The role of colostomy in the management of anorectal malformations

The role of the colostomy in the definitive correction of anorectal malformations is controversial with regard no only to indications for its use, but also to location and type. We reviewed the records of 272 patients with 307 colostomies and analyzed the frequency of complications related to these controversial points. There were 250 completely divided and 57 loop colostomies, constructed in either the sigmoid or transverse colon. Twenty-five colostomies were associated with complications that included retraction, stenosis, dehiscence, prolapse, infection, bowel obstruction, sepsis, and death. Twelve additional colostomies were placed in positions that impeded the definitive correction of the malformation: 9 sigmoidostomies were too distal and 3 were located in the right-upper abdominal quadrant and did not permit pull-through without tension. Colostomy prolapse and pull-through infection were statistically less likely with a completely diverting colostomy. Thirty-five patients with rectovestibular malformations were encountered in this series. Ten were referred from other institutions after attempted repair without a colostomy and all 10 had complications of infection, dehiscence, retraction, and reopening of the fistula. In contrast, there were no complications in the remaining 25, in whom the repair was preceded by a colostomy, nor after re-repair of the other 10. These findings support the need for a colostomy prior to the repair of this malformation. We recommend a carefully constructed, high, completely diverting sigmoid colostomy prior to the initial definitive repair of anorectal malformations. A right transverse colostomy is preferable preceding redo operations.     

Colorectal perforations in neonates with anorectal malformations

 Colorectal perforations in neonates with anorectal malformations (ARM) are rarely reported. Two cases, one each with a low and high ARM is presented. Delayed patient presentation and “closed-loop” intestinal obstruction seem to be possible causes of perforation in these cases. Both patients survived following surgical intervention. The pertinent literature is reviewed to emphasize the overall management of such cases. Accepted: 17 December 1999     

Additional congenital defects in anorectal malformations

From 1974 until 1995 a total of 264 (141 , 123 ) patients born with an anorectal malformation (ARM) were referred to the University Hospital Nijmegen in the Netherlands. All additional congenital defects (ACDs) were registered. Special attention was paid to whether the ACDs take part in associations, syndromes, or sequences. One or more ACDs were observed in 67% of the patients. In decreasing order the defects concerned the uro-genital tract (43%), skeleton (38%), gastrointestinal tract (24%), circulation (21%), extremities (16%), face (16%), central nervous system (15%), respiratory tract (5%), and remaining defects (5%). Associations were observed in 49% of the patients, mostly (in 44%) the Vertebral, Anorectal, Cardial, Tracheo-Esophageal, Renal and Limb association. In 5% of the patients syndromes were recognized. Sequences were seen in 2% of the patients. Remarkable is the combination of trisomy 21 and ARM without a fistula. The combination of ARM and the Zellweger syndrome has not been reported before.Conclusion Almost all combinations of ARM and ACDs can be classified as an association, syndrome or sequence. ARM-causing agents affect males and females in equal numbers but lead to different expression in the sexes. The origin of the Omphalocele, Extrophia of the bladder, Imperforate anus, Sacral anomalies complex probably differs from that of other forms of ARM.     

Postoperative internal sphincter function in anorectal malformations — a manometric study

An anorectal manometric assessment of 30 patients with operated high or intermediate anorectal malformations was performed in order to study internal sphincter function in the reconstructed anal canal. In 14 patients (group I, mean age 3.1 years) the rectal blind pouch and fistula, when present, were used in the reconstruction of the anal canal by posterior sagittal anorectoplasty (12 cases) or sacroperineal pull-through (2 cases). In 16 cases (group II, mean age 8.8 years) the anal canal was reconstructed from proximal rectum or sigmoid by sacroabdominoperineal pull-through. In 11 of the 14 patients in group I manometric findings suggested the presence of a functioning internal sphincter. The pattern of anal slow-wave activity and rectoanal inhibitory reflex was normal. None of the patients in group II had a rectoanal inhibitory reflex and the slow-wave activity was of a colonic type. The resting anorectal pressure profiles were significantly higher in group I than in group II (mean 38 cm H₂O vs. 25 cm H₂O). The fecal continence of patients in group I was superior to those in group II despite their much younger ages. The findings of this study indicate that in anorectal malformations there is internal sphincter function in the distal rectal blind pouch and that it can and should be preserved when the anal canal is reconstructed.     

