Congenital Cystic Polypoid Rectal Hamartoma in a Newborn Foal

A neonatal foal with signs of rectal bleeding was diagnosed with an intraluminal rectal mass and intussusception on surgical exploration of the abdomen. Histologically, the mass consisted of cystic spaces lined by simple columnar epithelium with numerous goblet cells and was surrounded by thin bands of smooth muscle in a myxomatous stroma. Although the mass shared similarities with retrorectal cystic hamartoma (tailgut cyst) and juvenile polyps, described in human medicine, location and histologic findings were not entirely consistent with either condition.

[Descending perineum syndrome in children: Pathophysiology and diagnosis]

OBJECTIVE

To propose a safer, simpler, and more exact method for the diagnosis of descending perineum syndrome (DPS).

MATERIAL AND METHODS

A total of 194 patients aged 5 days to 15 years were examined and divided into 2 groups: Group 1 consisted of 65 patients without anorectal anomalies (AA); Group 2 comprised 129 patients, including 66 children with functional constipation, 55 with AA and visible fistulas, who were preoperatively examined, and 8 patients with anorectal angle (ARA), who were postoperatively examined. All the patients underwent irrigoscopy that was different from standard examination in the presence of X-ray CT contrast marker near the anus.

RESULTS AND CONCLUSION

DPS is caused by puborectalis muscle dysfunction. A method was proposed to evaluate the status of the puborectalis muscle from the distance between the position of the ARA and the marker near the anus. This not only promotes an exacter estimate of DPS, but also allows refusal of defecography. The use of a barium enema with the minimum number of X-ray films decreases dose of ionizing radiation hazard and permits the use of this procedure not only in adults, but also in children with chronic constipation, fecal incontinence, and in AA for both pre- and postoperatively assessment of the causes of complications.

Long-term disease-specific quality of life in adult anorectal malformation patients

BACKGROUND

Fecal and urinary incontinence may differently influence various aspects of quality of life (QOL). The main aim of the present study is to determine whether fecal and urinary incontinence measured at time 1 of the study will predict QOL at time 2 (after 4 years), above and beyond the prediction already explained by fecal and urinary incontinence at time 2.

METHODS

Thirty-six adult patients from the Italian Parents' and Patients' Association for Anorectal Malformations answered items about urinary and fecal incontinence at time 1 of the study and completed the Hirschsprung Disease/Anorectal Malformation Quality of Life questionnaire after 4 years from the first questionnaire. Two sets of hierarchical regression analyses were conducted with fecal and urinary incontinence serving as predictors of QOL and the different areas of QOL from the Hirschsprung Disease/Anorectal Malformation Quality of Life serving as outcome variables.

RESULTS

The principal findings indicated that fecal continence is a strong predictor of QOL in the areas of social functioning, emotional functioning, and body image and that urinary incontinence predicted sexual functioning.

CONCLUSIONS

It seems that one's past experience with fecal incontinence is extremely relevant to current QOL, especially for body image. Urinary incontinence contributed less in explaining QOL in our patients, but because it is very relevant for sexual functioning, it should not be disregarded.

The morbidity of constipation in patients with anorectal malformations

BACKGROUND

Constipation in anorectal malformations (ARM) is extremely common, particularly in the lower types. Failure to adequately treat it can lead to significant morbidity.

METHODS

From our series of over 2000 patients with ARM, we reviewed 398 with good prognosis for bowel control and a tendency toward constipation; rectoperineal fistula (63), rectovestibular fistula (114), rectobulbar urethral fistula (104), imperforate anus with no fistula (46), rectal atresia or stenosis (9), and cloaca with a common channel below 3 cm (62). Those lost to follow-up, not yet toilet-trained (<3 years old), or with poor prognostic features were excluded. We compared morbidities in patients we operated on and managed primarily (group A, n = 268) to those managed at other institutions who suffered from constipation or incontinence and were referred to us for treatment (group B, n = 130). Those we managed primarily were subjected to an aggressive senna-based laxative program, started after their primary repair or after colostomy closure.

RESULTS

Morbidities associated with constipation were higher in the referral group and included fecal impaction (7.8% vs 38.5%), overflow pseudoincontinence (4.9% vs 33.8%), and megacolon (14.6% vs 54.6%). A loop or transverse colostomy (4.9% vs 9.2%), stoma or anorectal stricture, or a stenotic fistula (2.2% vs 28.5%) were contributing factors. Adequate laxative treatment with, in certain cases, resection of a megarectosigmoid (2.6% vs 23.1%) enabled many pseudoincontinent children to achieve bowel control (reported previously). Unneeded colorectal biopsies (1.9% vs 16.2%), Hirschsprung's-type pullthroughs (0% vs 3.1%), and, in retrospect, unneeded antegrade continent enema procedures (0% vs 3.1%) were higher in Group B. Overall, 19.8% of Group A and 66.2% of Group B experienced constipation-related morbidities.

CONCLUSION

The morbidity of constipation in ARM includes fecal impaction, megacolon, incontinence, and performance of unneeded surgeries. Inadequate treatment, the type of the original colostomy, and postoperative anal or stomal stricture as well as stenotic fistulae were key contributing factors. Children with ARM and good prognosis for bowel control are at the greatest risk for severe constipation and its consequences. With recognition and aggressive, proactive treatment, we have found that these morbidities can be reduced.

