12 views 0 likes

Dr. Todd Ponsky

Pediatric Surgery · View profile →

Panel Discussion and Case Presentation Part I: Pediatric Bowel Management 2013

Video Published 2019-01-11 Updated 2026-06-10

Timestops (4)

Sacral Ratio Calculation Technique

Detailed instruction on measuring sacral ratio on AP and lateral radiographs using four reference lines, with interpreta…

Case Discussion: Indications for Permanent Stoma

Interactive case exploring when permanent colostomy is indicated, establishing that incapacity to form solid stool is th…

Case Discussions: Prognosis by Malformation Type

Series of cases covering prognosis for Down syndrome patients (80%), rectal bladder neck fistula (15%), and rectal perin…

Cloacal Exstrophy Prognosis

Brief discussion establishing that while most cloacal exstrophy patients are fecally incontinent due to tethered cord, m…

Topic Overview

A panel discussion on prognostic indicators for bowel control in patients with anorectal malformations, focusing on sacral ratio calculation as a predictive tool. The speakers demonstrate how to measure sacral ratio on AP and lateral radiographs, establishing that a ratio of 0.7 or above indicates good prognosis while 0.4 or below predicts fecal incontinence. Through interactive case discussions, they emphasize that fecal incontinence alone is not an indication for permanent colostomy, that presacral masses must be ruled out even in favorable malformations like rectal perineal fistula, and that bowel management with enemas is the preferred approach for incontinent patients who can form solid stool.

Key Takeaways

Sacral ratio ≥0.7 predicts good bowel control; ≤0.4 predicts lifelong fecal incontinence requiring enema management. (1:50)
Fecal incontinence alone is not an indication for permanent colostomy; only inability to form solid stool warrants it. (5:38)
Always rule out presacral mass before prognosticating—even favorable malformations like rectal perineal fistula worsen with hemisacrum. (9:54)
Patients report better quality of life with bowel management programs than with permanent colostomy. (6:25)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — guest
Speaker 2
Speaker 3 — host
Speaker 4 — guest

Chapters

0:00Sacral Ratio Calculation Technique — Detailed instruction on measuring sacral ratio on AP and lateral radiographs using four reference lines, with interpretation thresholds of 0.7 for good prognosis and 0.4 or below for fecal incontinence.
4:14Case Discussion: Indications for Permanent Stoma — Interactive case exploring when permanent colostomy is indicated, establishing that incapacity to form solid stool is the only indication, not fecal incontinence, low sacral ratio, or complex malformations.
7:19Case Discussions: Prognosis by Malformation Type — Series of cases covering prognosis for Down syndrome patients (80%), rectal bladder neck fistula (15%), and rectal perineal fistula with hemisacrum, emphasizing the importance of detecting presacral masses.
10:54Cloacal Exstrophy Prognosis — Brief discussion establishing that while most cloacal exstrophy patients are fecally incontinent due to tethered cord, myelomeningocele, or abnormal sacrum, not all patients are incontinent.

Key claims

1:43In normal patients the sacral ratio is 0.7 or more — Speaker 1
1:50A sacral ratio of 0.7 or more means good prognosis for bowel control — Speaker 1
2:35When sacral ratio is 0.4 or less, the patient will be fecally incontinent regardless of the type of malformation — Speaker 1
2:56We have never seen a patient with a sacral ratio of less than 0.4 that is fecally continent — Speaker 1
2:56A patient with sacral ratio less than 0.4 will need enemas for life — Speaker 1
5:38The only indication for a stoma for life is incapacity to form solid stool — Speaker 1
5:59Patients with bad prognosis for bowel control are not candidates for stoma for life — Speaker 1
6:25Patients subjected to bowel management tell us that the quality of life with bowel management is much better than the quality of life of having a colostomy — Speaker 4
6:55With incapacity to form solid stool there is no bowel management — Speaker 4
7:57Patients with Down syndrome and anorectal malformation have 80% chance of bowel control — Speaker 1
8:01Most patients with Down syndrome have anorectal malformation without fistula — Speaker 1
8:55Only 15% of patients with rectal bladder neck fistula have bowel control — Speaker 1
9:01Rectal bladder neck fistula is a bad malformation in terms of prognosis for bowel control — Speaker 1
9:36Rectal perineal fistula is the malformation with the best prognosis — Speaker 1
9:49Good prognosis depends upon having a good operation, good sacrum, no tethered cord — Speaker 1
9:54It is important to rule out a presacral mass before discussing prognosis for bowel control — Speaker 1
10:19Hemisacrum indicates that the patient has a presacral mass — Speaker 1
10:19If a patient has rectal perineal fistula but also has hemisacrum and presacral mass, the prognosis for bowel control changes completely and cannot be called good — Speaker 1
10:54Many patients born with perineal fistula had terrible problems because the presacral mass was not detected and not treated when surgeons did not take an x-ray film of the sacrum — Speaker 4
11:55The majority of patients with cloacal exstrophy will be fecally incontinent because of high numbers of tethered cord, myelomeningocele, or bad sacrum — Speaker 1
11:55There are a few patients with cloacal exstrophy that are fecally continent — Speaker 1