Biofeedback conditioning for fecal incontinence in anorectal malformations

Twenty children aged 6–18 years who had deficient fecal continence after primary and secondary surgery for anorectal malformations were treated by biofeedback conditioning. The original malformation was high in 17 cases and low in 3. Pretreatment manometric assessments and training were performed with a perfused open-tip catheter connected to a recording unit where the manometric tracings could be inspected digitally or from the pressure curve. A latex balloon was used to stimulate the rectum. The patients were taught to develop maximal sphincter contraction and synchronize the contraction with rectal distention. Rectal sensitivity was conditioned by gradually decreased balloon volumes. There were 4–11 training sessions. The follow-up time was 2–24 months. Sixteen of the 20 patients responded favorably to the training. Fecal continence and the ability to take part in a normal social life improved significantly in the responders. In the responders, the contractile power of the sphincter increased significantly while other manometric parameters (basal anal canal pressure, rectal sensitivity, rectal capacity, rectoanal inhibitory reflux) could not be influenced. Biofeedback is a safe, simple, and effective method in treating fecal incontinence associated with anorectal malformations.     

The spectrum of anorectal malformations in Africa

Anorectal malformations (ARM) remain a significant birth defect with geographic variation in incidence, individual phenotypes and regional geographic subtypes. Although early studies indicated a low incidence in Black patients, there is a great paucity of knowledge as to the types, frequency and incidence of ARMs encountered in the African continent and their associated anomalies. Current evidence suggests a significant clinical load. This study set out to evaluate ARM in Southern and other parts of Africa to define the clinical load of ARM. We retrospectively collected data on 1,401 ARM patients from six South African Paediatric Surgical units plus representative samples from five other African countries from West, Central and Southern Africa. Data included ethnic group, age, gender as well as the anatomical pathology, classification and presence or absence of associated anomalies. ARM lesions classified by the Wingspread classification plus an analysis of fistula position was carried out in evaluable cases for purposes of comparison. South African centres reported a higher prevalence of cloacae and vestibular fistulae, whereas rectovaginal, recto prostatic and anorectal malformation without fistula were more prevalent in the Northern African group. 76% of 1,401 patients were ethnically Black African [gender ratio = 2 (vs gender ratio 1.38 overall)] and 49.8% were "low" lesions (Wingspread classification). High or intermediate lesions were mostly males (72%). Anal stenosis was most prevalent in black males and non-Black females. Fistulae were identified in 95% with 682 (52%) being low (perineal/covered anus/vestibular) fistulae. Perineal fistulae had a male predilection (n = 260; 20%), whereas vestibular fistulas (n = 416; 32%) was strikingly frequent in black females (55%). Of the remainder, 15 fistulae were rectovesical (1.2%), 544 recto-urethral or prostatic (42%), 16 recto-vaginal (1.2%). In addition, there were 43 cloacal lesions (3.3%). Isolated rare ARM anomalies included "Pouch" colon (2) and H-type fistula (2). Isolated lesions occurred in 81% but 163 associated anomalies were identified in 114 patients. These included chromosomal lesions (10), genito-urinary anomalies (50), genital (16), cardiac (31), skeletal anomalies (33), gastro-intestinal malformations (28). Other anomalies included CNS anomalies (14), anterior abdominal wall defects (2) and facial (8) abnormalities and neuroblastoma (1). The ARM is not uncommon in Black African populations and constitutes a significant clinical load to surgical practice in Africa. Ethnic differences appear to exist and vestibular fistulae predominate in black females. Cloaca (3.3%) did appear to be more prevalent. Isolated lesions are frequent but the types of associated anomalies appear similar to other series except chromosomal syndromes. This study illustrates the need for more objective data from developing countries to assess geographical differences.     

Surgical management of anorectal malformations: a unified concept

Posterior sagittal anorectoplasty (PSARP) is a new approach for the treatment of anorectal malformations. It has allowed direct exposure of the anatomy of these defects, enabling the author to describe the spectrum of this malformation. It also permits patients to be grouped on the basis of their potential for continence and the correlation of operative findings with clinical results. Traditional anatomic concepts have proved very inaccurate. The new approach allows separation of rectum from genitourinary tract without damaging important structures. The rectum is located within the limits of the striated muscle structures in a precise manner. This approach has important implications for therapy, evaluation of results, classification, and terminology. All defects can be treated with PSARP. The size of the incision will vary according to the complexity of the malformation, from minimal PSARP in low malformations to full PSARP in higher defects. In addition, approximately 10% of all cases will require a laparotomy. Colostomy is recommended in most patients except for those with low malformations. A new classification is proposed based on practical therapeutic purposes. Patients are also grouped according to their common potential for continence, which is important for the evaluation and comparison of results. The decision to create a protective colostomy is based on clinical facts in 80%–90% of cases and on invertograms and other diagnostic tests in the remaining 10%–20%.     