Laparoscopic excision of a newborn rectal duplication cyst

Congenital rectal duplication cyst is a rare entity treated with surgical excision. Without treatment, a rectal duplication cyst may cause a variety of complications, most notably, transforming into a malignancy. We report on a 7-week-old girl who was found to have a rectal duplication cyst. The rectal duplication cyst was successfully excised laparoscopically. Rectal duplication cysts are rare alimentary tract anomalies generally discovered during childhood. Complications include symptoms arising from the cyst and the possibility of malignant degeneration. They are typically managed by surgical excision.

External cystic rectal duplication: an unusual presentation of rectal duplication cyst

Duplications of gastrointestinal tract are rare anomalies, and rectal duplications account for five percent of the alimentary tract duplications. We present an unusual case of rectal duplication, which was located externally in a newborn female, and discuss the types of distal hindgut duplications.

Anorectal hamartoma in a neonate: a unique anorectal mass

Neonates presenting with perineal masses are uncommon. When encountered, most perineal masses are anorectal malformations, sacrococcygeal teratomas, rectal prolapse, or duplication cysts. We present an otherwise healthy newborn with a patent anal canal and a pedunculated anal mass. The mass was initially believed to be a prolapsed rectal duplication cyst. Further evaluation for concomitant congenital abnormalities was negative. The patient underwent mass excision at the bedside under local anesthesia. Histopathologic evaluation revealed benign hamartoma. This case is presented because of its rarity, unique presentation, and simplicity of management.

Associated malformations in patients with anorectal anomalies

Patients with congenital anorectal malformations (ARM) often have other associated congenital defects. The reported incidence and the types of associated malformations vary between different studies. The purpose of this investigation was to assess the prevalences at birth of associated malformations in patients of a geographically defined population with ARM which were collected between 1979 and 2003 in 334, 262 consecutive births. Of the 174 patients with ARM during the study period, 49.4% had associated malformations. Patients with associated malformations were further classified into groups with nonsyndromic multiple congenital anomalies; chromosomal abnormalities; nonchromosomal syndromes including Townes-Brocks, Walker-Warburg, Ivemark, Fetal alcohol, Klippel-Feil, Pallister-Hall, Facio-auriculo-vertebral spectrum, deletion 22q11.2; sequences, including OEIS, Pierre Robin and sirenomelia; and associations including VATER and MURCS. Malformations of the urogenital system (81.1%) and of the skeletal system (45.5%) were the most common other congenital anomalies occurring with ARM in multiply malformed patients without recognized entities, followed by malformations of the cardiovascular system, the digestive system, and the central nervous system. Weight, length, and head circumference of children with ARM and multiple associated malformations were lower than in controls, as was the weight of the placenta. Prenatal detection by fetal ultrasonographic examination was rarely made in isolated ARM. However, even in multiple associated malformations, prenatal detection by fetal ultrasonographic examination had a low sensitivity, 36%. In conclusion the overall prevalence of malformations, which was close to 1 in two infants, emphasizes the need for a thorough investigation of patients with ARM. A routine screening for other malformations may be considered in patients with ARM, and genetic counseling seems warranted in most of these complicated cases.

Outcome of excision of megarectum in children with anorectal malformation

BACKGROUND/PURPOSE

Megarectum in association with anorectal malformation contributes to chronic constipation and fecal incontinence. Resection of megarectum in anorectal malformation improves bowel function, but neuropathy and poor sphincter quality may affect the outcome of fecal continence adversely. The aim of this study was to evaluate the benefits of resection of megarectum in anorectal malformation and to ascertain the impact of anal sphincter quality and neuropathy on the outcome.

METHODS

We studied 62 children with intractable fecal incontinence after repair of anorectal malformation between January 1991 and January 2005. All patients were investigated with anorectal manometry and anal endosonography under ketamine anesthesia. On endosonography, an intact or scarred internal anal sphincter (IAS) was classified as good and a fragmented or absent IAS as poor. On manometry, a resting anal sphincter pressure equal to or more than 30 mm Hg was classified as good and a lower pressure as poor. Functional assessment of fecal continence was done before and after excision of megarectum using a modified Wingfield scores.

RESULTS

Sixteen children had excision of megarectum with median age of 9 years (range, 2-15 years) and postoperative follow-up of 5 years (range, 1-10 years). Seven had formation of antegrade continent enema stoma before excision of megarectum. Children were classified into three groups of anomalies: low (n = 6), intermediate (n = 4), and high (n = 6). All children were incontinent of feces. After excision of megarectum, of the 9 children with good IAS and no neuropathy, 7 became continent of feces. Of the remaining 7 children, 4 had poor IAS and 3 had neuropathy, 5 of whom required an antegrade continent enema stoma to be clean.

CONCLUSION

Excision of megarectum in children who had previous repair of anorectal malformation results in fecal continence in the presence of a good IAS and absence of neuropathy. Patients with a poor IAS or neuropathy will often require artificial means of fecal continence.

Sonic hedgehog, BMP4, and Hox genes in the development of anorectal malformations in Ethylenethiourea-exposed fetal rats

BACKGROUND

shh signaling pathway has been shown to be involved in the morphogenesis of many organ systems. In this study, we investigated the expression of shh and its targets, BMP4 and Hox genes, in the development of anorectal malformations in Ethylenethiourea (ETU)-exposed embryos.

