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1 Y a ] Ń f Y ] ] ] ] Y a ] f Y ] f a ] Ń ] ] f ] ] ] Y Y _ Y Alberto Pena 10 30% 70% 3 1 Pena : In spite of the fact that imperforate anus with perineal or vestibular fistula is considered to be a low anorectal anomaly the majority of surgeons use posterior sagittal anorectoplasty (Pena and de Vries) for its correction ie the same procedure that is used to correct high anomalies 10% to 30% of the postoperative patients suffer from total fecal incontinence and more then 70% V from chronic constipation It was shown that patients with these anomalies have normally formed anal canal However the opening of the fistula which is usually narrower than fecal mass is formed in the rectum with forward displacement from the proper location of the anal orifice Megacolon and chronic constipation develop as a result of this relative stenosis in patients who are 3 + months old The process of persistent straining of the puborectal muscle gradually results in the shortening of the anal canal The caudal part of the anal canal does not fully open to the normal width due to muscle rigidity of the perineum The operative procedure must be carried out before this pathologic alteration occurs The operating procedure of the anal orifice formation consists of brining the distal caudal wall of the anal canal to the tunnel inside the external anal sphincter using a curved catheter inserted into the fistula This wall is separated from the surrounding tissue on the depth of 1 cm and split Then its edges are sewn to the skin of the perineum After the daily widening of the anal canal closing of the fistula is 65

2 done under the colostomy protection Unlike the Pena operation this procedure spares pelvic muscles from injury And if it is done prior to megacolon development it has good functional prognosis Keywords: newborn imperforate anus rectal atresia anorectal fistula vestibular fistula pathologic physiology anorectal anomalies surgical treatment [1] [2] [3] S Gans c [4] : [4] J Caffey (1960 V1980 ) [5] 3 [6] 3 20 [7] V50 (43 Ó08 ) [8] V15 [8 9] 2 80 V90 66

3 P Meunier [9] [10] ( 1 ) [11] 10 2 V3 67

4 V ( 1 ) [12] [13] [14] (Iliococcigeus) (coccigeus) (pubococcigeus) [1] [2] (m levator ani) [1 2] A Shafik [15] ( 2) 68

5 V V : ) [16] [7] 9 35 V 45 (416 Ó34 ) 55 69

6 c [7] [16 17] 52 (94%) ( 3) ( 4) 70

7 () 1 2 () ( ) [18] ( 5) [16] (Foley) [10] ( 6 ) 2 5 ( 7) 71

8 5 : [19 20] [21] [21] 6 Foley 7 Foley 2 25 Foley 10 72

9 Foley [ ] 80 (cut back anoplasty) V (translocation anoplasty) (pullthrough anoplasty) [22] 1982 [23] [ ] 73

10 [23] :?? [25] Pena?? J Lin 10 30% [22] (73%) [26] W Mulder c [27] [28 29] 1983 [7] ) 15 V2 2 2 V3 20 [17] 05 V (2 ) (1 ) 4 5 1; 15;

11 V V V V V 100% 1 Pena A Potential anatomic sphincters of anorectal malformations in females / A Pena // Birth Defects Orig Artic Ser V 1988 V Vol 24 N 4 V P Stephens F D Potential anatomic sphincters of anorectal malformations in males / F D Stephens // Birth Defects Orig Artic Ser V 1988 V Vol 24 N 4 V P By the Japan sudy group of anorectal anomalies A group study for the classification of anorectal anomalies in Japan with comments to the International classification (1970) // Pediatr Surg V 1982 V Vol 17 V P Gans S L Congenital anorectal anomalies: changing concepts in management / S L Gans N B Fridman J S David // Clin Pediatr V 1963 V Vol 2 N 11 V P Caffey J Pediatric xray diagnosis / J Caffey V Chicago ets: Springer 1978 V 1737 p 6 / // V 1984 V 12 V C / [] // V 1983 V 4 V C

12 8 Frenckner B Anorectal manometry in the diagnosis of Hirschprung s disease in infants / B Frenckner // Acta Pediatr Scand V 1978 V Vol 67 N 2 V P Meunier P L exploration manometrique de l appariel anorectal de l enfant / P Meunier P Mollard J de Beanjew // Pediatrie (Lyon) V 1974 V Vol 29 N 7 V P / // V 1985 V 2 V C Nussel D Semiologie radiologique fonctionelle dans la maladie de Hirschprung et dans d autres formes de dischesie / D Nussel N Genton C Bozic // Ann Radiol V 1976 V Vol 19 N 1 V P Simultaneous endoluminal sonography and manometry to assess anal sphincter complex in normal subjects / R F Wong [et al] // Dig Dis Sci V 1998 V Vol 43 N 11 V P / // V 1983 V 8 V C / // V 1983 V 2 V C Videodefecography: a study of the motile pattern / A Shafik [et al] // Surg Radiol Anat V 2003 V Vol 25 N 2 V P // / V 1989 V 5 V C // / V 1990 V 8 V Cinedefecographic findings in patients with obstructed defecation sindrome A study in 420 cases / A Renzi [et al] // Minerva Chir V 2006 V Vol 61 N 6 V P hatterjee S K Double termination of the alimentary tract: second look / S K hatterjee // Pediatr Surg V 1980 V Vol 17 N 5 V P de Vries P A The staged sequential development of the anus and rectum in human embryos and fetuses / P A de Vries G W Friedland // J Pediatr Surg V 1974 V Vol 9 N 5 V P Normal and abnormal embryonic development of the anorectum in human embryos / R A Nievelstein [et al] // Teratology V 1998 V Vol 57 N 2 V P Lin J N Anorectal malformations V update 1998 / J N Lin // Changgeng Yi Xue Za Zhi V 1998 V Vol 21 N 3 V P de Vries P A Posterior sagittal anorectoplasty / P A de Vries A Pena // J Pediatr Surg V 1982 V Vol 17 N 5 V P Treatment of vestibular fistulas in older girls / R Sanchez Martin [et al] // Cir Pediatr V 2002 V Vol 15 N 4 V P Anorectal function and endopelvic dissection in patients with repaired imperforate anus / C C Chen [et al] // Pediatr Surg Int V 1998 V Vol 13 N 2 V P J Pediatr Surg / R Rintala [et al] V 1993 V Vol 28 N 8 V P Posterior sagittal anorectoplasty: functional results of primary and secondary operation in comparison to the pullthrough method in anorectal malformations / W Mulder [et al] // Eur J Pediatr Surg V 1995 V Vol 5 N 3 V P Prospective controlled longterm followup for functional outcome after anoplasty in boys with perineal fistula / M P Pakarinen [et al] // J Pediatr Gastroenterol Nutr V 2007 V Vol 44 N 4 V P Haider N Mortality and morbidity associated with late diagnosis of anorectal malformations in children / N Haider R Fisher // Surgeon V 2007 V Vol 5 N 6 V P