Clinical and manometric postoperative evaluation of posterior sagital anorectoplasty (PSARP) in patients with upper and intermediate anorectal malformations

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C lin ic a l a n d m a n o m e tric p o sto p e ra tiv e e v a lu a tio n o f

p o ste rio r sa g ita l a n o re c to p la sty (P S A R P ) in p a tie n ts w ith

u p p e r a n d in te rm e d ia te a n o re c ta l m a lfo rm a tio n s

Federal University of Siio Paulo - PSM - Siio Paulo, Brazil

P S A R P is c u rre n tly th e m o s t w id e ly -u s e d s u rg ic a l te c h n iq u e fo r s u rg ic a l c o rre c tio n o f h ig h a n d in te rm e d ia ry a n o re c ta l m a lfo rm a tio n s , b u t th e re is m u c h c o n tro v e rs y in th e lite ra tu re a b o u t th e p o s to p e ra tiv e e v a lu a tio n o f th e s e c a s e s . W e s tu d ie d 2 7 c a s e s o f a n o re c ta l m a lfo rm a tio n s o p e ra te d w ith P S A R P fro m c lin ic a l a n d m a n o m e tric a s p e c ts in o rd e r to a n a ly z e : 1 ) fe c a l c o n tin e n c e ; 2 ) th e re la tio n s h ip b e tw e e n fe c a l c o n tin e n c e a n d th e a s s o c ia te d s a c ra l a n o m a lie s a n d ; 3 ) th e re la tio n s h ip b e tw e e n th e p o s to p e ra tiv e m a n o m e tric e v a lu -a tio n a n d fe c a l c o n tin e n c e : F ro m th e a n a ly s is o f 2 7 c a s e s o f h ig h a n d in te rm e d ia ry a n o re c ta l m a lfo rm a tio n s , w e c o n c lu d e d th a t: 1 ) fe c a l c o n tin e n c e w a s a c h ie v e d in 4 8 .1 4 p e rc e n t o f th e c a s e s ; p a rtia l fe c a l c o n tin e n c e in 2 5 .9 2 p e rc e n t; a n d fe c a l in c o n tin e n c e in 2 5 .9 2 p e rc e n t o f th e c a s e s ; 2 ) th e p re s e n c e o f fe c a l in c o n tin e n c e w a s d ire c tly re la te d to th e a s s o c ia tio n o f s a c ra l a n o m a lie s a n d ; 3 ) a n o re c ta l m a n o m e try is a u s e fu l te s t to e v a lu a te th e p a tie n ts o p e ra te d b y P S A R p ' d u e to th e e x is te n c e o f a re la tio n s h ip b e tw e e n th e m a n o m e tric re s u lts a n d th e d e g re e o f fe c a l c o n tin e n c e .

U N IT E R M S : A n o re c ta l m a lfo rm a tio n s , P o s te rio r s a g ita l a n o re c to p la s ty .

IN T R O D U C T IO N

A

n o r e c ta lg r e a t c h a lle n g em a lf o r m a tio n sto th e p e d ia tr ic( A R M s )s u r g e o n .s till p r e s e n tS in c e th ea s tu d ie s o f P e n a a n d D e V r ie s , 1 _{p o s te r io r} _{s a g ita l}

a n o r e c to p la s ty ( P S A R P ) , h a s b e c o m e th e m a in tr e a tm e n t f o r u p p e r a n d in te r m e d ia te A R M s in m o s t p e d ia tr ic c e n te r s a r o u n d th e w o r ld . T h e s e a u th o r s a ls o h ig h lig h te d th e im p o r ta n c e o f s a c r a l m a lf o r m a tio n s b y s ta tin g th a t s a c r a l a n d A R M s to g e th e r le a d to le s s f a v o r a b le p o s to p e r a tiv e r e s u lts .

P o s to p e r a tiv e e v a lu a tio n o f p a tie n ts w ith A R M s is v e r y c o n tr o v e r s ia l. T h e r e f o r e , w e e v a lu a te d c lin ic a l a n d m a n o m e tr ic r e s u lts o f 2 7 c h ild r e n w ith u p p e r a n d in te r m e d ia te A R M s w h o u n d e r w e n t P S A R P .