METHODS

We used ETU murine model of the vertebral, anal, cardiac, tracheoesophageal, renal, and limb association. Ethylenethiourea 1% (125 mg/kg) was given to the pregnant females via gavage feeding on gestational day (gD) 10 and saline to control animals. Embryos were collected at gD12 to gD16 and gD21; hindguts were dissected and snap frozen. Highly purified RNA was isolated, and expression of shh, BMP4, Hoxa13, and Hoxd13 genes was confirmed with RT-PCR. Relative quantitative expression of shh and target genes at each time point was done with SYBR Green I qPCR. Normalized gene of interest expression was calculated by geNorm, and data analysis was done with 2-tail Student t test.

RESULTS

shh, BMP4, Hoxa13, and Hoxd13 transcripts were detected in all samples, confirming that shh cascade is active during the process of hindgut development in fetal rats. Relative quantitation demonstrated that shh cascade expression shows time-dependent changes in the developing hindgut.

CONCLUSION

This study shows that ETU disturbs the expression of shh signaling pathway during the development of hindgut. We provide evidence that shh plays a pivotal role in the hindgut morphogenesis, and its misexpression affect the expression of targets, BMP4 and Hox genes.

MRI of rectal disorders

OBJECTIVE

The objective of this pictorial essay is to provide a review of the diseases involving the rectal wall with an emphasis on the key clinical and radiologic differentiating features.

CONCLUSION

A wide spectrum of disease processes can involve the rectum in adults. MRI is the technique of choice in the definitive diagnosis of these disease conditions, mainly because of its superior tissue contrast differentiation.

Congenital pouch colon: follow-up and functional results after definitive surgery

PURPOSE

In this study, functional results with regard to fecal continence levels and other parameters were studied in 22 patients with congenital pouch colon associated with anorectal agenesis (CPC) more than 3 years old who had undergone definitive pull-through surgery 1 to 13 years earlier. An attempt was made to formulate treatment protocols for management of fecal incontinence and other problems associated with CPC.

METHODS

The study sample consisted of 14 males and 8 females. Three of the 8 female patients had had a cloacal malformation. The medical records of the patients were scrutinized and they were classified into 4 subtypes based on the length of normal colon proximal to the colonic pouch. The patients were further categorized into 3 groups based on the terminal bowel that had been pulled-through, namely, the ileum or colon proximal to the colonic pouch or a tubularized segment of the colonic pouch. The somatic growth of the patients was studied. Clinical assessment of fecal continence was performed by the Kelly and the Kiesewetter and Chang scoring systems. A computed tomographic scan of the pelvis with a barium enema was performed to assess the terminal bowel and its placement as well as the bony and muscular anatomy of the pelvis. The urinary system was assessed by a clinical history as well as by abdominal ultrasound and a micturating cystourethrogram. Various treatment modalities including dietary modifications, drugs, and enemas were instituted in patients with poor continence levels, and the response to treatment studied.

RESULTS

Thirteen patients (59.2%), all with an ileal pull-through, had height and weight less than 50% of that expected for their ages. Overall fecal continence was "poor" in 17 patients and "fair" in only 5 patients. Patients with pull-through of either ileum or normal colon often had very frequent passage of liquid or semisolid stools, whereas the 4 patients with pull-through of tubularized colon had infrequent passage of semisolid stools with abdominal distension and bloating. One of these 4 patients had massive colonic redilatation necessitating surgical correction. Mucosal prolapse and perineal excoriations were frequent findings. Ultrasonography and micturating cystourethrogram showed hydroureteronephrosis and vesicoureteric reflux in 5 patients. Radiologic assessment revealed that there were no significant sacral abnormalities and the striated sphincteric musculature was well developed, although the levator ani was thinner than normal in 15 patients (68%). The bowel was very well placed in the sphincteric complex in 19 patients (86%). In 7 of the 13 patients who had pull-through of normal ileum or colon, some improvement in continence levels was seen 3 to 6 months after institution of dietary measures, loperamide, and saline-water enemas. Two of 3 patients with pull-through of tubularized colon improved to some extent with colonic washouts alone. Overall, quality of life was poor in the 22 patients.

CONCLUSIONS

Despite the fact that the sacrum is usually normal, the sphincteric musculature well developed, and the terminal bowel well placed without any anal strictures, long-term prognosis with regard to fecal continence, growth and development, and quality of life appears to be dismal for all subtypes of CPC, irrespective of the type of definitive surgery performed. Corrective measures also appear to be of limited value. Various newer management modalities for management of fecal incontinence may be considered, but in several patients a permanent abdominal stoma may be a more practical solution.

[Evaluation of late results in the children with anorectal anomalies]

Anorectal malformations constitute the most varied group of congenital defects. Constant challenge for the surgeon being engaged in this subject are the studies of new factors which could improve the functional results of treatment.

AIM

The aim of the study was the evaluation of late results after surgical treatment in children with anorectal anomalies. Assessment of the qualification criteria for the kind of surgical repair: one-stage (OSR) or stage repair (SR), age of the patient at the end of treatment and accompanying sacral bone defects were taken into consideration as the factors of functional prognosis.

