title: Posterior sagittal anorectoplasty for failed imperforate anus surgery: lessons learned from secondary repairs.
abstract: OBJECTIVE
  The aim of this study was to evaluate secondary operations using a posterior sagittal approach in patients with fecal incontinence and impaction after primary repair of anorectal malformations.
  
  
  METHODS
  Twenty patients (14 boys, 6 girls) who had previous failed surgery for imperforate anus underwent secondary operations. The indications for surgery included fecal incontinence (n = 16) and fecal impaction (n = 4). Patients ranged in age from 2 to 30 years (mean, 11 years), with 4 over the age of 20 years. The primary procedures included abdominosacroperineal (n = 7), sacroperineal (n = 10), and perineal (n = 3) pull-throughs. At surgery, none of the patients underwent a diverting colostomy. The rectum was mobilized from the surrounding structures through a posterior sagittal approach. The surgical findings included anteriorly displaced anus (n = 17), laterally displaced anus (n = 3), mesenteric fat surrounding the rectum (n = 4), mega-rectosigmoid (n = 2), and others (n = 3). The rectum underwent reconstruction, which involved relocation of the rectum and anus to surround them with the muscle complex.
  
  
  RESULTS
  Patients underwent follow-up for periods ranging from 8 months to 6 years after surgery (mean, 3 years). To evaluate the functional results, fecal continence scores (Templeton and Ditesheim) were calculated for incontinent patients. Of the 16 incontinent patients, 12 achieved continence and 4 some improvement. Of the 4 patients with fecal impaction, 2 achieved daily voluntary bowel movement, whereas the other 2 have mild constipation and need occasional enemas.
  
  
  CONCLUSIONS
  Our study suggests that (1) a secondary operation through a posterior sagittal approach can restore fecal continence and is efficacious even in adolescents and adults and (2) a posterior sagittal procedure can be safely performed without a diverting colostomy.
authors.affiliation: Department of Surgery, Kobe Children's Hospital and Kobe University Faculty of Medicine, Japan.
authors.forename: C
authors.initials: C
authors.lastname: Tsugawa
authors.forename: K
authors.initials: K
authors.lastname: Hisano
authors.forename: E
authors.initials: E
authors.lastname: Nishijima
authors.forename: T
authors.initials: T
authors.lastname: Muraji
authors.forename: S
authors.initials: S
authors.lastname: Satoh
mesh_terms: D000293:Adolescent; D000328:Adult; D001003:Anal Canal / Q000601:surgery; D001006:Anus, Imperforate / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D003107:Colorectal Surgery / Q000009:adverse effects* / Q000379:methods; D005242:Fecal Incontinence / Q000209:etiology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D017060:Patient Satisfaction; D019651:Plastic Surgery Procedures / Q000379:methods*; D012007:Rectum / Q000601:surgery; D012086:Reoperation; D012189:Retrospective Studies; D017211:Treatment Failure; D016896:Treatment Outcome