annals 1-2.qxd - Centrum Zdrowia Dziecka

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value of MARP between manometric studies of the fistula,
the same studies undertaken in group 2 after reconstruction
of ARM and healthy controls.
The results of manometric studies of patients from
group 2 indicated that the manometric parameters describing
the proper function of IAS, both before and after reconstruction
of ARM, did not differ significantly in this group from
the normal values of healthy controls (table 4–6). The study
revealed also that in both groups (group 1 and 2) there were
no significant statistical differences in RSBD or the incidence
of postoperative constipation (Table 5).
Discussion
Significant improvement have been achieved during the last
two decades in the treatment of anorectal malformations.
Both the knowledge of the anatomy, physiology, and pathogenesis
of ARM and the methods of surgical correction and
assessment of results have radically changed [9, 12, 19–21].
The introduction and popularization of a treatment concept
described by Alberto Peňa [2, 19] and the acceptance of the
role of the internal anal sphincter (IAS) in the mechanism of
continence [13] have had an important influence on improving
the results of surgical corrections of ARM. Scientific
documentation of improvements in the results of treatment
still remains a problem due to differences in classifications
applied in the past and the present ant the subjectivity of clinical
methods for assessing continence. Not only the preservation
of the external sphincter (EAS) but also the utilization
of the internal sphincter (IAS), which are both still
a matter of debate, seem to be important.
ARMs with an external fistula in female patients, occurring
in about 90% of all girls with ARM [20, 21], offer
a classic opportunity to study the development of IAS and the
influence of its preservation during surgery on postoperative
continence. In the presented series ARMs with recto-cutaneous
or recto-vestibular fistula were recorded in 86% of patients.
These results are similar to data published by Peňa
[21], who found these fistulas to be the most common ARM
occurring in girls. In the presented series, in contrast to older
studies [4], the most common ARM was recto-vestibular
fistula, occurring in 40% of patients of both groups. This probably
resulted from differences in classification and difficulties
in the detailed clinical assessment of the perineum. Such
differences in classification and difficulties in assessment
may be responsible for the differences between data from published
series on the incidence of associated congenital anomalies.
In this series associated congenital anomalies were
noted in more than 50 % of girls with ARM and external fistula.
A high incidence of associated anomalies points to the
need of active screening, also in the group of patients with
„few defects”, in whom the incidence of associated anomalies
was underestimated in the past [3, 18]. In these studies
associated congenital anomalies were recorded in 17% of
girls with recto-cutaneous fistula and in 73% of girls with
recto-vestibular/vaginal fistula. Heinen [5] also stressed the
possibility of understanding the occurrence of congenital
CUN anomalies, which both in his series and in the presented
series were equal, occurring in 10% of girls with ARM.
Underestimation of these defects could be connected with the
problem of a broad application of modern imaging techniques
(CT, NMR) in diagnostic schedules in patients with ARM
[7, 14].
The use of clinical scales for the assessment of continence
indicated clear differences in postoperative continence
between both study groups. In group 1, compared to age-
-matched controls, the results of postoperative continence, as
assessed by all four clinical scales, were distinctly worse
with results achieving statistical difference. The most significant
statistical difference in the assessment of continence
was noted when using the Holschneider/Rintala scale, which
appears to be the most sensitive scale for all methods. In group
2, clinical assessment of postoperative continence with
three of the four methods did not reveal significant statistical
differences compared to healthy controls. The only statistical
differences were noted when using the Holschneider/Rintala
scale, which indicated even delicate disturbances
of continence between both study groups, and could be
explained by utilization in group 2 of the whole length of the
fistula containing the IAS, and the use of ASARP (in comparison
with PSARP) allowing a limitation in the length of
separation of the fistula during reconstruction of ARM [1].
Manometric studies for the assessment of continence also indicated
better results in postoperative continence in group
2 after the ASARP procedure. A direct comparison of all manometric
parameters indicated statistically significant better
results in group 2. This together with the fact, that no statistical
differences were noted between the manometric studies
in group 2 and the manometric results obtained in healthy
controls, is a strong argument for the use of the ASARP procedure
as a surgical technique for the reconstruction of ARM
in girls.
The presence and function of the internal anal sphincter
in the fistula in patients with ARM, as well as its utilization
during reconstruction and its influence on the quality of
postoperative continence are still a matter of debate. In the
presented series manometric studies were used for the assessment
of the quality and function of IAS in girls with ARM
and external fistula. The lack of differences in the results of
manometric studies of the fistula in girls with ARM and the
result in age-matched healthy controls, clearly point to the
functional presence of IAS in the fistula. These results together
with the evidence of recto-anal relaxation reflex in the
fistula in all girls before surgery for ARM and the evidence
of RARR in 96 % of patients from group 2 after reconstruction
of defects not only proves the presence of IAS but also
its full reflexive ability. The evidence of RARR in 3 patients
after PSARP procedure was probably connected with remnants
of the IAS remaining after resection of the end of the
fistula, while evidence of partial RARR in the fistula of girls
with ARM prior to reconstruction could be explained by partial
maldevelopment of the IAS and the presence of a common
vagina and fistula wall resulting in disturbances in relaxation
of IAS, as has been noted in other studies [23].