MATERIAL AND METHODS

93 children with different types of anorectal defects were operated on between 1990-2002 in Department of Pediatric Surgery in the Institute of Mother and Child. The evaluation was performed in 60 patients over 3 years old: in 30 after OSR (group I) and in 30 after SR proceeded by colostomy (group II). Anorectal malformations were classified according to Pena's division based on the place of fistula orifice. Most kinds of anorectal anomalies were operated on according to the principles of posterior sagital anorectoplasty (PSARP). In patients with congenital anal stenosis a modified cutback procedure was done. In long-term evaluation in every child precise diagnostics of sacral bone with definition of congenital sacral bone defects and sacral measurements were performed, in order to estimate their influence on the results of treatment of anorectal anomalies. In postoperative evaluation of functional results the following criteria were taken into consideration: physical examination, evaluation of fecal continence by using quantitative scoring method and manometric study. The control group included 20 children with constipation.

RESULTS

Sacral bone defects were diagnosed in 10% of the OSR group (group I) and in 73% of patients of the SR group (group II). Sacral measurements showed significant differences in SR group compared with OSR and control group. In clinical examination postoperative appearance of perineal and anal region depended on congenital development of perineal structure. In ST group of patients symptoms of 'flat perineum' were seen with various degree of muscles hypodevelopement, lack of perineal raphe and weakly marked anal dimple. Results of fecal continence in OSR group (group I) were defined as normal in 93% of patients and good in 7% of cases. In SR group (group II) the results were as following: normal in 41%, good in 17%, fair in 38% and poor in 4% of cases. The worst results were obtained in the patients with sacral defects in SR group. In manometric study there were no significant differences except for one parameter (anal resting pressure) between OSR group (group I) and the control group. In group II manometric study was different in three parameters: anal resting pressure, squeezing pressure and presence of internal sphincter reflex. The presence of sacral bone defects had the most important influence on manometric study results.

CONCLUSION

Functional results in the OSR group of patients were not different from the control group. Precise criteria for this kind of surgical treatment and lack of serious sacral defects were the most important factors for good prognosis. The results of late evaluation in SR group depended on coexisting sacral bone agenesis.

Social Adaptation of Children with Congenital Fecal Dysfunction: From the Viewpoint of the Mother-Child Relationship

Excretory dysfunction associated with congenital anal anomalies (a generic term that includes anal atresia and Hirschsprung's disease) is presumed to greatly affect the psychology of the affected children. In this study, we conducted a survey on the psychological status of children with excretory dysfunction, and investigated the relationship between the affected children and their families in addition to their social life. Four children with fecal dysfunction due to a congenital anal anomaly and their mothers were interviewed. The results of psychological tests in the children and mothers along with our findings in the interviews with the children and mothers, were included in the data analysis. We found that regardless of the degree of excretory dysfunction, the child's state of mind was influenced by whether the mother exhibited warmth or criticism towards her child and whether there was a support system for the mother and child. We suggest that psychiatric consultation is necessary for these children.

Surgical management of perineal masses in patients with anorectal malformations

BACKGROUND

The aim of this study was to review the outcome of surgical management of various types of perineal masses encountered in patients with anorectal malformations (ARM).

METHODS

Retrospective review from 2 large pediatric anorectal referral centers.

RESULTS

Twenty-two patients with a perineal mass were identified in more than 2000 patients treated for an ARM over a 15-year period. The 22 patients (4 men) represented all levels of severity of ARMs. The lesions were of 3 types: lipomas (n = 10), vascular anomalies (n = 4), and hamartomas/choristomas (n = 8). The lipomas were carefully removed from between the muscle fibers during the posterior sagittal anorectoplasty. The vascular anomalies (3 of 4 were hemangiomas) underwent magnetic resonance imaging preoperatively, but none were found to invade deeply and all were excised at the time of the posterior sagittal anorectoplasty. The hamartomas/choristomas all occurred in women, and 50% arose as a pedunculated mass from the vulva. The lesions contained tissues such as glia, osteoid, nephrogenic rests, and endocervical-type mucosa. One was initially misinterpreted as a teratoma, prompting a wider excision. This and all subsequent patients have been correctly diagnosed pathologically as having either hamartomas or choristomas, which were not widely excised. Follow-up ranges from 5 months to 12 years. Six of the 10 lipoma patients are continent. One vascular anomaly was re-excised and there was minor wound separation in another. None of the hamartoma/choristoma lesions recurred.

CONCLUSION

The presence of unusual perineal masses can add to the complexity of ARMs; however, most of these lesions can be carefully excised with preservation of the muscle complex and ultimate continence. Hamartomatous lesions can be mistaken for teratomas but do not require aggressive excision with clear margins.

Rectal prolapse following posterior sagittal anorectoplasty for anorectal malformations

PURPOSE

Rectal prolapse is a known postoperative problem in children with anorectal malformations. The aims of this study were to determine the incidence of significant rectal prolapse (>5 mm), to objectively quantify its predisposing factors, and to offer recommendations as to its prevention and surgical treatment.