A d d re s s fo r c o rre s p o n d e n c e : J o s e L u iz M a rtin s

R u a d o s O to n is , 1 3 1 - V . C le m e n tin o S a o P a u lo /S P - B ra s il - C E P 0 4 0 2 5 -0 0 0

P A T IE N T S

W e s tu d ie d 2 7 w h ite c h i I d r e n w ith 2 1 u p p e r a n d 6 in te r m e d ia te A R M s , o f w h ic h 1 7 w e r e m a le a n d 1 0 w e r e f e m a le , a n d a ll o f w h o m p r e s e n te d f is tu la s ( 1 7 u r e th r a l, 5 v a g in a l, 5 v e s tib u la r ) . A g e s v a r ie d f r o m 4 to I I y e a r s .

T h e s e p a tie n ts u n d e r w e n t c o lo s to m ie s w ith 2 o p e n in g s p r io r to P S A P R , a n a l d ila tio n s w ith H e g a r 's c a n d le s d u r in g th e p o s to p e r a tiv e p e r io d , a n d th e c lo s in g o f th e c o lo s to m ie s . W e a s s e s s e d th e s e p a tie n ts c lin ic a lly a n d w ith a n o r e c ta l e le c tr o m a n o m e tr y in o r d e r to e v a lu a te f e c a l c o n tin e n c e , r e la tio n s b e tw e e n f e c a l c o n tin e n c e a n d a n y a s s o c ia te d s a c r a l m a lf o r m a tio n s , a n d r e la tio n s b e tw e e n f e c a l c o n tin e n c e a n d e le c tr o m a n o m e tr y .

A n o r e c ta l m a n o m e tr y w a s p e r f o r m e d w ith r e c ta l a n d s p h i n c te r b a llo o n s .2 _{W e c o n n e c te d} _{th e b a I lo o n s to p r e s s u r e}

tr a n s d u c e r s ( D ix ta l) in tu r n c o n n e c te d to a M P - I 0 0 a m p lif ie r , a v id e o m o n ito r , a n d a 3 - c h a n n e l r e g is te r , a ll o f w h ic h w e r e f u n c tio n a lly c o n s tr u c te d a n d m o d if ie d to a s s e s s a n o r e c ta l p r e S S lJ r e .3 .4 A ll e x a m s w e r e d o n e w ith o u t

M A R T IN S , J .L . & P IN U S , J . - C lin ic a l a n d m a n o m e tric p o s to p e ra tiv e e v a lu a tio n o f p o s te rio r s a g ita l a n o re c to p la s ty (P S A R P ) in p a tie n ts w ith u p p e r a n d in te rm e d ia te a n o re c ta l m a lfo rm a tio n s

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s e d a tio n ; r e g is te r s e n s itiv ity w a s c a lib r a te d a t N

=

1 0 m m /

m v w ith a s p e e d o f Im m /s e c . ,

M a n o m e tr ic a s s a y w a s d o n e b y f o llo w in g th e s e s te p s :

I .I n itia l r e s tin g p r e s s u r e m e a s u r e m e n t" ( in m m H g ) .

2 . S tu d y o f s p h in c te r - r e c ta l r e f le x e s b y f illin g r e c ta l

b a llo o n a n d o b s e r v in g th e p r e s s u r e r e s p o n s e in th e

s p h in c te r b a llo o n . R e f le x e s w e r e c o n s id e r e d p r e s e n t w h e n

a c le a r p r e s s u r e d e c r e a s e in th e s p h in c te r b a llo o n w a s

o b s e r v e d , a n d c o n s id e r e d a b s e n t w h e n th is w a s n o t

o b s e r v e d .

3 . T h e p r e s s u r e r e s p o n s e o f th e s p h in c te r b a llo o n

d u r in g c o u g h in g w a s m e a s u r e d ( in m m H g ) .