Cases discussed

9:06Newborn with rectal perineal fistula and hemisacrum on radiograph

Open questions

Is it necessary for gastroenterologists to know what kind of anorectal malformation the patient has?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Sacral Ratio and the Architecture of Prognosis in Anorectal Malformations

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

The Sacral Ratio as Prognostic Threshold

The sacral ratio is calculated from four lines drawn on AP and lateral sacral radiographs: the first follows the sacrum's direction, the second marks the top of the iliac crest, the third marks where the sacrum last joins the iliac bones, and the fourth marks the last identifiable sacral bone. The ratio divides the distance between the second and third lines by the distance between the first and second lines 1:43. In normal patients this ratio is 0.7 or more, which predicts good prognosis for bowel control 1:43 1:50. When the ratio falls to 0.4 or less, the patient will be fecally incontinent regardless of the type of malformation 2:35. One discussant stated flatly: "we have never seen a patient with a sacred ratio of less than 0.4 that is fecally continent" 2:56. These patients will require enemas for life 2:56.

The Single Indication for Permanent Stoma

The only indication for a stoma for life is incapacity to form solid stool 5:38. Patients with bad prognosis for bowel control — low sacral ratio, rectal bladder neck fistula, complex cloacas — are not candidates for permanent stoma 5:59. They are candidates for bowel management. The discussants emphasized that patients subjected to bowel management report that their quality of life is much better than living with a colostomy 6:25. Where there is no capacity to form solid stool, there is no bowel management 6:55 — liquid stool without control would be catastrophic. But fecal incontinence alone, even when predicted by anatomy, does not justify abandoning reconstruction.

Malformation Type Modifies But Does Not Determine Outcome

The type of malformation carries prognostic weight, but it is not destiny. Patients with Down syndrome and anorectal malformation — most of whom have the malformation without fistula — have an 80% chance of bowel control 7:57 8:01. Rectal perineal fistula is the malformation with the best prognosis 9:36. Rectal bladder neck fistula sits at the opposite end: only 15% of these patients achieve bowel control 8:55 9:01. But even good anatomy can be undone by associated defects. Good prognosis depends on having a good operation, a good sacrum, and no tethered cord 9:49.

Hemisacrum as a Red Flag for Presacral Mass

Before discussing prognosis for bowel control, it is essential to rule out a presacral mass 9:54. Hemisacrum on radiograph indicates that the patient has a presacral mass 10:19. If a patient has rectal perineal fistula but also has hemisacrum and presacral mass, the prognosis for bowel control changes completely and cannot be called good 10:19. The discussants described patients born with perineal fistula who had terrible problems because the presacral mass was not detected when surgeons failed to obtain a sacral radiograph before operating 10:54. The lesson is procedural: obtain the films, read them for hemisacrum, and adjust your counseling accordingly.

Cloacal Exstrophy and the Limits of Prediction

The majority of patients with cloacal exstrophy will be fecally incontinent because of high rates of tethered cord, myelomeningocele, or bad sacrum 11:55. But there are a few patients with cloacal exstrophy who are fecally continent 11:55. The discussants did not quantify "a few," but the point stands: even in the most severe malformations, continence is not impossible. The architecture of prognosis is probabilistic, not deterministic. The sacral ratio, the fistula type, the associated defects — these shape the odds, but they do not foreclose the outcome. What they do is tell you which patients will need bowel management and which will not, and that distinction drives every decision that follows.