METHODS

The authors reviewed their series of 1619 patients with anorectal malformations; 1169 underwent primary posterior sagittal anorectoplasty (PSARP) at their institution between 1980 and 2002, and complete records were available for 833. The series was analyzed for incidence of prolapse, type of anorectal malformation, status of the sacrum, muscle quality, associated vertebral and spinal anomalies, and postoperative constipation. A specific technique for prolapse repair was used.

RESULTS

Of 833 patients, 45 developed significant rectal prolapse (3.8%). The mean age at the time of PSARP was 0.73 years (range, 0.19-5 years). The average time to recognition of prolapse following PSARP was 13.1 months. Of these 45 patients, 32 required surgical repair and of those, 3 required a second surgical repair. The incidence of prolapse varied by complexity of anorectal defect: cloaca (6.2%), rectobladder neck fistula (6.8%), rectourethral fistula (5.4%), rectovestibular fistula (1.2%), rectal atresia (0%), and rectoperineal fistula (0%). There was a significantly increased incidence of prolapse in patients with a low muscle quality score and in patients with vertebral anomalies (20% vs 3.2%). The presence of a tethered cord and an abnormal sacral ratio did not correlate with an increased incidence of prolapse. Twenty-two patients developed prolapse following colostomy closure, and of these, 12 (55%) suffered from constipation.

CONCLUSIONS

The overall incidence of significant rectal prolapse following PSARP is low. Prevention of prolapse with the PSARP technique may be because of key technical steps. Patients with higher anorectal malformations, poorer muscle quality, and vertebral anomalies had a greater risk of developing postoperative rectal prolapse. The presence of tethered cord and quality of the sacrum were not predictive of postoperative prolapse. Constipation seems to be a factor in the development of prolapse.

An audit of neonatal colostomy for high anorectal malformation: the developing world perspective

A high divided sigmoid colostomy has been recommended for staged management of high anorectal malformation. We audited our cases of neonatal colostomy for high anorectal malformation to assess its effectiveness. A retrospective study was carried out of all surgical newborns admitted with high imperforate anus as the single diagnosis at our centre between December 1998 and December 2000. Morbidity and mortality were analysed after retrospective stratification into two groups (group A: birth weight >2.5 kg; group B: birth weight <2.5 kg). The chi square test was used to test the statistical significance in terms of outcome in the two groups. Overall mortality was 16%. Group A consisted of 34 babies: 30 with divided sigmoid colostomy and four with transverse loop colostomy. One baby with a divided sigmoid colostomy died from wound complications and septicaemia (mortality 2.9%). All four babies with transverse loop colostomy done under local anaesthesia survived, despite being sick on arrival. Group B consisted of 16 babies: 15 with sigmoid colostomy and one with transverse loop colostomy, with seven deaths (44%). None of the five babies with transverse loop colostomy done under local anaesthesia died, despite being sick on arrival, whereas all eight babies who died had undergone sigmoid colostomy under general anaesthesia. The difference in the outcomes of babies in groups A and B is highly significant ( p <.01). Sick, small (<2.5 kg) and septic babies arriving late to the unit do not appear to tolerate general anaesthesia and divided sigmoid colostomy well, despite that procedure's long-term advantages. Divided sigmoid colostomy has produced excellent results in babies >2.5 kg, but in the context of the developing world and limited critical care availability, transverse loop colostomy under local anaesthesia may save lives.

Bowel function following primary repair of anorectal malformations at Kenyatta National Hospital

OBJECTIVES

To evaluate bowel function following primary repair of anorectal malformation.

DESIGN

A ten-year retrospective study.

SETTING

Kenyatta National Hospital, Nairobi, Kenya.

SUBJECTS

All patients with anorectal malformations attended to at Kenyatta National Hospital (KNH) within the study period who had posterior sagittal repair as a primary definitive procedure. All the children were over three years of age, toilet trained, and had their colostomies closed with an adaptation period of at least six months.

RESULTS

Posterior sagittal repair was used to repair anorectal malformations in 352 patients. One hundred and ninety three patients were evaluated. Overall voluntary bowel movement (VBM) was achieved in 71.5% of the patients, soiling was present in 21.2% of the patients and constipation in 7.3% of the patients. More than seventy nine per cent of children who had their colostomy fashioned before the age of one month achieved VBM, while 61.1% of the patients achieved VBM when the colostomy was fashioned after five years. Overall, 77.0% of the females achieved VBM compared to 63.8% of males. Patients with a perineal fistula achieved VBM in 79.1% of males and 75.0% of females, 76.0% with vestibular fistula, 73.9% with a recto-urethral fistula, 56.0% of anorectal anomalies without a fistula, 25.0% of vaginal fistulae and 12.5% in vesical fistulae. Overall patients with sacral defects achieved VBM in 25.9% compared to 78.9% in patients with a normal sacrum. The patients with low anomalies achieved VBM in 75.4% compared to 46.1% with high anomalies.

CONCLUSIONS

Posterior sagittal repair has been used to repair all anorectal malformations and has improved the quality of life of our patients, with better functional results expected in female patients, early colostomy fashioning and definitive repair, low or simple anomalies, and absence of sacral defects. The repair was associated with low morbidity and mortality.

