title: Anorectal malformations (ARM): quality of life assessed in the functional, urologic and neurologic short and long term follow-up.
abstract: Imperforate anus represents a wide spectrum of anorectal malformations associated with urologic, neurologic and orthopedic malformations. The outcome from the various corrective measures has improved due to new surgical techniques as well as to a better understanding of the pathology. Other factors which influence the overall outcome include the degree of patient acceptance, family support as well as the ability of the health care structure to support the patient's needs on a clinical, functional and psychologic level.
  
  
  OBJECTIVE
  Assess (with the new techniques available) the quality of life in the adult patient with ARM and compare it to that experienced by a younger patient; also we wish to determine the correlation between the observed abnormalities with the functional, neurologic and urologic outcome.
  
  
  METHODS
  Sixty-six patients were subjected to PSARP (36 M; 30 F). Six presented with cloaca and 60 with ARM (23 high and 37 low). All patients underwent the same workup to include L/S MRI diagnostics, evaluation for incontinence (urinary and bowel), a urology screening, and if required, a subsequent urodynamic study with rehabilitation and/or bowel management. All answered questionnaires (AIMAR: Italian parent's association of ARM) in order to assess their satisfaction with the current health condition, with the information received and with the treatment and follow-up sessions. The patients were classified into one of two groups. Group A, totaled 33 patients (4 cloacae) with an age range between 2 and 12 years who were operated after 1995. The second, group B, was made up of 33 patients who had been surgically treated before 1995 (age range 15-41 years), had followed the study protocol and had also a neuropsychiatry consult.
  
  
  RESULTS
  Overall fecal continence was 69% and of this number 37% were clean without constipation. Twe2nty-one patients (32%) suffered from some form of constipation. Constipation was the most common functional disorder observed in patients who have undergone PSARP. The highest incidence of constipation was found in the ARM (low type), a favorable prognostic group with 43% constipation. Patient with "high" defects and a cloaca had a lower incidence of constipation (18%). Of the 59 patients evaluated, 85% were urinary continent and 15% were incontinent. All of the incontinent patients were in the unfavorable prognostic group of malformations. Urodynamic studies showed 7 neurogenic bladders (NB) and 2 patients with a neurovescical dysfunction (NVD). Of the 50 "dry" patients. 20 had voiding disturbances due to a voiding dysfunction, in the absence of neurologic abnormalities, and presented occasional daytime or nighttime wetting. There was no correlation between the level of the anatomic defect and the urodynamic patterns in the group. Abnormal MRI findings were observed in thirty out of fifty-two patients evaluated. The MRI findings were classified as follows. Severe abnormalities: 7 patients (13%) presented with a combination of skeletal (sacral/lumbar) and spinal cord anomalies. Only spinal cord abnormalities: 12 patients (21%). Only skeletal abnormalities: 11 (19%) patients. Patients were divided into high, low and cloacal malformations. A high degree of statistical correlation was noted between the patients belonging to the cloacae and high defect groups and the abnormal MRI findings. No significant correlation was found between the low defect group and dysrafism, abnormal MRI results and the severity of the malformation. The incidence of Tethered Cord (TC) in our limited number of patients was limited in our study (9% in the high and 7% in the low defect group) when compared to the current literature. Furthermore there was no statistically conclusive evidence that TC by itself affects the urinary or fecal control in our patients. Our recommendation is nevertheless to obtain an MRI study in all patients with ARM.
  
  
  CONCLUSIONS
  All patients 17 and older reported a "good quality of life". Four are married, two with children. Aclose working relationship with the medical personnel is not only necessary but is also well received by the family particularly when younger patients are involved. The adult patient easily adapts even when information is initially scarce. He quickly reaches autonomy with personalized solutions but prefers a longer follow-up time during which, specialized medical facilities will play an important role in the treatment of ARM. Our findings illustrate the importance of both global disease-specific functioning and perceived psychosocial competencies for enhancing the QL of these patients.
authors.affiliation: Maternal-Pediatric Department. Pediatric Surgery Operative Unit, San Bortolo Hospital, Vicenza, Italy. angelica.fabbro@ulssvicenza.it
authors.forename: M A
authors.initials: MA
authors.lastname: Fabbro
authors.forename: F
authors.initials: F
authors.lastname: Chiarenza
authors.forename: S
authors.initials: S
authors.lastname: D'Agostino
authors.forename: B
authors.initials: B
authors.lastname: Romanato
authors.forename: M
authors.initials: M
authors.lastname: Scarpa
authors.forename: L
authors.initials: L
authors.lastname: Fasoli
authors.forename: I
authors.initials: I
authors.lastname: Iannucci
authors.forename: V
authors.initials: V
authors.lastname: Pinna
authors.forename: L
authors.initials: L
authors.lastname: Musi
mesh_terms: D000015:Abnormalities, Multiple / Q000503:physiopathology / Q000601:surgery; D000293:Adolescent; D000328:Adult; D001003:Anal Canal / Q000002:abnormalities* / Q000503:physiopathology* / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D003248:Constipation / Q000209:etiology; D005242:Fecal Incontinence / Q000209:etiology / Q000503:physiopathology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D011379:Prognosis; D011788:Quality of Life; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000379:methods; D012007:Rectum / Q000002:abnormalities* / Q000503:physiopathology* / Q000601:surgery; D018570:Risk Assessment; D012307:Risk Factors; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome; D014549:Urinary Incontinence / Q000209:etiology / Q000503:physiopathology; D014563:Urodynamics