4 . T h e p r e s s u r e r e s p o n s e o f th e s p h in c te r b a llo o n

d u r in g v o lu n ta r y s p h in c te r c o n tr a c tio n w a s m e a s u r e d ( in

m m H g ) .

5 . T h e tim e o f s u s ta in e d , v o lu n ta r y c o n tr a c tio n w a s

m e a s u r e d ( in s e c o n d s ) . '

6 . T h e p r e s s u r e r e s p o n s e to s tim u la tio n o f p e r ia n a l

s k in w ith a n e e d le w a s m e a s u r e d ( in m m H g ) .

7 . T h e p r e s s u r e r e s p o n s e to p a tie n t's c r y in g w a s

m e a s u r e d ( in m m H g ) .

8 . T h e a n a l p r e s s u r e w a s r e g is te r e d a f te r th e

in tr o d u c tio n o f s p h in c te r b a llo o n in to th e u p p e r r e c tu m

a n d c o n s ta n t w ith d r a w a l a t 1 c m e v e r y 5 s e c o n d s ( s im p le

p r e s s u r e c u r v e ) .

9 . T h e a n a l p r e s s u r e c u r b w a s r e g is te r e d d u r in g

w ith d r a w a l o f s p h in c te r b a llo o n w h ile p a tie n t w a s e ith e r

c o u g h in g , c r y in g , o r v o lu n ta r ily c o n tr a c tin g th e a n u s

( s tim u la te d p r e s s u r e c u r v e ) .5

B a s e d u p o n th e s e f in d in g s , th e c h ild r e n w e r e

c la s s if ie d in to th e f o llo w in g th r e e g r o u p s :

I .C o n tin e n t - th o s e w h o d e f e c a te d o n c e o r tw ic e a

d a y , w ith n o s o ilin g , n o f e c a l o r a n a l a lte r a tio n s , a n d w ith

g o o d u p p e r a n d lo w e r r e c ta l c o n tr a c tio n d u r in g

e x a m in a tio n .

2 . P a r tia lly c o n tin e n t - th o s e w h o d e f e c a te d th r e e to

f iv e tim e s a d a y , w ith n o r m a l f e c e s a n d f r e q u e n t s o ilin g ,

w h o p r e s e n te d r e c ta l p r o la p s e , a n d w ith m o d e r a te u p p e r

o r lo w e r c o n tr a c tio n d u r in g r e c ta l e x a m in a tio n .

3 . I n c o n tin e n t - c h ild r e n w h o d e f e c a te d m o r e th a n

f iv e tim e s a d a y , w ith liq u id f e c e s a n d a c o n s ta n t a n d to ta l

f e c a l lo s s , a n a n u s w ith a la r g e o p e n in g , r e c ta l p r o la p s e ,

a n d a v is ib le lo s s o f f e c e s a n d w h o p r e s e n te d lig h t o r n o

u p p e r o r lo w e r c o n tr a c tio n d u r in g e x a m in a tio n .

S ta tis tic a l a n a ly s is w a s d o n e w ith c h i- s q u a r e d te s ts

f o r 2 X N ta b le s to c o m p a r e th e c o n tin e n t, p a r tia lly

c o n tin e n t, a n d in c o ~ tin e n t g r o u p s a c c o r d in g to th e a b o v e

-m e n 'tio n e d c h a r a c te r is tic s . A n a ly s e s o f v a r ia n c e u s in g

F r ie n d m a n 's r a n k te s t w e r e u s e d to c o m p a r e e a c h p a tie n t's ,

in itia l p r e s s u r e s , v o lu n ta r y c o n tr a c tio n , a n d p e r ia n a l

T a b le 1

R e la tio n b e tw e e n fe c a l c o n tin e n c e a n d s a c r a l

,m a lfo r m a tio n s

W ith S a c ra l W ith o u t S a c ra l T o ta l

M a lfo rm a tio n s M a lfo rm a tio n s

C o n tin e n t 1 1 2 1 3

P a rtia lly 3 4 7

c o n tin e n t

In c o n tin e n t 6 7

s tim u la tio n , a n d th e th r e e g r o u p s ; in c a s e o f s ig n if ic a n t

d if f e r e n c e s , m u ltip le c o m p a r is o n te s ts w e r e a ls o

p e r f o r m e d .6 _{W e u s e d} _{K r u s k a ll- W a llis '} _{te s t} _{to c o m p a r e}

p a tie n ts o f a ll th r e e g r o u p s in r e la tio n to p r e s s u r e v a lu e s ,

w h ic h w e r e c o m p le te d b y m u ltip le c o m p a r is o n te s ts .