Retrorectal developmental cysts in adults: clinical and radiologic-histopathologic review, differential diagnosis, and treatment

Developmental cysts are the most common retrorectal cystic lesions in adults, occurring mostly in middle-aged women. They are classified as epidermoid cysts, dermoid cysts, enteric cysts (tailgut cysts and cystic rectal duplication), and neurenteric cysts according to their origin and histopathologic features. Although developmental cysts are often asymptomatic, patients may present with symptoms resulting from local mass effect (eg, constipation, rectal fullness, lower abdominal pain, dysuria), with a palpable retrorectal mass at digital rectal examination, or with a complication. Infection with fistulization, bleeding, and malignant degeneration are the major complications of developmental cysts. A well-defined, unilocular or multilocular, thin-walled cystic lesion is the main imaging feature. Uncommonly, a sacral bone defect and calcifications are associated with developmental cysts. The differential diagnosis includes cystic sacrococcygeal teratoma, anterior sacral meningocele, anal duct or gland cyst, necrotic rectal leiomyosarcoma, extraperitoneal adenomucinosis, cystic lymphangioma, pyogenic abscess, neurogenic cyst, and necrotic sacral chordoma. Complete surgical excision is indicated to establish the diagnosis and avoid complications.

Aspiration cytology and core biopsy of a carcinoid tumor arising in a retrorectal cyst: a case report

Retrorectal cysts are uncommon lesions of uncertain histogenesis, and primary carcinoid tumors arising in retrorectal cysts are extremely rare. We present the case of a 52-yr-old man who had a 22-cm partially cystic, partially solid mass in the presacral space. A computed tomography-guided fine-needle aspiration of the mass was performed. The smears contained abundant keratinous debris and rare groups of tumor cells. The tumor cells were cuboidal, with slightly granular cytoplasm and centrally located nuclei with speckled chromatin and inconspicuous nucleoli. Immunocytochemical analysis revealed strong reactivity for chromogranin and keratin, and focal reactivity for synaptophysin and neuron-specific enolase. The cytological diagnosis of a carcinoid arising in a tail-gut cyst was confirmed histologically. This is the first reported case of a carcinoid arising in a retrorectal cyst diagnosed preoperatively by cytology. This diagnosis is possible in the setting of consistent clinical, radiographic, and cytological findings.

[The diagnosis of disorders of the colorectal innervation in children]

The problem of congenital and acquired defects of innervation of the distal colon has many unsolved questions for making clinical and histological diagnosis, classification and using methods of treatment. Clinical, radiological and morphological aspects of treatment of 153 patients aged from 2 days to 14 years with disturbances of the colorectal innervation were analyzed. Radiological examination was not sufficient for making the diagnosis. Histological signs of aganglionosis, hypoganglionosis, dysganglionosis, type-A and type-B neuronal intestinal dysplasia in full-thickness biopsy specimens were used to confirm the diagnosis of congenital defects of innervation of the distal colon. The scheme of patho- and morphogenesis and clinico-morphological classification of disturbances of the colorectal innervation were proposed. Hirschsprung's disease was classified as a variant of the disturbance of the colorectal innervation.

A case of incomplete Currarino triad with malignant transformation

A case of an incomplete Currarino triad is reported. The baby underwent an emergency laparotomy due to a life-threatening intestinal obstruction caused by severe rectal stenosis. During the posterosagittal anorectoplasty (PSARP), a presacral teratoma was identified and resected. The tumor recurred three times; she initially responded to chemotherapy, but nonetheless died at the age of 4 years. In cases with evidence of anorectal stenosis, a presacral mass should be suspected. PSARP is the best choice of treatment for both the anorectal anomaly and excision of the presacral mass. The presacral region should be followed up closely for recurrence of the tumor.

Pediatric rectal and perineal problems

Infants and children have surgical disorders of the anus, rectum, and perineum that are largely quite different from the pathology seen in adults. This article presented some of these problems, which physicians encounter, and outlined methods of their management.

MR imaging of anorectal malformations and associated anomalies

Congenital anorectal malformations are found in many forms, and are frequently associated with other anomalies, especially of the spinal cord, spine, and urogenital system. Decisions concerning initial management of children with anorectal malformations can be made only after accurate determination of (a) the level and type of malformation, (b) the type of fistula, (c) the developmental state of the sphincter muscle complex, and (d) the presence of associated anomalies. Magnetic resonance imaging has proven to be the only modality to answer all these crucial questions, and has contributed to a better insight in the morphology and pathogenesis of such complex congenital malformations.

Cystic dysplasia of the testis associated with ipsilateral renal agenesis and high anorectal anomalies

Scrotal masses in young children are often caused by hydrocoeles and hernias. When they arise from the testis, testicular tumor or orchitis, although rare in this age group, is often the diagnosis. Cystic dysplasia of the testis, a rare condition frequently associated with renal anomalies, is another possible differential diagnosis. Herein the authors describe a case in which cystic dysplasia of the testis is associated with ipsilateral renal agenesis as well as high anorectal anomalies.

Retrorectal cyst-hamartomas and sacral dysplasia: MR appearance

Retrorectal cyst-hamartoma, an uncommon lesion, arises from hindgut embryonic remnants and may be associated with sacral anomalies. Such a lesion is presacral, multicystic, and lined with glandular or transitional epithelium. Malignant transformation of these lesions has been reported. We describe the clinical, pathologic, and imaging findings in an infant.

