Imperforate anus, the common name representing a wider spectrum
of anorectal malformations in newborns is one of the major congenital lesions in
pediatric surgery. Since the establishment of pediatric surgery in Seoul National
University (1978), more than 500 cases of anorectal anomalies had been treated
up to 1990. To evaluate the quality of life after corrective treatment, defecation
patterns were studied using clinical Kelly scores in 90 patients with high type
ano-rectal anomalies repaired during the 1978-1985 period. These 90 patients
were treated by two surgical repair methods (26 Rehbein, 64 Pena). Not only the
continence scores but also other aspects of social adaptation as well as an index
of quality of life were compared with a control group. Although precise
anatomical repair under direct view (Pena) will give a better defecation pattern
compared to the blind type of abdomino-perineal repair, their long term
adaptation is not significantly superior. This study showed that the function is not
always the net result of anatomic repair. Thus, the importance of the initial
corrective operation is again emphasized

Jung, Seong Eun

Kim, Woo-Ki

Lee, Seong-Cheol

Park, Kwi-Won

SNU Open Repository and Archive

The Seoul/ournalo~ jlled~c~ne Vol 3.1, No 1 35-39, ,bf(zrch 1993 Defeca t i on  Pat terns  a f te r  P o s t e r i o r  S a g i t t a l  A n o r e c t o p l a s t y  w i t h  an O b j e c t i v e  S c o r i n g  System' Woo-Ki Kim, Kwi-Won Park, Seong-Cheol Lee and Seong Eun Jung Depurmlent of Si~rger-y. Seoul Narionul Uni~tersit?, College cf Medicine, Seoul I 1  0-799, Korea = A bs t rac t =Imperforate anus, the common name representing a wider spectrum of anorectal malformations in newborns is one of the major congenital lesions in pediatric surgery. Since the establishment of pediatric surgery in Seoul National University (1978), more than 500 cases of anorectal anomalies had been treated up to  1990. To evaluate the quality of life after corrective treatment, defecation patterns were studied using clinical Kelly scores in 90 patients with high type ano-rectal anomalies repaired during the 1978-1985 period. These 90 patients were treated by two surgical repair methods (26 Rehbein, 6 4  Pena). Not only the continence scores but also other aspects of social adaptation as  well as  an index of quality of life were compared with a control group. Although precise anatomical repair under direct view (Pena) will give a better defecation pattern compared t o  the blind type of abdomino-perineal repair, their long term adaptation is not significantly superior. This study showed that the function is not always the net result of anatomic repair. Thus, the importance of the initial corrective operation is again emphasized. Key Wo rd  s : Imperforate anus, Anorectal malformations, Posterior sagittal aizorectoplasty, Kelly score, Incontinence is not that greatly different. The purpose of this INTRODUCT l O N  study is to analyze with an objective scoring system the results of the correction of 90 cases Potts (1959) made the famous remark about of high type imperforate anus who were treated 3 decades ago: "In general, atresia of the during the 1978-85 period and were followed up rectum is more poorly handled than any other for more than 6 years (6-13.5 years). Most congenital anomaly of the new born .  " pediatric surgeons agree that these imperforate Unfortunately, even after 30 years, current status anus or anorectal malformations are one of the most difficult, unsolved problems. It is well known that the term "imperforate anus" has been Received January 1993, and in final form March 1993. tThis stucly was supported by a 1989 Seoul National University Hospital used for a long time. But it is too simplified and Research Grant and an Insong Foundation Research Grant. non-descriptive. Ano-rectal malformation is a ~j84qz qqqz$' : 4+7], q;~l$, O]AJ 2 , more proper term. But, for convenience, it will be A4 LL o L- used interchangeably in this study. Since the establishment of the first pediatric surgical units in universities in Korea, a fairly large number of patients were collected during earlier years. It was handled by a single surgeon in the earlier stage. Anorectal malformation is the most common congenital anomaly in our patient population. This does not mean we have an epidemic of this disease. It simply means we have more patients compared to other hospitals in Korea. MATER l ALS AND METHODS During the 1978-1990 period, more than eight hundred operations were performed for the repair of imperforate anus, although the actual number of anomalies was 539. One hundred and seventyone patients or thirtyone per cent belonged to the high type anomaly. For the high type, the Rehbein type abdominoperineal repair (Rehbein 1967) was used at the beginning (1 978-1 981 period) . Then, the posterior sagittal approach (deVries and Pena 1982) has been used since 1982 (Table 1 ) .  