Takeaways from this story

Sacral ratio ≤0.4 predicts fecal incontinence regardless of malformation type; these patients need lifelong enemas, not stoma.
Incapacity to form solid stool is the only indication for permanent colostomy; fecal incontinence alone is not.
Hemisacrum on radiograph indicates presacral mass, which changes prognosis even in favorable malformations like perineal fistula.
Rectal bladder neck fistula has poor prognosis (15% continence); rectal perineal fistula has the best prognosis.
Always obtain sacral films before surgery to detect presacral masses that will cause problems if missed.

Hemisacrum on Initial Radiograph: When Perineal Fistula Prognosis Collapses

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Case narrative · AI-written, human-reviewed

Presentation

A newborn presented with a rectal perineal fistula, visible on examination. The initial radiograph showed hemisacrum 10:19.

The Decision Point

Rectal perineal fistula carries the best prognosis among anorectal malformations 9:36. With a good operation, intact sacrum, and no tethered cord, these patients typically achieve voluntary bowel control 9:49. The sacral ratio — calculated by dividing the distance between specific anatomic landmarks on AP and lateral radiographs — predicts continence: 0.7 or above indicates good prognosis, while 0.4 or below predicts lifelong fecal incontinence 1:43 1:50 2:35. The discussants have never seen a patient with a sacral ratio below 0.4 achieve continence 2:56.

But hemisacrum changes everything. It indicates a presacral mass 10:19. Even when the anorectal malformation itself is favorable, the presence of hemisacrum and presacral mass fundamentally alters the prognosis for bowel control — the parents cannot be told the prognosis is good 10:19.

The fork: Does the surgeon recognize the hemisacrum on the initial film and adjust the prognostic discussion accordingly, or does the favorable fistula type dominate the assessment and the presacral pathology go undetected?

What Happened

In this case, the hemisacrum was identified before definitive repair. The discussants used it as a teaching point: ruling out a presacral mass is essential before discussing prognosis for bowel control 9:54. The outcome for this specific patient was not described.

One discussant noted that many patients born with perineal fistula experienced significant complications because the presacral mass was not detected and not addressed when surgeons failed to obtain sacral radiographs 10:54. The implication is clear: operating on the fistula without addressing the presacral mass leaves the patient with complications that could have been anticipated and managed differently had the hemisacrum been recognized.

What the Case Changes

The transferable judgment is this: sacral anatomy overrides fistula type in prognostic assessment. A rectal perineal fistula with hemisacrum is not a good-prognosis malformation. The initial radiograph must be examined for sacral defects before any prognostic conversation with the family.

The discussants' approach to poor prognosis is also instructive. A sacral ratio below 0.4 predicts lifelong incontinence 2:35, and these patients will require enemas for life 2:56. But that is not an indication for permanent colostomy 5:38 5:59. Patients on bowel management programs report better quality of life than those with colostomy 6:25. The only indication for permanent stoma is incapacity to form solid stool, because without formed stool, enema-based bowel management cannot work 5:38 6:55.

This distinction matters. A surgeon who sees hemisacrum and poor sacral ratio might reflexively consider permanent diversion. The discussants argue otherwise: even patients with rectal bladder neck fistula — where only 15% achieve continence 8:55 — are candidates for bowel management, not permanent stoma 9:01. The same principle applies to cloacal exstrophy, where the majority are incontinent due to tethered cord, myelomeningocele, or poor sacrum 11:55, yet a few achieve continence 11:55 and the rest can be managed with enemas rather than permanent diversion.

The case teaches restraint in prognostic optimism and restraint in surgical nihilism. Hemisacrum means the prognosis is not good, but it does not mean the patient is unsalvageable. It means the family needs a different conversation, the surgical plan may need to address the presacral mass, and the long-term management will likely involve bowel management rather than spontaneous continence. Missing the hemisacrum means having the wrong conversation, doing the wrong operation, and discovering the error only when the patient fails to achieve the continence the family was promised.