Tailgut Cyst, an unusual evolution

Developmental Tailgut Cyst (TGC) arise in the presacrococcygeal space. Most of these cysts are discovered during rectal examination. They may be the source of chronic perirectal symptoms but rarely undergo malignant change. There is a female predominance and TGC may grow to a considerable size. Biopsy and drainage lead to recurrence and infection. TGC, even when asymptomatic, should be totally excised.

Rectal atresia and stenosis

Rectal atresia and stenosis are rare and peculiar anorectal malformations for which many and varied surgical procedures have been described, ranging from simple perforation of the atresia to extensive sacro-abdomino-perineal pull-through operations. The results of the operations have been generally unsatisfactory, chronic constipation being a common postoperative feature. In the authors' experience, the Duhamel pull-through is the operation of choice for this problem.

A tailgut cyst found accompanying rectal cancer: report of a case

Tailgut cysts are rare congenital lesions. To date, only four cases have been reported in Japan, and the occurrence of a tailgut cyst with rectal cancer has never been documented. We describe here the case of a patient in whom a tailgut cyst in the retrorectal space was associated with rectal cancer. Preoperative computed tomography scans and endorectal ultrasonography failed to identify the lesion as cystic, instead suggesting an involved lymph node. This case emphasizes the necessity for careful diagnosis of masses in the retrorectal space in patients with rectal cancer.

[Congenital stenosis of the anus and rectum (Problems of nosology and pathogenesis)]

The work deals with the differential analysis of two forms of congenital rectal stenosis--"membranous" which is consequent upon incomplete obliteration of the anal membrane and "tubular" with involvement of the rectum along its length. It is pointed out that in most cases tubular rectal stenosis is a component of the complex of anomalies of the caudal region described for the first time by G. Currarino (1981) and called the ASP-triad. From analysis of 12 cases of the ASP syndrome a new scheme of the pathogenesis of the complex of anomalies constituting the syndrome is suggested. The authors identified a component of the syndrome which was not described earlier, namely, specific dysplasia of the pelvic floor and the external sphincter muscles of the anus, which provided the basis for naming the complex the PFASP syndrome (PF--Pelvic Floor Dysplasia). Problems of surgical correction of the PFASP complex of anomalies are discussed. A pathogenetically substantiated analysis of postoperative complications is made.

Hereditary sacral agenesis with presacral mass and anorectal stenosis: the Currarino triad

A family with autosomal dominant inheritance of sacral agenesis is described. Ten members were affected; four had associated presacral teratomas and anterior sacral meningoceles, giving rise to serious complications in three, including bacterial meningitis, local recurrence of teratoma and perianal sepsis. Three of those with presacral masses presented initially with anorectal anomalies. Other associated abnormalities included tethering of the cord, hydrocephalus, duplex ureter, hydronephrosis, vesicoureteric reflux, neurogenic bladder, bicornuate uterus, rectovaginal fistula and hereditary spherocytosis. Early diagnosis and surgical excision of a presacral mass is advised to prevent future morbidity and mortality.

Anorectal electromanometry in the diagnosis of neuronal intestinal dysplasia in childhood

The diagnosis of neuronal intestinal dysplasia (NID) is currently established by histochemical procedures. From October 1, 1981, until July 31, 1990, we submitted a total number of 737 patients under 15 years of age with several distinct colonic and anorectal disorders, to clinical, radiological, electromanometrical, histochemical and histological evaluation. 573 had a clinical diagnosis of chronic constipation, and in 38 of these NID could be demonstrated by histochemical examination. Motivated by our own findings with the anorectal electromanometry in these patients we performed a double-blind prospective study to find out if there are any particular and pathognomonic manometric parameters of NID in childhood. 80% of our patients with NID diagnosed prospectively since April 1st, 1986, had a relaxation of the internal anal sphincter which was not proportional to the volume of rectal distention. Anorectal hyperexcitability was also present in these patients, whereas a statistically highly significant (p less than 0.01) increase of the amplitude of anorectal fluctuations (7.27 +/- 1.12 mmHg) as compared to the values measured in our own patients with functional chronic constipation (2.87 +/- 0.33 mmHg) could be demonstrated. Considering only those patients who simultaneously presented all of the above mentioned electromanometric criteria (e.g. non-proportional relaxation of the internal anal sphincter, anorectal hyperexcitability, increased amplitude of anorectal fluctuations) without an increase of the anorectal pressure profile, we could demonstrate that the correlation between the electromanometric diagnosis of NID and the final histochemical diagnosis was 100%. Nevertheless, under these conditions, 30% (9 out of 30) of patients with NID were not recognized electromanometrically because they had been excluded as false negative cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Rectal diverticulum in an infant

The occurrence of rectal diverticula are rare. They are invariably accompanied by colonic diverticulosis, especially the sigmoid segment. To our knowledge, this condition has not been previously detected during childhood, and the youngest patient reported was 18 years old. In this report we present a solitary rectal diverticulum in a 25-day-old infant without accompanying colonic diverticula. The existence of rectal diverticulum in this infant convincingly suggests a congenital etiology.

[Anterior rectal duplication. Value of ultrasonic diagnosis]

A case of neonatal anterior rectal duplication is reported. Abdominal ultrasonography revealed a prerectal cystic mass. The different types of rectal duplications and the main differential diagnosis are described. Mechanical obstruction and neoplastic risk make early surgery necessary.