R E S U L T S

1. Fecal continence

T h ir te e n o f 2 7 c a s e s s u b m itte d to P S A R P p r e s e n te d

f e c a l c o n tin e n c e , 7 c a s e s p r e s e n te d p a r tia l c o n tin e n c e , a n d

7 in c o n tin e n c e .

2. Relation between fecal continence and sacral malformations

T h is r e la tio n is d e p ic te d in T a b le I .

3. Relation between fecal continence and manometric assays

T h is r e la tio n is s h o w in T a b le 2

A ll p a tie n ts in th e th r e e g r o u p s p r e s e n te d a n a b s e n c e

o f th e s p h in c te r - r e c ta l r e f le x .

S ta tis tic a l a n a ly s is o f th e d a ta s h o w e d th a t in itia l

p r e s s u r e , p r e s s u r e a f te r c o u g h in g , p r e s s u r e a f te r v o lu n ta r y

c o n tr a c tio 'n , p r e s s u r e a f te r p e r ia n a l s tim u la tio n , a n d

p r e s s u r e a f te r c r y in g w e r e s ig n if ic a n tly h ig h e r in c o n tin e n t

p a tie n ts . T h e r e w e r e n o s ta tis tic a lly s ig n if ic a n t d if f e r e n c e s

w h e n s tu d y in g s u s ta in e d c o n tr a c tio n s .

A n a ly s is o f th e s h a p e s o f th e n o r m a l a n d s tim u la te d

p r e s s u r e c u r v e s s h o w e d th a t th e p e r c e n ta g e o f n o r m a l

c u r v e s in in c o n tin e n t p a tie n ts w a s s ig n if ic a n tly lo w e r th a n

in th e o th e r p a tie n ts . P r e s s u r e le v e ls s h o w e d m u c h h ig h e r

r a te s o f n o r m a lity in c o n tin e n t p a tie n ts w h e n c o m p a r e d to

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Table 2

Relation between fecal continence and manometric evaluation

N o . o f IP * C o u g h V C * S V C * * P S * C R Y *

C o n tin e n t p a tie n ts

1 3 1 3 .9 2 2 3 .2 5 2 2 .8 5 8 .7 5 1 6 .4 2 1 4 .2

P a r tia lly c o n tin e n t

p a tie n ts

7 1 0 .8 6 1 6 .6 7 1 7 .2 9 9 .8 3 1 2 .8 6 2 2

In c o n tin e n t p a tie n ts

7 6 .5 7 6 .6 7 9 .8 6 5 .5 0 8 1 0 .3

IP

=

In itia l p r e s s u r e ;

VC

=

V o lu n ta r y c o n tr a c tio n ;

SVC

=

S u s ta in e d v o lu n ta r y c o n tr a c tio n ;

PS

=

P e r ia n a l s tim u la tio n *

=

m m H g ; * *

=

s e c o n d s

in c o n tin e n t a n d p a rtia lly c o n tin e n t p a tie n ts . A lth o u g h th e

fre q u e n c y o f c o n tra c tio n s c o u ld n o t b e s ta tis tic a lly

a n a ly z e d , a h ig h e r in c id e n c e o f c o n tra c tio n s in c o n tin e n t

p a tie n ts w a s s u g g e s te d .

L S .F ~ . A.A.R. Alla . f .R .t: .• P .O . dr A .k .P .~ .J '.

, .,.t .t - - • . I t . ,

~

Figure 1 -M a n o m e tr y o f c o n tin e n t p a tie n t.

