Type of Anorectal Malformation at Birth is Predictive of Fecal Continence

Recently published research shows the rate of fecal continence among 4-year-olds who underwent surgery for an anorectal malformation (ARM) as infants averages 40%, and the type of malformation — which reflects severity — is predictive of the outcome.

Though previous studies by others suggest that two additional factors, sacral ratio and spinal abnormalities, may predict continence, these researchers found no association. They, however, suggest larger and better-controlled studies of the factors are necessary.

The low continence rate for the children, the investigators say, supports the need for long-term follow-up and bowel-management programs to help children born with an ARM achieve continence. Their study is published in the Journal of Pediatric Surgery.

“Even for the malformation considered the least severe, perineal fistula, the rate of continence was only 60%,” says lead author Peter Minneci, MD, MHSc, a member of the Pediatric Surgery team and principal investigator in the Center for Innovation in Pediatric Practice at Nationwide Children’s Hospital. “That’s much lower than what’s been reported. Previously we told parents that children born with a perineal fistula had a 90% chance of being continent.”

“It’s opened the eyes of pediatric surgeons that we’re probably not doing as well as we all think,” says Dr. Minneci, who is also an associate  professor of pediatric surgery at The Ohio State University College of Medicine. “The reason for this is probably because we don’t see these patients long-term and we weren’t all using the universally-accepted definition of continence.”

Richard Wood, MBChB, FCPS(SA), chief of the Department of Pediatric Colorectal & Pelvic Reconstructive Surgery at Nationwide Children’s and coauthor, says this study establishes an outcome baseline for general pediatric surgery, which they will compare to the outcomes from his department and other pediatric colorectal surgery centers.

The centers provide additional and tailored care to these children, says Dr. Wood, who is also an assistant professor of pediatric surgery at The Ohio State University College of Medicine. “We’ll see if the outcomes differ.”

In this study, researchers from 10 children’s hospitals in the Midwest Pediatric Surgical Consortium identified 341 children who had undergone surgery for their ARMs as infants, and whose medical records included images of their spines and sacra. The researchers sent their families surveys asking if the children were continent as defined by Rome III diagnostic criteria — one or fewer fecal accidents per week at age 4.

Their analysis of the 144 responses showed the rate of continence overall was 40%. Divided into groups according to the severity of their ARMS, 18% of children in the highest risk group, which included cloacal exstrophy and rectovesical fistula, were continent; 26% in the moderate-risk group, which included rectoprostatic fistula and rectovaginal fistula; and 48% in the lowest risk group, which included perineal fistula and anal stenosis.

Dr. Wood is leading a similar study among nine programs that specialize in colorectal surgery and are part of the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). The study will take several more years to gather data.

“If our outcomes are the same as those in general pediatric surgery, we will all need to make changes,” Dr. Wood says. “If the outcomes are different, can we pinpoint particular aspects of care in the colorectal centers that add the most value? Perhaps  we can then work out which steps are the most important for all of us to implement.”

Reference:

Minneci PC, Kabre RS, Mak GZ, Halleran DR, Cooper JN, Afrazi A, Calkins CM, Corkum K, Downard CD, Ehrlich P, Fraser JD, Gadepalli SK, Helmrath MA, Kohler JE, Landisch R, Landman MP, Lee C, Leys CM, Lodwick DL, Mcleod J, Mon R, McClure B, Rymeski B, Saito JM, Sato TT, St. Peter SD, Wood R, Levitt MA, Deans KJ, on behalf of the Midwest Pediatric Surgery Consortium. Can fecal continence be predicted in patients born with anorectal malformations? Journal of Pediatric Surgery. 2019 Jun;54(6):1159-1163.