先天性直肠肛门畸形盆腔MR三维重建图像及临床意义

目的 建立先天性直肠肛门畸形(anorectal malformations,ARM)盆腔MR三维重建图像,探讨其临床意义.方法 患儿28例,其中先天性直肠肛门畸形组14例,男9例,女5例;年龄3 d1例,2～5个月12例,13岁1例.对照组14例,男8例,女6例;年龄3个月～10岁,平均2.9岁,为无直肠肛管疾患而因其他疾病需行盆腔或臀部MR扫描的患儿.应用Siemens 1.5T MR成像仪,对28例小儿盆腔行横断位、矢状位和冠状位T_1WI和T_2 WI扫描,横断面和矢状面T_1WI加脂肪抑制序列.采用体绘制和3D-Doctor软件进行三维重建;利用三维图像,判断直肠肓端、横纹肌复合体(SMC)位置及发育情况.结果成功建立了28例小儿盆腔的MR三维重建图像,能清晰显示直肠盲端与SMC的关系、瘘管位置.根据三维重建图像上直肠盲端和SMC的关系,14例术前接受检查的ARM患儿中,5例直肠盲端位于SMC以上,诊断为高位闭锁,4例直肠盲端部分穿过SMC,诊断为中位闭锁,5例直肠肓端完全穿过SMC,诊断为低位闭锁,与X线或造影诊断相符,并经手术证实,诊断正确率为100%.每例ARM患儿SMC大小、分布不一致,即使在同一类型的患儿也不同,高位畸形最明显.对照组患儿,SMC边缘整齐,厚度均匀,起于耻骨后面,分两束向后行经直肠两侧并在其后方交汇,形成漏斗样结构,直肠位于中央.结论 盆腔MR三维重建图像能清楚地显示骨盆解剖结构的关系,为ARM诊断和手术提供直观形态学依据,为虚拟手术奠定基础.     

Feasibility of perineal sagittal approaches in patients without anorectal malformations

Perineal sagittal approaches (posterior sagittal anorectoplasty and anterior and posterior sagittal transanorectal approaches) allow complete anatomic exposure of the perineum and lower pelvis. Moreover, they reduce the risk of damaging important structures because the incision is led in the midline. Therefore, many surgeons have used these approaches to treat diseases other than anorectal malformations (ARM), including intestinal dysganglionosis, trauma, pseudohermaphroditism, presacral mass, and rectal duplication. The aim of this study was to describe a small series of patients operated on via these approaches at Gaslini Childrens Hospital over a 5-year period. We retrospectively evaluated 10 patients consecutively operated on via a perineal sagittal approach, with or without sphincteric structure involvement, between January 1997 and December 2001. All of these patients were without ARM. Indications included retrorectal abscesses (two), iatrogenic anal canal stenosis (one), postinflammatory anal canal stenosis (one), internal anal sphincter neurogenic achalasia (one), female pseudohermaphroditism (one), benign sacrococcygeal teratomas (two), malignant sacrococcygeal teratoma (one), and perineal rhabdomyosarcoma (one). Protective colostomy was used in four patients. The parameters that we analysed included technical details, possible complications, perineal cosmetic appearance, and outcome. No complications were experienced. The postoperative cosmetic perineal appearance was excellent in all patients, and continence, when assessed, was always considered satisfactory. All tumours underwent complete gross resection. However, one patient with malignant sacrococcygeal teratoma died as a result of the malignant process 2 years after surgery. Although our study was carried out on a small series of patients, it confirmed that perineal sagittal approaches can be used not only for ARM but also for other conditions involving perirectal pouches, presacral space, and urogenital structures, as these approaches are safe and provide excellent cosmetic results as well as satisfactory functional outcome. Although tumours can be treated via these approaches, outcome remains related to the nature and malignancy of the disease itself.     