For the objective evaluation of defecation patterns, clinical Kelly (1 972) scores have been used. Zero to two points are given to each aspect of continence of the fecal stream, staining of the anus or underpants, and sphincter contraction on digital examination. To make a fair comparison, new cases of both Table 1. Number, operative methods of imperforate anus by study period groups 1978-81 1982-85 1986-90 total operation available for flu lost to flu operative death unrelated death new, primary repair converted to Pena low type 26 Rehbein 26 0 0 20 (6) 135 69 76 Pena Pena 64 1 1 3 44 flu: follow up quantitative continence scores were compared to Kelly's. Toilet training, accidents, the need for extraunderpants, social problems, activity restriction and presence of rashes were given scores of 0, 0.5, and 1. For fair comparison, 1981 and 1982 results were studied. This close proximity of repair periods can minimize the differences in the surgeon's skill level. Finally, to check the satisfaction level of parentlor patient, a scoring system was made by us (Table 2). To emphasize social activity, higher scores were given to school, camp or overnight trips, sport and popularity among friends. To give a similar feeling, 0-2 were regarded as u ~ h a p p y  and scores of 5-6 were regarded as happy. types of corrective operation are analyzed in detail. To test the correlation with other scoring systems in this study, Templeton's (1985) Tab l e 2. Scoring of satisfaction level, both parents and patients 1) Will you take another operation to improve your condition a little? yes (0 point) no (1 point) 2) Will you take another operation to improve your condition significantly yes (0 point) no (1 point) 3) Is youlyour children socially continent? missing school yes (0 point) no (1 point) missing camping trip: yes (0 point) no (1 point) missing sport activity: yes (0 point) no (1 point) unpopular among friends: yes (0 point no (1 point) 1 point to each "No": happy (6-5 point), unhappy (0-2 points) RESULTS 1. Continence resul t  The results of clinical Kelly scores on 3rd, 6th year post-repair and current year (1992) are in Table 3. As a whole, neither Rehbein nor Pena groups showed significant improvement as time passed. But new patients in each group and redo Pena showed some signif icant improvement in mean value. But, for the new cases, although there is statistically significant improvement in mean Kelly scores, there are no significant changes in the proportion of so-called good (score 5-6), fair (score 3-4) and poor (score 0-2) groups. Table 3. Clinical Kelly score(mean) at 3rd, 6th year post-repair 3rd year 6th year Current(1992) 26 Rehbein 3.9 4.2 4.3 20 new cases * 4.0 4.3 4.5 6 reoperation 3.8 3.9 4.0 64 Pena 4.2 4.5 4.6 44 new cases * 4.5 4.8 4.9 20 redo * 2.9 4.0 4.2 - -- -. - - -- *: statistically significant improvement in mean value. 2. C o r r e l a t i o n  w i t h  o t h e r  s c o r i n g  systems Both clinical and radiologic Kelly scores were compared to the TempletonIDitesheim scoring system for the patients of the 1981-82 period. The close proximity of year in the two group was to provide fairness of comparison (Table 4). These three scores are statistically correlated in mean value. 3. Parent/pat ient sat isfact ion  scores These Kelly's assessments were compared with our parent satisfaction scores. It was found that these two scoring systems are very closely related in most cases (Table 5). But this parent scoring system was only made last year, its real value has to be tested more over time. In summary, based on these findings, anatomic repair under direct vision (posterior sagittal approach) gave the best results at the moment. The initial operation is so important because time does not improve this much. The Kelly score is very useful, and closely correlates with clinical status. Parent satisfaction levels were tested. These gave a very close correlation to the Kelly as well as other objective scores. D l  SCUSS l ON At the end of the 20th century, as death from ano-rectal malformation became less likely, Table 4. Comparison of Kelly score and TempletonIDitesheim score in patients 1981-82 group (1 1 Rehbein, 29 Pena) scoring system clinical Kelly (year) (score 0-6) radiologic Kelly Templeton score (score 0-6) (score 0-5) 11 Rehbein* (1981) mean 4.27* (2-6) mean 4* (2-6) mean 3.18** (1.5-4.5) mean 4.75 (2-6) mean 4.83 (2-6) mean 4.15 (1.5-4.5) *:2 converted Pena * correlation coefficientkappa= 0.9401 **  kappa=0.9004 *** :  in 29 Pena, three scoring system is significantly correlated Table 5. Correlation between subjective feeling and Kelly score in 1992, expressed as per cent of each group: -.. .- (Kelly : good fair poor) Rehbein No.: 20 45% 30% 25% happy (5-6) 6 (30%) unhappy(0-2) 10 (50%) Pena 44 60% 25% 15% happy (5-6) 24 (54%) unhappy (0-2) 15 (34%) -- ~ . .. .- . -  (by Spearman rank correlation coefficient:rs P<0.01) Kelly scores were expressed as good, fair, and poor group on top row. incont inence became a major problem in dealing with this anomaly (Stephens and Smith 1971 ) .  