Evaluation of rectum and sphincter localization in patients undergone laparoscopic-assisted anal atresia repair with magnetic resonance imaging to analyze fecal incontinance and diverticulum

Abstact İntroduction and Aim of Study Anorectal malformations (ARM), consist of some different deformity of congenital structures including anus and rectum. In this complex group of anomaly, the goals of surgical correction are to promote anatomic reconstruction, establish socially acceptable bowel function and avoid undesirable sequelae such as fecal incontinence, urinary incontinence and sexual dysfunction. Main goal of surgical correction of ARM is to open the blind rectum to anus in the most appropriate position and close possible urinary fistulas. After 1980's with the description of posterior sagittal anorectoplasty technique, long term satisfying solutions were gained in the treatment of ARM. Spreading of minimally invasive surgery by passage of time, usage of laparoscopy is to come order in ARM surgery. Laparoscopy assisted anorectoplasty (LAARP) was first described by Georgeson and friends in 1998 in the correction of high type of ARM. LAARP is an advantageous technique in replacing rectum in the most appropriate position between the sphincter complex with providing good visualition for pelvic anatomic structures, fistula localisation and low risk of injuring external anal sphincter and nerves around the puborectal muscles. Relatively few patient numbers and systematically analyzed results, in larger studies are causing an obstacle for the datas of fecal incontinence and long term complications. Early prognostic indications are encouraging about continence but we need long term clinical follow-ups to review fuctional results. İn the long term follow-up of postoperative period of ARM, different imaging techniques are using such as barium enema graphies, defecographies and anorectal manometry. İn recent years, magnetic resonance imaging (MRI) is using commonly. MRI, is a good imaging modality in the evaluation of anatomic relation between puborectal muscles and pull-through rectum. Even though, we know the clinical results of open anal atresia repair, in LAARP patients there is not enough data about the suffiency of corrective surgery and complication ratios. Add to this, comparative studies between the series of patients who undergone open surgery or LAARP, are limited. İn this study, we aim at evaluation of rectum and sphincter localization in patients undergone laparoscopic-assisted anal atresia repair in our clinic with magnetic resonance imaging to analyze fecal incontinance and diverticulum. Materials and Methods 14 patients (14 male), who undergone LAARP in our clinic between years 2002-2014 were incorporated to this study. Demographical characteristics, methods used for diagnosis, type of anomaly, laboratory findings, radiological findings, type of colostomy, other surgical techniques, postoperative complications and concominant anomalies were evaluated by analyzing the files of these patients retrospectively. İn pelvic MRI of patients; localization of rectum, sphincter and presence of posterior urethral diverticulum were being evaluated. Patients with fecal incontinence were evaluated by Krickenberg criterions and analyzed for the relationship between rectum localization, presence of posterior urethral diverticulum and sacral ratio. Statistic Analyze Datas were analyzed by SPSS for Windows 11,5 packet programme. Distrubition of permanent and intermittent variants among normal variants were researced by Shapiro Wilk test. Descriptive statistics were represented with average ± 1SD or median for permanent and intermittent variants and with case number or (%) for nominal variants. Student's t test was used for analyzing the signifiance of average values between the groups and Mann Whitney U test was used for analyzing the signifiance of median values. Nominal variants were analyzed by Pearson's Chi-square test or Fishers' Certain Result Chi-square test. Statistically pvalues less than .05 were considered significant. Results Median age of 14 patients undergone LAARP at the time of MRI and continence evaluation was 60 months (17–120). All of the patients have high type ARM (2 of rectovesical fistula, 4 of rectobulbar fistula, 8 of rectoprostatic fistula). All of the patients were operated by LAARP technique.Median age of patients at the time of LAARPwas 12 months (4–24). Average time of colostomy (all sigmoid end colostomy) closure after LAARP operation was 9.6 ± 6.1 months (2–20). Median age of patients at the time of colostomy closure was 18 months (8–54). In MRI, in 8 patients pelvic floor muscles were thin and anomalous. In 8 patients sphincter muscles were asymmetric. In 1 patient rectum localization was eccentric (1 patient at the left hand side of sphincter). In all patients anal canal was central. In 4 patients posterior urethral diverticulum was determined by MRI. İn all patients cardiac anomalies (PDA, ASD, VSD, PFO, PHT) were present. İn 5 patients renal anomalies and in 5 patients GIS anomalies were present. İn MRI, 5 patients had spinal anomaly. No early postoperative complications were developed. İn late postoperative time, 4 compliacations were improved; 1 rectal stricture, 2 rectal prolapses and 1 anal stenosis. Conclusion LAARP is a safe technique when it's used by the appropriate technique and true indications. LAARP is an effective technique to open the rectum in anus in central position by transposing it anatomically through the muscle complex. The effect of the transposition of the rectum through the muscle complex in ideal anatomic position is not enough in supplying continence and avoiding constipationby itself. It's important and also necessary to follow up the patients strictly in long term and in planned bowel management programmes. We hope this study will be a step by comparing the clicinical results in improvement the techniqual details of LAARP.