Bowel function after surgery for anorectal malformations in patients with tethered spinal cord

Tethered spinal cord (TC) is an anomaly frequently recognized in association with anorectal malformations (ARM). However, the influence of TC on bowel function in children with ARM remains unknown. Furthermore, there are few studies that have assessed anorectal function in children with ARM and TC. The aim of this study was to evaluate anorectal function in ARM patients with TC using clinical assessment and anorectal manometry. Among 258 patients with ARM, this retrospective investigation included 35 patients who underwent spinal magnetic resonance imaging (MRI) after surgery for ARM. The patients were divided into two groups based on the presence or absence of TC, and bowel function was assessed by Kelly’s clinical score and anorectal manometry. Tethered cord was found in nine of the 35 patients (26%) with ARM. Of the ARM patients, TC was noted in four of 11 (36%) with high type anomalies, one of 8 (13%) with intermediate type anomalies, two of 14 (14%) with low type anomalies, and two of two patients (100%) with cloacal anomalies. Kelly’s clinical score did not significantly differ between the two groups. However, two of the nine patients with TC had poor bowel function (Kelly’s score; 2–0 points). On the contrary, patients without TC did not have poor bowel function. Anorectal manometry did not show a significant difference between patients with and without TC. However, the two patients with TC who had poor bowel function by Kelly’s score had low anal resting pressure, which was essential for achieving fecal continence. In conclusion, the present study showed that tethered cord was more frequently found in patients with more severe anorectal anomalies. Patients with TC were more likely to have poor bowel function, but this did not reach statistical significance. Presented at the 14th International Paediatric Colorectal Club, York, UK, 14–16 July 2007.     

Postoperative psychological status of children with anorectal malformations

Our purpose was to clarify factors that influence the level of depression of Japanese children with anorectal malformations (ARM). The subjects comprised 66 children with ARM, aged 0–16 years, and their mothers. Patients were divided into three groups (Group 1: aged 0–5 years, Group 2: 6–11 years, and Group 3: 12–16 years). The level of depression of the children aged 6–16 years was investigated by Kovac’s children’s depression inventory (CDI). The psychological status of their mothers was assessed by Spielberger’s state-trait anxiety index (STAI) and Zung’s self-rating depression scale (SDS). The classification of ARM and the clinical condition were also investigated. Defecation scores were assigned for the degree of bowel dysfunction. The level of depression in the patients was more marked in Group 3 than in Group 2 according to the CDI score. Significant correlations between the CDI score of the child and the STAI-1, STAI-2 and SDS scores of the mother were observed in Group 2, but not in Group 3. In Group 2, the STAI-1 score of the mothers was significantly influenced by the degree of bowel dysfunction in her child. In Group 3, the CDI score was significantly correlated with the constipation score. This study revealed that bowel dysfunction is the important factor that influences the level of depression of the children with ARM. In the period of childhood during which the child attends primary school, bowel dysfunction indirectly influences the level of depression of children through the psychological status of mothers. However, bowel dysfunction directly influences the level of depression of children in adolescent patients.     

Neurovesical dysfunction in children after surgery for high or intermediate anorectal malformations

Aim: To evaluate problems with bladder dysfunction in patients operated on for imperforate anus. Methods: All patients (11M, 25F) with high or intermediate imperforate anus seen in this institution between 1987 and 1997 were subjected to the investigation. They had all undergone a posterior sagittal anorectoplasty procedure with the aim of preserving as much as possible of the fistula. Hospital charts were reviewed. A detailed and structured interview regarding micturition habits was performed. If the results of this were abnormal the patients were also subjected to flow registration, measurements of residual urinary volume and in some cases also cystometry. Results: Micturition habits were normal in 30 out of 36 children. The remaining six, considered to have neurovesical dysfunction (NVD), had difficulties in emptying their bladder and exhibited pathological residual volumes. Two were boys with rectourethral fistulae, two were girls with cloacal malformations and two were girls with rectovestibular fistulae. Four out of six children with NVD had sacral anomalies.

Conclusion: NVD may occur even in the absence of sacral anomalies. A 4 h micturition observation is recommended in all newborns with intermediate or high anorectal anomalies to recognize the occurrence of NVD at an early stage.     

