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Ehiichi

Kohda,
M.D.
Mutsuhisa
Fujioka,
M.D.
Hiromichi
Ikawa,
M.D.
Johtarou
Yokoyama,
M.D.

Anorectal
computed

Congenital

were evaluated
by
(CT) scanning
in
23 patients.
CT scans
showed
clearly
the
anatomy
of the anal sphincter
muscles
in
relation
to the intestine
and the amount
of muscle
mass present.
These
findings
correlated
well with
the results
of direct
visualization
and electromyograms
in patients
who underwent
surgery.
The information
revealed
by CT scans is considered important
in preoperative
planning
for surgical
repair
and in predicting
a patients
prognosis.
In cases of postoperative incontinence,
CT scans demonstrated
the location
of the pulled-through
intestine, including
whether
it had been correctly
placed
in the levator
sling.
Where
the intestine
was outside
the levator
sling,
CT scans could
be used in considerations
of further
surgery.

Radiology

Anomaly:

CT

[valuation1

anomalies
tomography

Index
terms:
Anus,
imperforate,
757.1433
digestive
system,
757.1433
#{149}
Rectum,
computed
tomography,
757.1211
#{149}
Rectum,
surgery

Anorectal

Infants,

#{149}

1985; 157:349-352

anorectal
anomaly
is a relatively
common
congenital malformation,
with
an incidence
of one per 1,000-9,630
live
births
(1). It is usually
classified
on the basis
of anatomic
configuration:
whether
the visceral
deformity
is low, intermediate,
or high
in
relation
to the levator
sling
(2). A high
anomaly
is a challenge
to the
pediatric
surgeon
because
there
is poor
prognosis
for continence
even
after
surgical
repair.
Several
kinds
of rectoplasty
have
been
proposed,
using
the original
and/or
other
muscles
(3, 4). Although
ONGENITAL

preoperative
definition
of anatomy
(Figs.
1-3) is important
in such
corrective
procedures,
almost
no radiologic
method
has been
available
to show
the exact
anatomy
of the involved
musculature.
We
discuss
the use of computed
tomography
(CT) scanning,
with
emphasis
on visualizing
the anal
sphincter
muscles
in each
type
of
congenital
anorectal
anomaly
as well
as the anatomic
relation
between
the pulled-through
intestine
and the levator
sling
in postopenative scans.

MATERIALS

AND

METHODS

Twenty-three
children
with
anorectal
anomalies
were
studied
by CT
scanning
on 27 occasions.
The patients,
16 boys and seven
girls, ranged
in
age from 2 months
to 12 years.
Eight children
were scanned
preoperatively;
19 were scanned
postoperatively.
CT sections
were viewed
from the base of
the bladder
to the perineum
at 1-cm intervals
parallel
to the pubococcygeal
line. Section
thickness
was 5-10 mm, depending
on the age of the patients
and the extent
of the anomaly.
All CT scans were obtained
using
a GE 8800
CT/T (General
Electric
Medical
Systems,
Milwaukee,
Wis.). Findings
of the
CT studies
were
compared
with
the results
of direct
visualization
and
electromyograms
during
surgery
in seven
patients.

RESULTS
In seven
patients
who
underwent
surgery,
CT study
findings
correlated
well
with
those
seen
directly
during
surgery
and
with
the findings
of electromyograms.
CT scans
showed
well-developed
sphincter
muscles
in all patients
with
low and intermediate
types
of
anorectal
anomaly
(Fig.
4a and
b); however,
muscles
in the high
type
of the anomaly
were
poorly
developed
or not identified.
In
patients
with
cloacal
anomalies
or rectovesical
fistulas,
CT scans
showed
no or very
poorly
developed
sphincter
muscles
(Fig. 5a and
b). On the other
hand,
four
of the six patients
with
rectourethrah
fistulas
had
poor
but some
development
of sphincter
musculature
(Table
1, Fig.
6). In all postoperative
patients,
CT scans
clearly
demonstrated
the anatomic
location
of the pulled-through
intestine
in relation
to the levator
sling
(Fig. 7). In an incontinent
9-year-old
girl who
had previously
undergone
surgery
for rectovesical
fistula
by the
pulled
intestines
From
the Departments
of Diagnostic
Radiology
(E.K., M.F.) and Pediatric
Surgery
(H.!., J.Y.), Keio
University
School
of Medicine,
Tokyo,
Japan.
Presented at the 70th Scientific
Assembly
and Annual
Meeting of the Radiological
Society
of North
America,
Washington,
D.C., November
25-30,
1984. Received
April
2, 1985; accepted
May 28.
#{176}RSNA, 1985