Takeaways from this story

Hemisacrum indicates presacral mass and negates favorable prognosis from perineal fistula alone
Sacral ratio below 0.4 predicts lifelong incontinence but is not an indication for permanent colostomy
Only incapacity to form solid stool contraindicates pull-through; all other poor-prognosis patients are candidates for enema-based bowel management
Patients report better quality of life with bowel management than with permanent colostomy

Sacral Ratio and Presacral Anatomy: Prognostic Markers That Determine Bowel Management Strategy

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Teaching arc · AI-written, human-reviewed

Quantifying the Sacrum to Predict Continence

The sacral ratio is a radiographic measurement that predicts bowel control capacity with remarkable reliability. On both AP and lateral sacral films, four lines are drawn: the first along the direction of the sacrum, the second at the top of the iliac crest, the third where the sacrum last joins the iliac bones, and the fourth at the last identifiable sacral bone 1:43. The ratio is calculated by dividing the distance between the second and third lines by the distance between the first and second lines. In normal patients the sacral ratio is 0.7 or more 1:43, and a ratio at or above this threshold means good prognosis for bowel control 1:50.

When the sacral ratio falls to 0.4 or less, the patient will be fecally incontinent regardless of the type of malformation 2:35. The discussants emphasized that they have never seen a patient with a sacral ratio below 0.4 achieve fecal continence 2:56. This is not a relative contraindication to reconstruction — it is an absolute predictor. These patients will need enemas for life 2:56, but that does not mean they need a permanent stoma.

The Single Indication for Permanent Colostomy

The only indication for a stoma for life is incapacity to form solid stool 5:38. Fecal incontinence, low sacral ratio, unfavorable malformation type — none of these justify permanent fecal diversion 5:59. Patients subjected to bowel management report that their quality of life with a structured enema regimen is much better than life with a colostomy 6:25. With incapacity to form solid stool there is no bowel management 6:55 — liquid stool without control is unmanageable — but for patients who can form stool, even those with poor prognosis for spontaneous continence, bowel management is the answer, not a permanent stoma.

Malformation Type Modifies but Does Not Determine Prognosis

Patients with Down syndrome and anorectal malformation have an 80% chance of bowel control 7:57, in part because most have anorectal malformation without fistula 8:01. At the opposite end of the spectrum, only 15% of patients with rectal bladder neck fistula achieve bowel control 8:55 — it is a bad malformation in terms of prognosis 9:01. Rectal perineal fistula is the malformation with the best prognosis 9:36, but good prognosis depends upon having a good operation, good sacrum, and no tethered cord 9:49.

Hemisacrum Signals Hidden Pathology

It is important to rule out a presacral mass before discussing prognosis for bowel control 9:54. Hemisacrum on plain film indicates that the patient has a presacral mass 10:19. If a patient has rectal perineal fistula but also has hemisacrum and presacral mass, the prognosis for bowel control changes completely and cannot be called good 10:19. Many patients born with perineal fistula had terrible problems because the presacral mass was not detected and not treated when surgeons did not take an x-ray film of the sacrum 10:54. The lesson: obtain sacral imaging before counseling families and before operating, even in favorable malformations.

Complex Malformations Carry High Incontinence Risk but Not Absolute

The majority of patients with cloacal exstrophy will be fecally incontinent because of high numbers of tethered cord, myelomeningocele, or bad sacrum 11:55. But there are a few patients with cloacal exstrophy that are fecally continent 11:55. The discussants' point: even in the most severe malformations, continence is not impossible, and the decision tree still begins with the sacral ratio and the capacity to form solid stool, not with the diagnosis alone.

The Framework

The teaching arc here is a decision algorithm built on measurable anatomy. Sacral ratio below 0.4 predicts incontinence but not the need for permanent diversion. Inability to form solid stool is the only absolute indication for colostomy. Malformation type refines the estimate but does not override sacral anatomy. And hemisacrum, even in a favorable malformation, signals presacral pathology that changes everything. The discussants returned repeatedly to this point: prognosis is not guesswork — it is radiographic measurement, anatomic assessment, and honest counseling about what bowel management can and cannot achieve.

Takeaways from this story

Sacral ratio below 0.4 predicts fecal incontinence but not the need for permanent colostomy — these patients are candidates for bowel management.
Hemisacrum on plain film indicates a presacral mass that changes prognosis even in favorable malformations like rectal perineal fistula.
The only indication for permanent stoma is incapacity to form solid stool — not low sacral ratio, not unfavorable malformation type.
Rectal bladder neck fistula has only 15% bowel control rate; Down syndrome with anorectal malformation has 80% — malformation type matters.

