Management of FI After Surgery of ARM
Condition: Fecal Incontinence; Childhood ALL; Anorectal Malformations
MeSH terms: Precursor Cell Lymphoblastic Leukemia-Lymphoma; Fecal Incontinence; Anorectal Malformations; Congenital Abnormalities
Study type: Observational

Summary: 
      The posterior sagittal approach to anorectal malformation (ARM) has radically changed the
      outcome of these patients, improving the preservation of anal sphincters, owing to their
      anatomical identification. However, in long term follow-up, fecal incontinence and severe
      constipation remain the most frequent and disabling postoperative clinical problems, having a
      significant influence on quality of life. Current therapeutic measures for Fecal Incontinence
      include biofeedback, sacral nerve stimulation, radiofrequency energy delivery, surgical
      treatment and sphincter replacement. Biofeedback combined with SNS has achieved satisfactory
      results. However, not all patients have an improvement in their weakened anal sphincter and
      achieve acceptable continence.

      A detailed assessment of anorectal sphincter morphology and function can predict therapeutic
      outcome. Magnetic resonance imaging(MRI) can help to judge the anal atresia type, to display
      the presence and running of the fistula, and to show the nature of anal sphincter, such as
      the shape, thickness, directions and position of the anal sphincter complex and location in
      the pelvic floor and other systems malformations, finally to provide a reliable diagnostic
      basis for surgical program and prognostic assessment. High-resolution anorectal manometry
      (HR-ARM) is the latest internationally recognized examination for the evaluation of anorectal
      function. A standardised protocol of HR-ARM can characterise FI from dyssynergic or other
      neuromuscular and sensory problems. As a result, HR-ARM provides a more appropriate
      management in patients with FI. In order to assess whether patients with fecal incontinence
      should choose biofeedback therapy, our study included children with FI after anorectal
      malformation, and combined HR-ARM and MR to predict the efficacy of sacral nerve stimulation
      and pelvic floor rehabilitation.
    

Detailed description: 
      The posterior sagittal approach to anorectal malformation (ARM) has radically changed the
      outcome of these patients, improving the preservation of anal sphincters, owing to their
      anatomical identification. However, in long term follow-up, fecal incontinence and severe
      constipation remain the most frequent and disabling postoperative clinical problems, with an
      important impact on quality of life. A cluster of physical and psychological problems appear
      in pediatric patients, including repeated infections, skin ulcer and scar, social anxiety
      disorder, behavioral problems, self-abasement or isolation and other problems, which cause
      children full of guilt and embarrassment and increase the risk of bullying.

      Current therapeutic measures for FI include biofeedback, sacral nerve stimulation,
      radiofrequency energy delivery , surgical treatment, and sphincter replacement. Zhengwei Yuan
      et al. conducted a follow-up study on 31 patients with FI after ARM, and confirmed that
      biofeedback combined with SNS has a good effect on patients with FI after ARM. However,not
      all patients improve their impaired anal sphincter and acquire satisfactory continence. A lot
      of time and treatment costs are wasted. Therefore, it is necessary to clarify the indications
      for the application of biofeedback combined with SNS.

      Severity of ARM affects the degree of development of internal and external anal sphincters. A
      detailed assessment of anorectal sphincter morphology and function can predict therapeutic
      outcome. In clinical practice, endoanal ultrasound and endoanal magnetic resonance imaging
      (MRI) are the main imaging modalities for the anatomical assessment of the anal sphincter
      complex. Sphincter MR is more suitable for observing the nature of the anal sphincter such as
      the shape, thickness, directions, and position of the anal sphincter complex and its location
      on the pelvic floor. MR examination has a high clinical value in the diagnosis of ARM. It can
      help determine the anal atresia type, display the presence and running of the fistula,
      evaluate the perianal muscle development and other systems' malformations, and finally
      provide a reliable diagnostic basis for surgical program and prognostic assessment. The role
      of MR is similar to that of EUS in some aspects. However, the sphincter MRI can clearly
      demonstrate the sphincter pattern, the position of the sphincter on the pelvic floor, and
      several indicators that cannot be detected by EUS. High-resolution anorectal manometry
      (HR-ARM) is the latest internationally recognized examination for the evaluation of anorectal
      function. A standardised protocol of HR-ARM can characterise FI from dyssynergic or other
      neuromuscular and sensory problems.Therefore, HR-ARM provides a more appropriate management
      in patients with FI. The anorectal manometry is a functional study that can evaluate the
      potential for muscular sphincterial recovery after BFB; the assessment derives greater
      benefit also from a morphological evaluation (MRI) in particular when the manometry is
      unfavorable.

      The study included children with FI after ARM, and the investigators combined HR-ARM and MR
      to predict the efficacy of sacral nerve stimulation and pelvic floor rehabilitation to
      determine whether patients with fecal incontinence should choose biofeedback therapy.
    

Observational model: Cohort
Time perspective: Prospective
Sampling method: Probability Sample
Study population: 
        Fecal Incontinence after surgery of Anorectal Malformation