F ig u re s I ,2 , a n d 3 s h o w m a n o m e tric re a d in g s fro m

a c o n tin e n t, a p a rtia lly c o n tin e n t, a n d a n in c o n tin e n t p a tie n t, re s p e c tiv e ly .

S c h n a u fe r e t £11.7 dem onstrated th e a p p lic a b i lity o f

a n o re c ta l m a n o m e try in th e p o s to p e ra tiv e e v a lu a tio n o f

a n o re c ta l m a lfo rm a tio n s . S e v e ra l a u th o rsX

-'4 h a v e a lre a d y

re p o rte d a n o re c ta l m a n o m e try in th is k in d o f e v a lu a tio n .

A n a ly s is o f th e in itia l p re s s u re o f o u r p a tie n ts in c o m p a ris o n to fe c a l c o n tin e n c e s h o w e d s im ila r re s u lts to

s e v e ra l o th e r re p o rts ; th e re a re p re s s u re ra n g e s d e fin e d

fo r c o n tin e n t, p a rtia lly c o n tin e n t, a n d in c o n tin e n t p a tie n ts ,

w ith a d ire c t re la tio n b e tw e e n in itia l p re s s u re a n d fe c a l c o n tin e n c e a s m e n tio n e d b y H a b e rk o rn e t £11.1 5 _{a n d Iw a y}

e t £11."

M is c h a la n y e t a l.1 fi _{re p o rte d} _{d u rin g} _{th e} _{" F irs t}

In te rn a tio n a l S y m p o s iu m o f A n o re c ta l M a n o m e try " th a t

it is d iffic u lt to e s ta b lis h a p a tte rn in a n o re c ta l m a n o m e try

re s u lts , a s m a n y ty p e s o f e q u ip m e n t a n d d iffe re n t m e th o d s o f e v a lu a tio n a re u s e d a ro u n d th e w o rld . F ro m 1 9 8 7 to

1 9 9 5 w e u s e d e le c tro m a n o m e try w ith th e b a llo o n m e th o d

o n 1 ,1 5 3 p a tie n ts ,1 7 a n d s i n c e 1 9 9 5 w e h a v e b e e n u s i n g

c o m p u te riz e d a n o re c ta l m a n o m e try . IX

T h e a b s e n c e o f th e s p h in c te r-re c ta l re fle x a m o n g o u r

p a tie n ts w a s e x p e c te d , a s th e y p re s e n te d u p p e r o r in te rm e d ia te a n o re c ta l m a lfo rm a tio n s in w h ic h th e re is

e ith e r a lo w -fu n c tio n in g o r a b s e n t s p h in c te r. E v e n a m o n g

lo w e r m a lfo rm a tio n s , in w h ic h in te rn a l s p h in c te r fib e rs a re ru d im e n ta ry , I I )th e re fle x is p re s e n t in o n ly 7 0 p e rc e n t

o f th e c a s e s .2 0

P re s s u re s o b ta i n e d w i th c o u g h i n g , v o lu n ta ry c o n tra c tio n , c ry in g , p e ria n a l s tim u la tio n , a n d th e tim e o f

s u s ta in e d c o n tra c tio n a llo w e d u s to e v a lu a te d s tria te d m u s c le s o f th e s p h in c te r c o m p le x .

M A R T IN S , J .L . & P IN U S , J . - C lin ic a l a n d m a n o m e tr ic p o s to p e r a tiv e e v a lu a tio n o f p o s te r io r s a g ita l a n o r e c to p la s ty ( P S A R P ) in p a tie n ts w ith u p p e r a n d in te r m e d ia te a n o r e c ta l m a lfo r m a tio n s

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Table 3

Relation between fecal continence and manometric

evaluation of simple (SPC) and stimulated (StPC)

pressure curves

C

=

C o n tin e n t; P

=

P a r tia lly c o n tin e n t; I

=

L o w ; F

=

F r e q u e n t;

S = S e ld o m

Pressures

upon

coughing

give us an idea of the

reflexive

resistance

of the upper

part of the anorectal

sphincter com plex

to a sudden rise in abdom inal

pressure.