More precise anatomic repair became surgeons' aim since they saw many incontinent unhappy children. The main controversies are about the anatomy of the sphincter of the rectum (deVries and Cox 1985, Pena 1991, Okada 1992) and the assessment of continence. Since many surgeons (Swenson and Donnellan 1967, Kiesewetter 1967, Kim 1987) report their results with remarks like "poor, fair and good", an objective type of system is required to evaluate and compare the results of repair. Stephens and Smith (1971) introduced what is known as the Kelly score. It is the most well-known continence scoring system. This scoring system is over simple. But it is useful even for retrograde study since one can easily observe if they have had an accident, smearing of undergarments, and the power of rectal squeeze. In this study, Kelly's scoring system of incontinence was used for three reasons: its originality and easiness to check, and its close correlation with other scoring systems. All one has to do is ask if the patient has had an accident in defecation, stained underpants,  and do  a rectal examination. Kelly (1 969) also used radiologic evaluation on these patients to add credibility. Since then, many systems of scoring have been devised by several authors. (Rehbein 1967: Stephens 1971 : Templeton and Deteshein 1985). StephensISmith also advocated use of other parameters, such as rectal sensation, stool consistency, appearance of the anus and others (age, mentality, sociallparental adequacy). Other parameters are very important. But very difficult to score ojectively. Kelly suggested combining cl inical and radiologic scoring together to strengthen his over simple cl inical  score. Although there are numerous newly advocated objective scoring systems, we are quite satisfied to use this original clinical score. In this study, clinical Kelly scores are closely correlated to the actual quality of life, especially the level of satisfaction of both parents and patients. Improvement of Kelly score per se can be observed in the new cases, especially in patients with Pena operations. But change of class (good, fair, poor) is rare. In other words,the initial corrective operation is very critical since signif icant improvements over t ime are uncommon in this study. Kelly scores in the reoperated group showed very poor results which is also closely correlated to the level of satisfaction. However, it is not certain if the Kelly score can be used as a criterion for reoperation. Sphincter tone with digital rectal examination is still the most reliable criterion for reoperation in our experience. It is very difficult to get a Kelly score during the first 2 years after surgery. For the evaluation of that period, cine radiographic scores are more reliable. But in most cases, early assessment is not required unless it is a reoperation. For more satisfactory results after corrective surgery, controversies on the anatomy and function of the "pelvic muscle complex" should be resolved. Also a more precise assessment can b e  achieved only after the resolution of controversy. REFERENCES deVries PA, Cox KL. Surgery of Ano-rectal anomalies. Surg Clinic N Am 1985; 65: 1139-69 deVries PA, Pena A. Posterior sagittal anorectoplasty. J Ped Surg 1982; 17:638-43 Kelly JH. Cine radiography in anorectal malformations, J Ped Surg 1969; 4:538-41 Kelly JH. The clinical and radiological assessment of anal continence in childhood. Aust NZ J Surg 1972; 42:62-3 Kiesewetter WB. !Imperforate anus: I1 The rationale and technique of the sacro-abdomino-perineal operation. J Ped Surg. 1967; 2: 106-1 0 Kim W. Posterior sagittal anorectoplasty for imperforate anus and anorectal malformations. J Korean Surg SOC 1987; 32:344-52 Okada A, Kamata S. Anterior sagittal anorectoplasty for recto-vestibular and anovestibular fistula. J Ped Surg 1992; 27:85-8 Pena A. The surgical treatment of anorectal malformations, an intensive workshop & teaching course. Taipei, Taiwan, Dec 12-1 4, 1991 Potts WJ. The surgeons and the child. Saunders, Philadelphia 1959; p.  213 Rehbein F. Imperforate anus: Experiences with abdomino-perineal and abdomino-sacro-perineal pull through procedure. J Ped Surg 1967; 2:99-105 Stephens FD, Smith ED. Anorectal Malformations in Children. Year Book Medical Publishing, Chicago. 1971 Swenson 0, Donnellan WL. Preservation of the puborectalis sling in imperforate anus repair. Surg Clinic N Am 1967; 47:173-93 Templeton JM, Ditesheim JA. High imperforate anus- quantitative results of long-term fecal continence. J Ped Surg 1985; 20: 645-52 

Defecation Patterns after Posterior SagittaI Anorectoplasty with an Objective Scoring System

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Defecation Patterns after Posterior SagittaI Anorectoplasty with an Objective Scoring System

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