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Relation between the internal anal sphincter and defecation disorders in patients with anorectal malformations
Venla E C den Hollander1, Monika Trzpis1, Paul M A Broens1,2
1Department of Surgery, Anorectal Physiology Laboratory, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
Insights
The rectoanal inhibitory reflex (RAIR) is often present in patients with anorectal malformations (ARMs). Surgery can impair the RAIR, potentially leading to constipation and fecal incontinence.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Anorectal Physiology
Background:
- Congenital anorectal malformations (ARMs) present complex surgical and functional challenges.
- Understanding anorectal physiology is crucial for managing long-term outcomes in pediatric patients with ARMs.
Purpose of the Study:
- To investigate the association between the rectoanal inhibitory reflex (RAIR), types of ARMs, surgical interventions, and functional outcomes such as fecal incontinence and defecation problems.
- To determine the prevalence of RAIR in pediatric patients with various types of ARMs.
Main Methods:
- Retrospective analysis of 69 pediatric patients with ARM treated over 10 years.
- Assessment of anorectal physiology using Rome IV criteria and anorectal function tests.
- Correlation of RAIR presence with ARM type, surgical history, rectal volumes, and fecal incontinence.
Main Results:
- The RAIR was present in 67% of patients across all ARM types.
- Patients not operated on or with less extensive surgery retained the RAIR; posterior sagittal anorectoplasty was associated with a 44% RAIR presence.
- Absence of RAIR correlated with constipation, enlarged rectal volumes, and potentially fecal incontinence, though direct statistical significance with incontinence was not found.
Conclusions:
- The RAIR is generally present in ARM patients regardless of malformation type but can be impaired by corrective surgery.
- Preserving the RAIR during surgical correction is vital to prevent long-term functional issues like constipation and fecal incontinence.
- Minimizing the use of extensive surgical procedures may help preserve anorectal function.
Objectives:
To investigate associations between the rectoanal inhibitory reflex (RAIR), type of congenital anorectal malformations (ARMs), type of operation that patients with ARM had undergone, and objectively measured fecal incontinence and defecation problems.
Methods:
We retrospectively included 69 pediatric patients with ARM. All underwent anorectal function tests at the University Medical Center of Groningen during the last 10 years. We assessed anorectal physiology using the Rome IV criteria and anorectal function tests.
Results:
We found the reflex in 67% of patients and all types of ARMs. All patients who had not been operated on, and those who had undergone less extensive surgery possessed the reflex. In contrast, patients who underwent posterior sagittal anorectoplasty, 44% possessed it. We found no difference between mean rectal volumes in patients with and without the reflex (251 vs. 325 mL, respectively, p = 0.266). We found that over time, patients without the reflex seemed to develop significantly higher rectal volumes than patients who had it. We did not find a significant difference between the reflex and fecal incontinence; however, it seems that the absence of the reflex, resting anal sphincter pressure, and fecal incontinence are related.
Conclusion:
The RAIR seems present in patients with ARM irrespective of their malformation type. Corrective surgery, however, may impair this reflex. Seemingly, its absence results in constipation with enlarged rectal volumes and fecal incontinence. Every effort should be made to preserve this reflex during surgery and to use extensive surgical procedures as sparingly as possible.
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