Keywords

anorectal malformation Down syndrome rectal bladder neck fistula rectal perineal fistula cloacal exstrophy fecal incontinence presacral mass hemisacrum tethered cord myelomeningocele sacral ratio calculation bowel management enemas colostomy pull through

Hashtags

#PediatricSurgery #Gastroenterology #AnorectalMalformation #FecalIncontinence #BowelControl #SurgicalPrognosis #PediatricCare #MedicalEducation #ClinicalPractice #DownSyndrome #Surgery #PatientCare #Healthcare #SurgicalTechniques #PediatricGastroenterology #MedicalTraining #Anatomy #PatientOutcomes #ClinicalAssessment #BowelManagement #ColorectalSurgery

Transcript

Show you how to calculate the sacred ratio because as you saw in Doctor Pena's presentation many times we said a normal sacrum and I just saw that there's a question here in the poll asking if it's necessary for the gastroenterologist to know what kind of anorectal malformation. The patient has, well, ideally yes because that it correlates with the prognosis, but in our center we actually received many patients that were operated in China and we don't have access to any of their medical records. In that case we don't know what malformation they have and what we are looking for are signs to tell if this patient was born with good prognosis or not and the. Sacrum is one excellent sign to help us if the patient has good prognosis for bowel control or bad prognosis for bowel control, and I'll show you how to calculate right now. So here you can see an image of the sacrum and the 3 lines, the 4 lines that we're gonna draw, the first one is the middle one where we wanna draw the line in the direction of the sacrum. Then on the top line, we wanna go to the top of the iliac crest. The the second line is where the sacrum joins the iliac bones for the last time and the last line is the last bone of the sacrum that you can identify. Some patients have a. Coccyx other patients don't have a coccyx and then you're gonna divide and I'm gonna try to show with my arrow here you're gonna divide the distance between the 2nd line and the 3rd line by the distance between the first line and the 2nd line. And we know that in normal patients this ratio is 0.7 or more. So if you calculate the sacral ratio and your patient has 0.7 or more, that means good prognosis for bowel control, and we should do the same thing on the lateral view. So the first line is just on the direction of the sacrum the line A is on the top of the iliac. Bone line B is at the last point where the sacrum joins the iliac bone and the last line, line C, is at the last bone of the sacrum. Sometimes it will be the coccyx, sometimes it won't be, and then you divide, you divide the BC, the distance between B and C, to the. Distance between A and B and again 0.7 or above it's good prognosis for bowel control and when we have 0.4 or less, that means that the patient will be fecally incontinent regardless of the type of malformation that the patient has we have. Never seen a patient with a sacred ratio of less than 0.4 that is fecally continent, so if you calculate and you find 0.4, you know that this patient is fecally incontinent and he or she will need enemas for life. So now we're gonna see in a real case, so that's the first line. The second line in the top of the iliac bones some somebody's moving. The third line at the last point where the sacrum touches the iliac bone and the final line at the last bone that you can identify in this case the sacrum ratio was 0.6 and now in the lateral view we are gonna draw the first line on the direction of the sacrum. Line A is in the top of the iliac crest. Line B is at the last point where the iliac bones touch the sacrum, and then at the last bone we can identify and the lateral view was 0.7. So now we're gonna move to some case discussion to see if you already learned the first portion of this session. So we're gonna go to case discussion number one. So be ready to answer all the questions so we can see if you're really learning or if you're not paying attention. Yeah. You come up here first, OK? You want me to do it until it loads on you. So the first question. Is in which patient with anorectal malformation, a stoma for life is indicated. Option one, the ones that will be fecal incontinent. Option two, patients with a sacred ratio of less than 0.4. Option three, rectal bladder neck fistula. Option 4, complex cloacas. Option 5, none of the above. Please answer the questions and let's see what's the answer of the poll. Can you put the pole up? I'm activating. OK. Um, they may have to put their answers in the chat. People can write their, uh, their answers in the chat box as well. Do we have access to the chat? Uh, why don't you just go ahead and. So this one you were lucky you didn't have to answer but the answer is they did OK so the answer is none of the above we don't think the only indication for a stomach for life is incapacity to form solid stool because in. Those cases they are not going to respond to our bowel management as you're going to learn