[size=20px]A six-year old male born with imperforate anus and a rectourethral fistula underwent repair during infancy via a posterior sagittal anorectoplasty. He was initially successfully managed with daily enemas but they have become increasingly difficult to administer.

 

The most appropriate management of this patient with a difficult to manage bowel program is

 

A continued daily retrograde enemas.

 

B appendicostomy for antegrade irrigations.

 

C ileostomy.

 

D colostomy.

 

E excision of a megarectum.[/size]

b

(Untitled)

 

B

Correct answer

B appendicostomy for antegrade irrigations.

 

Despite the appropriate surgical treatment of anorectal malformations difficulties with fecal incontinence are common. The prognosis is associated with the type of fistula, spinal cord malformations and sacral anomalies. Optimal bowel management typically involves a combination of cathartics, stool softeners and scheduled defecation. Biofeedback has also been utilized. A program of enemas can be used to facilitate fecal evacuation and promote “social continence” even in situations with very poor anorectal sphincter function. Functional outcomes generally improve with age. However, in those children with ongoing difficulties, continued use of transanal retrograde enemas becomes increasingly problematic.

 

The use of an appendicostomy for antegrade colonic enemas has emerged as an effective and acceptable option to achieve colonic evacuation, minimize fecal accidents and improve quality of life. Neoappendicostomy or cecostomy are reasonable alternatives - particularly in children without a suitable appendix. Megarectosigmoid has been reported in 10 to 50% of children with anorectal malformations. Excision has been advocated and acutely reduces capacitance of the colon. However, long term bowel functional outcome is similar following nonoperative management.