant the surgery is.

A sacral ratio of 0.7 or greater usually means normal or close to normal sphincters and good muscle tone, indicating that spine innervation of that area is probably good.

Higher anorectal malformations have worse prognosis for continence.

Patients with myelomeningocele have much more trouble with continence than those with tethered cord.

Visual inspection looks for the anal dimple and a midline raised area where the sphincters are and where the anoplasty ought to be.

It is amazingly common to have a mislocated anus because surgeons either miss where the center is during laparoscopic pull-through or open the PSARP incision first before marking sphincters.

A key pitfall is opening the PSARP incision first; instead, mark the sphincters first, then open the PSARP, to avoid confusion when placing the anoplasty.

The electrical stimulator used for sphincter mapping is the same one anesthesia uses for train of four, with an inexpensive connection with little pins.

Anesthesiologists should not give skeletal muscle relaxant when using the electrical stimulator because it is weaker than the traditional expensive stimulator.

In higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated.

If the anatomy is known to be off, the redo should be done, and there is an advantage to getting the anatomy right when the child is younger.

For a two-year-old with mislocated anus or bad prolapse, offer a redo and let them live in diapers for a year or two with better anatomy, then see if they can successfully potty train.

Many patients present after potty training age because they are incontinent, and evaluation reveals the reason is they did not have the best operation.

When doing a redo for incontinence in an older child, usually add a Malone at the same time so they can learn to get control with their new anatomy before attempting voluntary bowel movements.

The process of learning control with new anatomy after redo may take six to twelve months.

For a patient with an anoplasty 50% within the sphincter complex at three and a half years old who is incontinent, one approach is to redo them, do a Malone, get them perfectly clean mechanically, then see if they can develop bowel control.

An alternative approach for borderline anatomy is to be more conservative and let the child take their car out for a ride first to see how it works before considering redo.

If patients have not declared their continence yet because they are not old enough behaviorally, give them a chance as they may succeed.