285
tinence using the Wingspread criteria [11]. All the patients
were fully continent without any soiling, had normal
defecation, and no anterior shift of the anus. There was
no case of fecal impaction or rectal dilation.
Discussion
The association of a fistula in the perineum along with a
normal anal opening has been described by many authors
[2, 4, 5, 8, 9, 11, 12, 13] with varied nomenclatures. The
term PC should be applied to those cases in which the
fistula is infralevator in origin (Chaterjee and Talukder [3],
Tsuchida et al. [11]). All the patients in the present series
met to this criterion, and therefore, the term PC has been
used. This anomaly constitutes about 4% of reported series
of A R M [2, 11] and has been seen predominantly, though
not exclusively, in females [2, 3, 11]. In the present report,
females also constituted the majority of cages.
The presence of a PC should be suspected in any female
child with persistent perineal excoriation, inflammation, or
vaginal discharge. This may at times be the only manifesta-
tion. The passage of fecal matter through the anus as well as
a fistula is diagnostic, and the origin of the fistula from the
rectum/anal canal can be determined by probing it with a
Hegar dilator while doing a simultaneous rectal examina-
tion. We feel that radiologic studies, as advocated by
Tsuchida et al. [11], are not routinely necessary when
probing shows the fistula to be infralevator.
Anatomically, a variety of double terminations of the
ailmentary tract have been described [2, 7, 9, 12]. Chaterjee
[2] has classified these patients on the basis of the level of
origin of the fistula in relation to the levator ani. We did not
come across a supralevator fistula in any of our patients.
Such a condition would require radiologic studies [11], and
for correction the posterior sagittal approach would be
preferable.
Review of our patients shows that adequate preparation
and timing of the operation are crucial to a good result. We
have not operated on any perineum that was not dry and
infection-free, delaying surgery for as long as 12 weeks if
necessary. This has resulted in a low complication rate, in
contrast to some previous reports [2, 3, 12]. Categorization
of the patients and complete control of perineal inflamma-
tion before the definitive operation has produced uniformly
good results in our hands.
For the last 27 years we have utilized the anterior
sagittal approach for the correction of PC as well as other
intermediate and low A R M in female children. The oper-
ation allows anatomic exposure for separation of the rectum
from the vagina and a tension-free anoplasty is possible
without leaving any buried or apposing suture lines, which
have created significant problems with other procedures [3,
11 ]. The perineal body and anal sphincter are reconstructed,
posterior transposition of an anterior ectopic anus is possi-
ble simultaneously, and a normal-looking perineum is the
end-result. Even in the patient with one failed operation,
repair of the anomaly was possible despite local fibrosis.
Over the years, this procedure has stood the test of time;
perioperative care is minimal, no prolonged fasting or
restraints are necessary, and the patient is usually in the
hospital for less than a week.
Follow-up results in our patients have been good. The
children are continent and there is a high degree of
subjective and objective satisfaction with the procedure.
PC is an uncommon ARM, but with early and appropriate
treatment by ASARP, it is amenable to cure with an
excellent quality of life for the patient.
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