Megarectum

Evaluation of the rectum by barium enema does not correlate well with rectometrographic studies and is not predictive of bowel function. The purpose of the present study was to describe clinical and functional data in patients with chronic idiopathic constipation, where a megarectum was diagnosed by a rectometrogram. Among 355 patients who underwent rectal elasticity studies, 35 were found to have a megarectum (maximum tolerable volume above 320 ml in women and 440 in men) for which no specific etiology was recognized. They, and a group of 11 healthy controls who were not sensitive to stress, underwent studies of stool frequency, colonic transit time of radiopaque markers, rectal elasticity, and anorectal pressures and reflexes. The elasticity coefficient of the rectal wall was decreased in patients as compared to controls (P less than 0.01). Seven patients had onset of symptoms at birth, with maximum tolerable volume in the rectum between 460 and 900 ml, and all were incontinent for feces. Studies of colonic transit times demonstrated normal function in the right and left colon, but there was rectosigmoid stagnation (transit time of 122 +/- 17 hr vs 8 +/- 2 in stress-free controls; X +/- SE; P less than 0.001). In the other 28 patients (late-onset megarectum), in contrast to the congenital group, there was a marked female preponderance, and their recorded stool frequency (4 +/- 0.7/week) was greater than the recalled frequency (1.4 +/- 0.2/week; P less than 0.001). Only half suffered from fecal incontinence. They did not have a greater rectal capacity when colonic transit times were prolonged (455 +/- 27 ml) than when normal (422 +/- 27). Rectal pressure was similar at the level of conscious sensation of filling, regardless of rectal capacity, suggesting a motor, rather than a sensory, abnormality. The amplitude of the rectoanal inhibitory reflex was decreased (P less than 0.001) as compared to controls, sometimes mimicking the findings of Hirschsprung's disease, but increasing rectal distension always induced a relaxation of the internal anal sphincter. The notion of a megarectum, which tolerates large amounts of fluid without sensation, lacks elasticity, and is accompanied by an abnormal rectoanal inhibitory reflex, provides an explanation for one of the mechanisms of constipation by outlet obstruction.

Retrorectal cyst-hamartomas: CT diagnosis

Retrorectal cyst-hamartomas (RRCH) are congenital lesions characterized by the presence of cysts lined by multiple types of epithelium, often predominantly mucin-secreting. Three cases of RRCH are presented with their associated histologic and CT findings. The lesion requires complete surgical excision to prevent complications of recurrence, infection, or metastasis.

Parasacrococcygeal approach for the resection of retrorectal developmental cysts

Congenital developmental cysts are the most common retrorectal tumors. Five adult patients, two men and three women, with congenital developmental cysts were operated on via a posterolateral approach through a parasacrococcygeal incision. All wounds healed primarily with no infection or other complications. Recurrent perianal infections and repeated anorectal operations suggest the possibility of retrorectal growths; thus diagnosis requires physician awareness. Computerized tomography is the best preoperative diagnostic test to delineate anatomy and to rule out bony involvement. Because of an infection rate of approximately 30 percent, as well as the presence of symptoms and malignancy in 8 percent of the patients, surgical excision is the treatment of choice. The authors use a posterolateral approach that provides excellent exposure and obviates the need for removal of the coccyx or transection of the sphincter muscle. The authors believe this to be the procedure of choice for excision of retrorectal cystic lesions.

Congenital rectal stenosis: a sign of a presacral pathologic condition

Congenital rectal stenosis may be detected in the newborn during the initial physical examination. Failure of conservative therapy (dilatation) should alert the physician to the presence of an associated pathologic condition in the presacral space. Presacral teratoma, anterior sacral meningocele, or bony anomalies may be the underlying extrinsic causes of congenital rectal stenosis. Prompt recognition and appropriate operative management directed at the presacral lesion will relieve obstructive symptoms and minimize morbidity.

Hirschsprung's disease. A clinical review

Experience with 38 cases of Hirschsprung's disease seen over a 20-year period is described. Only 24 per cent of cases presented with a combination of symptoms and signs such as to suggest the correct diagnosis on clinical grounds. Barium-enema examination carries a high ‘true-positive’ rate, but cases reported as negative must be viewed critically. A radiological diagnosis of idiopathic megacolon should not be accepted without supplementary rectal biopsy and/or anorectal pressure studies. Survival without surgery is compatible with Hirschsprung's disease, but the dangers of enterocolitis must be acknowledged. Rectosigmoidectomy, which includes resection to an area of normal innervation proximally and excision of part of the internal sphincter of the rectum distally, produces a satisfactory late functional result at an acceptable mortality-rate. A colostomy prior to rectosigmoidectomy is advisable when there is a history of repeated attacks of subacute obstruction and one or more episodes of enterocolitis. A colostomy after rectosigmoidectomy is advisable in those cases which are submitted to laparotomy for intestinal obstruction in the period following operation, even when no mechanical cause for obstruction is demonstrable. Patients with problems relating to coprostasis following treatment of congenital anorectal disorders should be submitted to rectal biopsy, since a proportion of these patients reveal a deficiency of innervation of the distal large bowek which approximate to that seen in Hirschsprung's disease.