Evaluation of outcome of anorectal anomaly in childhood: the role of anorectal manometry and endosonography

The aim of this study was to evaluate role of anorectal manometry (ARM) and anal endosonography (ES) in assessment of the internal anal sphincter (IAS) quality on continence outcome following repair of anorectal anomalies (ARA). We devised a scoring system to evaluate the quality of the IAS based on ARM and ES and correlated the scores with clinical outcome, using a modified Wingfield score (MWS) for faecal continence. We also assessed the implication of megarectum and neuropathy on faecal continence. Of 54 children studied, 34 had high ARA and 20 had low ARA. Children with high ARA had poor sphincters on ES and ARM, and also poor faecal continence compared to those with low ARA. The presence of megarectum and neuropathy was associated with uniformly poor outcome irrespective of the IAS quality. The correlations between MWS on one hand, and ES and ARM scores for IAS on the other hand were weak in the whole study group, ES r = 0.27, P < 0.04, and ARM r = 0.39, P < 0.004. However, the correlations were strong in those who had isolated ARA without megarectum or neuropathy, ES r = 0.51, P < 0.02 and ARM r = 0.55, P < 0.01, respectively. In conclusion, the ARM and ES are valuable in evaluation of continence outcome in children after surgery for ARA and those with good quality IAS had better faecal continence. The IAS is a vital component in functional outcome in absence of neuropathy and megarectum.     

Window rectostomy: an alternative method of fecal diversion for high anorectal malformations in males without a urinary fistula

This report analyzes our initial experience with window rectostomy (WR) as a new method of fecal diversion for high anorectal malformations (ARM) in 27 males without a urinary fistula between May 1994 and May 1998; total correction was achieved in two stages. In the first stage, during the neonatal period, the dilated rectum was exteriorized as a WR through the left lower abdomen. In the second, after 3–5 months an abdominoperineal pull-through (APPT) procedure was performed in which the window rectostomy was mobilized and taken down to form a new anus. The results were compared with cases of high ARM with urinary fistula that were managed in three stages, i.e., proximal sigmoid colostomy, APPT, and colostomy closure. All 27 cases showed satisfactory results without any mortality or major pelvic infection. The main advantages of WR are that it provides more functioning bowel length after diversion and avoids a colostomy-closure operation and repeated hospitalizations, thus reducing the total cost of treatment. Accepted: 6 October 1999     

Anorectal malformations — results of treatment and long-term follow-up in 208 patients

During a 20-year period (1964–1983) 208 patients with anorectal malformations (143 males, 65 females) were treated; 98 had low and 110 had high or intermediate malformations. Associated anomalies were detected in 67.8%. The overall mortality in the series was 14.4%; most deaths were related to associated anomalies and/or prematurity. Four different procedures were used for high and intermediate anomalies: (1) abdominoperineal (18 cases); (2) sacroabdominoperineal (38); (3) sacroperineal (8); and (4) posterior sagittal anorectoplasty (7). Neonatal anoplasty was used to correct male low anomalies. Female low and intermediate anomalies with vestibular fistula were treated with anal transposition. More than one-half of the patients with high or intermediate anomalies had complications related to surgical therapy. Major secondary surgery was performed in 41 cases (12 resections of megarectum, 29 late sphincter reconstructions). Of the living patients, 90% (159/178) were followed up for 5–25 years. A majority (93%) of the patients with low anomalies had a good outcome at the last follow-up examination. In patients with high and intermediate anomalies continence improved with time; the greatest improvement occurred after 10 years of age. At the last follow-up examination 73% of the patients with high or intermediate anomalies had acceptable social continence. Manometric evaluation revealed a rectoanal inhibitory reflex in all assessed patients with a low anomaly, indicating a functioning internal sphincter. In patients with intermediate and high anomalies a rectoanal inhibitory reflex was found only when full-thickness terminal bowel had been used in the reconstruction (by perineal and posterior sagittal repair); presence of the reflex correlated with superior fecal control. Acceptable fecal continence may be achieved in the majority of patients with anorectal anomalies. Operative methods that optimally utilize the voluntary sphincters and preserve the potential internal sphincter in the terminal rectal pouch seem to facilitate earlier development of fecal continence. Offprint requests to: R. Rintala     

Posterior sagittal anorectoplasty: Results in the management of 332 cases of anorectal,malformations

