Pediatric Surgery

Pediatric Surgery

Anorectal malformations

Anorectal malformations (also called imperforate anus) are a variety of congenital disorders in boys and girls that involve imperfect formation of the rectum and anus and sometimes involve a connection between the rectum and genitourinary system. Depending upon the nature of the abnormality, anorectal malformations are managed in different ways. Some will require placement of a colostomy in the newborn period to allow stool to exit the body if there is no connection of the rectum to the skin (a fistula) near the scrotum or vagina. Others can be managed temporarily by dilating the fistula to the skin. Eventually, all these malformations will be managed with an operation that brings the rectum to the skin where the anus should be and places the rectum within the muscles in the pelvis that allow for control of stool (continence).

Even when this operation (posterior sagittal anorectoplasty) has been performed perfectly, many children have difficulties with control of stool because of a deficiency of the muscles in the pelvis and/or a deficiency on the nerves that supply those muscles. In these children, we aggressively pursue a program of bowel management, which consists of dietary modification and enema administration, which is described below.

The objective of bowel management is to prevent stool soiling and keep children completely clean during the day so that they can go to school without diapers or worry about stool accidents. This is very important for social and emotional development. Enemas are administered at night in order to clean out the colon. When a regimen is found that results in no soiling, we then consider placement of an 'appendicostomy," a procedure that brings the appendix to the abdominal wall to allow for the colon to be cleaned out from the top by insertion of a tube rather than by enema. Other web sites offer a wealth of information about anorectal malformations and bowel management.

Enema preparation and administration

Mix together in a large container:

4 Cups of tap water =1,000 CCs
3 tsp. of table salt
1 Pediatric Fleet's Enema (3.5 oz) =105 CCs

Total CCs=1,105

For children less than two years old:

Refill Pediatric Fleets Enema bottle with the mixture. Administer 1-2 bottles via the rectum/appendicostomy tube every evening after the last meal of the day. The child's bottom should be elevated above the rest of the abdomen so that the fluid can pass into the entire colon. For small children this is best accomplished by placing the child on your lap, face down. We will instruct you in the amount of fluid to administer. Have your child sit on the potty for a minimum of 45 minutes. Use this time to read to your child or play a special game. Don't be surprised if the child passes a small amount of stool or mucous one hour after bowel movement.

For children older than two years:

Pour 1/4 (approx. 275 CCs) to 1/2 (approx. 550 CCs) of the mixture into an enema bucket and administer via the rectum/appendicostomy tube every evening after the last meal of the day. The child's bottom should be elevated above the rest of the abdomen so that the fluid can pass into the entire colon. For larger children this is best accomplished by having the child position themselves on their arms and knees with their abdomen on a pillow and their bottom facing up. We will instruct you in the amount of fluid to administer. Have your child sit on the potty for a minimum of 45 minutes. Use this time to read to your child or play a special game. Don't be surprised if the child passes a small amount of stool or mucous one hour after bowel movement.

The goal of this program is to:

1. Have a daily bowel movement.
2. Prevent "accidental" leakage of stool.
3. Allow your child continence during the night and the following day.

Please call us if you have any questions or concerns. (909) 558-4822

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