A ccording

to Scharli and K iesew etter,21 the receptors that

trigger reflex contractions

m ay be situated in the puborectal

m uscle.

Pressure

during

voluntary

contraction

is of m ajor

im portance

in m anom etric

evaluation,

since it reflects the

Figure2 - M a n o m e tr y o f p a r tia lly c o n tin e n t p a tie n t.

patient's

capacity to halt defecation

w ith the action of the

striated m uscles of the sphincter

com plex,

by the closing

the low er

rectum

using

the external

sphincter,

and by

elevating

and tightening

the upper

rectum

using

the

puborectal

m uscle.

Perianal

stim u lation

triggers

the contraction

of

striated

m uscles

according

to the degree

of stim ulation,

integrity

of the m uscle,

and innervation.

Continence

is

better in patients w ith a good response to this stim ulation.

'4

Pressures

after

crying

allow

good

sphincter

evaluation

in sm all children due to w ave contractions

that

are triggered

by tightening

reflexes.

Som e com m ents

should be m ade regarding

pressure

curves.

A hran

et alY started

using

pressure

curves

to

evaluate

the extension

and pressure

of the anal canal in

operated

anorectal

m alform ations,

publishing

their study

in 1976.

1 0

G il-V ernet

et al,22 highlighted

the im portance

of pressure

profiles done w ith progressive

w ithdraw al

of

catheters from the rectum to the anus at a constant

speed,

obtaining

a pressure

curve usecl to evaluate

the treatm ent

of fecal incontinence

in children

w ho underw ent

surgical

correction

of anorectal 'm alform ations.

S S

S

F

S S F F F F F

F

S F F F F F F S tP C

S h a p e

PL

C tr c .

A L A L

N N N N

N N N F

N N N N

N L N L

N N N N

N L N L

N N N N

N L N L

A L A L

N L N L

A L A L

N L N L

A L A L

S P C

S h a p e

PL

15

_I

19

_I

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,

..

,.

.

~

__ ~.~.~~

( eL

F ig u re 3 - M a n o m e try o f in c o n tin e n t p a tie n t.

T h e in itia l p a rt. o f th e s im p le p re s s u re c u rv e s s h o w

th e re p e rc u s s ip n o f th e a n a l le v a to r m u s c le , e s p e c ia lly o f

th e p u b o re c ta l p o rtio n ; th e d is ta l p o rtio n s h o w s th e p re s s u re

in th e e x te rn a l s p h in c te r o f th e a n u s . A s tim u la te d c u rv e is

o b ta in e d b y a s k in g th e p a tie n t to c o u g h o r to c o n tra c t th e

a n u s v o lu n ta rily ; m o re o v e r, th is c a n a ls o b e o b ta in e d d u rin g

c ry in g . T o ta l o r p a rtia l c o n tra c tio n s o b s e rv e d in th e c u rv e

d u rin g w ith d ra w a l o f th e c a th e te r a t c o n s ta n t s p e e d

d e m o n s tra te w h ic h re g io n s a re c a p a b le o f c o n tra c tin g .

P S A R P is u s e d th ro u g h o u t th e w o rld fo r p rim a ry

tre a tm e n t o f u p p e r a n d in te rm e d ia te A R M s . H o w e v e r, it

is a d iffic u lt te c h n iq u e w h ic h re q u ire s fro m th e s u rg e o n a

c o n s u m m a te k n o w le d g e o f a n o re c ta l a n d u ro g e n ita l

a n a to m y , a n d a ls o k n o w le d g e o f a n o re c ta l fu n c tio n s fo r

a n a d e q u a te p ro c e d u re a n d p o s to p e ra tiv e fo llo w -u p Y

T h e s u rg e o n m u s t fo llo w -u p p a tie n ts fo r m a n y y e a rs

b y e v a lu a tin g fe c a l c o n tin e n c e a n d d ire c tin g "b io fe e d b a c k "

p h y s io th e ra p y 2 4 .2 5 tre a tin g th e p a tie n t c o m p re h e n s i v e ly ,

in c lu d in g p s y c h ia tric a lly .