throughout the show. So all of those others, if the patient has bad prognosis for bowel control, that does not mean that he's a candidate for stoma for life. So Andrea, a lot of people answer number 2. Number 2, sacred ratio less than 0.4. That's because we didn't explain yet how to do bowel management. Once they learn how to do bowel management and treat patients with enemas, then they will know that this is not an indication for a stoma for life. Because the bowel management that we are discussing today is for patients with fecal incontinence, and our patients subjected to bowel management. Believe and they tell us that the bowel, the quality of life that they have with bowel management is much better than the quality of life of having a colostomy and that's why the only contraindication for a pull through or the only indication for a permanent stomach. Is a patient that is incapacity to form solid stool because with incapacity to form solid stool there is no bowel management and it would be tragic to have liquid stool and with no control in the underwear. So options 123, and 4 means that they are good candidates for bowel management with enemas, but they do not need a colostomy for life. So we're gonna move to the next question. So the next question, this is a male patient born with anorectal malformation and Down syndrome, so what is the prognosis for bowel control? This is just to see if you paid attention when Doctor Pena was speaking. So everybody can answer. Yeah, please, uh, for these couple of polls, just type your, your response into the chat box. So you tell us what the answer is. So 100%, 80%, 60%, 40% or 20%? We got some twos and threes, OK? And the answer is number 2. So patients with Down syndrome, if you remember from the talk, most of them, they have the anorectal malformation without fistula and they have a good prognosis for bowel control, 80% chance of bowel control. We're gonna move to the next question. If you have any questions, just please write in the chat and we'll be happy to answer. So this is a 3 year old male patient born and operated due to rectal. Bladder neck fistula. Parents want to know what is the prognosis for bowel control in a patient with rectal bladder neck fistula 95%, 75%, 50%, 25%, or 15%? Oh, some people in Brazil already know the answer. Some people in California also know the answer. So what's the answer? 5. Very good, 5. Only 15% of the patients have bowel control. It's a bad malformation in terms of prognosis for bowel control. So the next question, this is a newborn with a rectal perineal fistula. So look very carefully in his, um, x-ray cause I'm gonna ask you what's the prognosis for bowel control. So everybody looks careful, examine everything that you can. Take your time. Take your time. And I'm gonna move to the next slide so you can answer. So regarding the prognosis for bowel control, this patient has a 100% chance of bowel control because he has a rectal perineal fistula and it's the malformation with the best, best prognosis. Good prognosis depends upon having a good operation, good sacrum, no tetrachord. It is important to rule out a pre-saccrum mass before discussing prognosis for bowel control or options two and three. We're getting a lot of 4s here. A lot of 4s. Oh, I see that my panelists, they get all of them right. I'm so proud. Very good. Options two and three. So, now we're going to go back to the x-ray so we can see for those of you that didn't notice, this patient has a hemisacrum right here and that indicate, Indicates that the patient has a presacral mass and even if the patient has a rectal perineal fistula, if we saw a hemisacral and a presacral mass that changed the prognosis for bowel control completely in this case we cannot tell the parents that the prognosis is good, very good people are doing very well. And we have seen, we have seen many patients in our hospital that were born with a perineal fistula. The surgeons did not take an extra film of the sacrum. They operated the perineal fistula, and the patient has terrible problems because the, the presaccular mass was not detected and was not treated. Now the next question, all patients with cloao atrophy will be fecally incontinent? Is this true or false? Option one or option two? Some people are saying I don't have that option, so you will have to pick one, true or false. So the thing we have to do is wait about 10 seconds because all the viewing audience is 10 seconds behind us. Oh, so I'm giving the answer to them. So you have to wait about 10 seconds. No, they're, everything's, but so we have to wait when they type. So everyone is saying 2. Everyone is saying false. That's very good. It's false. Not everybody. The majority of patients with cloaco atrophy will be fecally incontinent because we have a huge number of tetrachord of myelomeningocele of bed sacrum, but there are a few patients that are fecally continent, so very good the answer is false. Mm Is that the end? That's the end. So now we're gonna move.

Comments

Loading comments…