This is a retrospective evaluation of the functional results obtained in 332 patients who underwent posterior sagittal anorectoplasty (PSARP) for the treatment of an anorectal malformation. All patients were operated on by the same person between September 1980 and June 1987. One hundred sixty-one patients were excluded: younger than 3 years, mentally retarded, colostomy still open, deaths, lost to follow-up, and having complex malformations. Patients were grouped according to their potential for continence. Voluntary bowel movements were considered one of the best indicators of fecal continence and were found among patients with a normal sacrum in 77% of those with rectourethral fistula and 30% of those with a vesical fistula. Except in 1 case, all patients with a normal sacrum and low malformation, vestibular fistula, anorectal agenesis without fistula, persistent cloaca, and atresia or stenosis had voluntary bowel movements. Different degress of soiling were present in patients with a normal sacrum including 20% with vestibular fistula, 30% with no fistula, 25% with atresia or stenosis, 61% with rectourethral fistula, 75% with cloacas, 50% with vesical fistulae, and 0% low malformations. Different degrees of constipation were found in patients with a normal sacrum including 50% with low malformations, 70% with vestibular fistulae, 55% with no fistula, 25% with atresia or stenosis, 30% with urethral fistulae, 75% with cloacas, and 50% with vesical fistulae. In contrast, only 20% of patients with more than 3 sacral vertebrae missing achieved voluntary bowel movements; 60% suffered constant soiling, 20% constipation, and 60% urinary incontinence. All evaluations were done without medical management. The average age of patients with voluntary bowel movements was 4.5 years; for patients without voluntary bowel movements it was 4 years. Patients with a normal sacrum and fecal incontinence operated upon elsewhere underwent secondary PSARP, achieving marked improvement in 45% of cases, some improvement in 37%, and no improvement in 18%. In contrast, those with an abnormal sacrum achieved 20%, 30%, and 50% respectively in each of the above-mentioned categories.     

Spectrum of genitourinary malformations in patients with imperforate anus

A retrospective review of 244 cases of imperforate anus demonstrated a 48% incidence of associated genitourinary (GU) anomalies. The incidence and severity of associated GU anomalies was directly related to the level of the fistula between the blind-ending rectum and the GU tract. High-level fistulae to the bladder neck in males and the cloaca in females demonstrated a 90% incidence of associated genitourinary anomalies. In contrast, lower-level fistule to the perineum revealed only a 14% incidence of associated GU anomalies. Classification of anorectal anomalies by fistula level provides an accurate means of predicting the likelihood of an associated GU malformation.     

Long-term outcome of anorectal malformations: the patient perspective

To assess the long-term outcome of surgery for anorectal malformations (ARM) from the patient’s perspective. One hundred and sixty seven children were operated for ARM between 1982 and 2000. Disease impact questionnaires to assess both clinical and psychological outcomes were sent to 137 eligible families. Statistical analysis was performed using SPSS version 11.5. The response rate was 61% (n = 84). Sixty six percent had soiling. There was no significant difference in the incidence of soiling between genders or between the younger child and adolescent. Soiling was significantly increased in high (86%) and intermediate (79%) compared to low (43%) malformation (P = 0.001). Constipation was seen in 62% and abdominal pain in 49%, with no significant difference between malformation levels. Overall, 71% had associated anomalies. Although 44% had a documented urological abnormality, clinical significant problems were seen in only 30%. Eighty percent of the children had one or more behavioural problems and 15% expressed suicidal thoughts. ARM had a negative impact on the social life of the child in 52% and on family functioning in 50%. Soiling (P = 0.000), presence of associated anomalies (P = 0.001), constipation (P = 0.005), level of ARM (P = 0.015) and abdominal pain (P = 0.039) correlated significantly with psychosocial morbidity. Despite these findings, 62% of adolescents and 71% of children below 12 years with their parents reported above average global hopefulness score, remaining hopeful for the future. Children with ARM have ongoing physical and social morbidity, indicating the need for continuing multidisciplinary review and support to optimise their quality of life.     

Repair of anorectal anomalies in the neonatal period

In a 3-year period between 1986 and 1988, 147 patients with anorectal anomalies were seen in our department; 93 were neonates, of which 35 had low malformations treated by anoplasty soon after birth. Fifty-eight had high and intermediate types; 26 of these had defunctioning colostomies. One of the 26 patients had the definitive repair done in the neonatal period, the other 32 were operated on with posterior sagittal anorectoplasty (PSARP) as a one-stage procedure in the neonatal period. The majority (85%) were operated on within 4 days of birth. There was no operative mortality. The commonest complication was wound infection, which was mild in 15 patients and severe in 2. There were no anal strictures. The functional results were good in 30 and average in 3 patients. A comparison with 60 older children who had a similar operation done as a staged procedure in the same period showed equally low morbidity and good functional results. Based on these results, it was found that one-stage repair of high and intermediate types of anorectal anomalies in the neonate using PSARP is safe and feasible.