A s S m ith a ffirm s ,2 6 e a c h g e n e ra tio n o f p e d ia tric

s u rg e o n s b rin g s n e w te c h n iq u e s a n d ta c tic s to A R M

tre a tm e n t, w h ic h d e s p ite a ll th e e n th u s ia s m a n d h o p e th e s e

m a y g e n e ra te , s h o u ld b e th o ro u g h ly a n d c ritic a lly te s te d .

C O N C L U S IO N S

I. P S A R P m a in ta in e d fe c a l c o n tin e n c e in 4 8 .1 4

p e rc e n t o f th e c a s e s a n d m a in ta in e d p a rtia l c o n tin e n c e in

2 5 .9 2 p e rc e n t o f th e c a s e s .

2.

F e c a l in c o n tin e n c e w a s a s s o c ia te d d ire c tly w ith

s a c ra l m a lfo rm a tio n s .

3 . A n o re c ta l m a n o m e try w a s u s e fu l in e v a lu a tin g

p a tie n ts , a s th e d e g re e o f c o n ti n e n c e c o rre s p o n d e d to

m a n o m e tric fin d in g s .

RESUMO

A a n o rre to p la s tia s a g ita l p o s te rio r (A R P S P ) e o p ro c e d im e n to c iru rg ic o m a is u tiliz a d o a tu a lm e n te p a ra a c o rre r;a o d a s a n o m a lia s a n o rre ta is a lta s e in te rm e d ia ria s . E x is te m u ita c o n tro v e rs ia n a Iite ra tu ra a re s p e ito d a a v a lia r;a o p 6 s -o p e ra t6 ria d e s s e s p a c ie n te s .

B a s e a d o n e s s e fa to , e s tu d a m o s 2 7 c a s o s d e a n o m a lia s a n o rre ta is o p e ra d o s c o m a A R P S P d o p o n to d e v is ta c lin ic o e

m a n o m e tric o , c o m a fin a lid a d e d e a v a lia r: 1.C o n tin e n c ia fe c a l; 2. R e la y a o e n tre a c o n tin e n c ia fe c a l e a n o m a lia s s a c ra is

a s s o c ia d a s ; 3 . R e la y a o e n tre a a v a lia y a o m a n o m e tric a p 6 s -o p e ra t6 ria e a c o n tin e n c ia fe c a l. D a a n a lis e d o s 2 7 c a s o s d e

a n o m a lia s a n o rre ta is a lta s e in te rm e d ia ria s , c o n c lu im o s q u e :1 .A c o n tin e n c ia fe c a l fo i c o n s e g u id a p le n a m e n te e m 4 8 ,1 4 % d o s c a s o s , p a rc ia lm e n te e m 2 5 ,9 2 % d o s c a s o s , e a in c o n tin e n c ia fe c a l fo i o b s e rv a d a e m 2 5 ,9 2 % ; 2 .A p re s e n c ;;a d e in c o n tin e n c ia

fe c a l fo i d ire ta m e n te re la c io n a d a c o m a a s s o c ia c ;a o d e a n o m a lia s s a c ra is ; 3. A m a n o m e t ria a n o rre ta l fo i e x tre m a m e n te L J til

p a ra a v a lia r o s p a c ie n te s o p e ra d o s p o r a n o m a lia s a n o rre ta is d e v id o

a

e x is te n c ia d e u m a re la y a o e n tre o s re s u lta d o s

m a n o m e tric o s e0g ra u d e c o n tin e n c ia fe c a l.

M A R T IN S , J .L . & P IN U S , J . - C lin ic a l a n d m a n o m e tric p o s to p e ra tiv e e v a lu a tio n o f p o s te rio r s a g ita l a n o re c to p la s ty (P S A R P ) in p a tie n ts w ith u p p e r a n d in te rm e d ia te a n o re c ta l m a lfo rm a tio n s

(6)

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