Rehbein
through
were

procedure,
CT scans
showed
that
the
colon
outside the levator anii (Fig. 8). The pulled-through
correctly
positioned
in the other
patients.

was

DISCUSSION
Normal
There
are
the internal

Anorectal
three
muscle
sphincter,

Anatomy
compartments
the external

in the
sphincter,

anorectal
and
the

sphincter:
levator
ani

349

Figure
1.
Schematic
drawing
of
muscles.
Note
the
anterior
angulation
muscle
with
respect
to the rectum.

Figure
thral
muscle.

3.

Pathologic

fistula.

Arrows

specimen
point

of
to

anorectal
of the

Figure
2.
CT scan of normal
anorectal
muscles.
Note
that the puborectal
muscle
(arrows)
surrounds
the
external
and
internal
sphincter
muscles,
extending
anterior
to the
pubic bone.

sphincter
puborectal

rectoure-

puborectal

a.

b.
Figure

case

have

a.

4.
CT scans show
low-type
8). Sphincter
muscles
show
normal

been

anomaly
(a, case 3) and
development
in both

case 18).
(urethral

(Fig.
1).
intrinsic
canal
The
350

5.
CT scans show cboacal type of anomaly
(a, case 22)
There
is no sphincter
muscle
in a. Scan
b shows
a muscle
tube
is inserted)
but almost
no anal sphincter.

The
internal
sphincter
muscle
surrounding

just beneath
the
external
sphincter
#{149}
Radiology

the

is an
anal

mucosal
layer.
comprises

three
layers:
subcutaneous.
sphincter
important

and

anomaly
rectal

(b,
tubes

inserted.

b.

Figure

intermediate-type
cases.
Urethral

and rectovesical
surrounding

deep,
The

is considered
muscle
for

fistula
(b,
the urethra

superficial,
and
deep
external
to be the
its function.

most
The

Figure
6.
CT scan of rectourethral
fistula
(case 11) shows
poor
but some
development
of the puborectal
muscle
(arrows) and
other
sphincter
muscles.

levator
ani
comprises
four
muscle
groups:
pubococcygeus,
levator
prostatae
(in the
male)
or pubovaginalis
(in the female),
puborectahis,
and ihioNovember

1985

Table
Summary

of 23 Patients

No.
Patient

S.

Anorectal

with

Age

(yr)I
Sex

12/F

2
3

1/M
2M

5/M

5
7
8
9

1/F
/2M
1/F
8/,2F
2M

10
11
12
13
14
15
16
17
18
19

4/2M
4/M
1/M
9/M
9/12M
6/M
6/M
8/M
%2M
9/F

20
21

4/M
6/M

22
23

/2F
5/F

Anomalies
Sphincter

Classification

Development(CT
Normal
Normal
Normal
Normal
Normal
Normal

Intermediate
Intermediate
Intermediate

Normal
Normal
Normal

Intermediate
High
High
High
High
High
Highs
High
High
High5

Normal
Intermediate
Intermediate
Poor
Poor

High

Poor

High
Hight
Hight

Poor
Poor
Poor

Intermediate
Poor
Poor
Poor

Rectourethral
fistula.
Rectovesical
fistula.
Cloaca
malformation.

Figure
This

gery.

scans)

Intermediate

Figure

7.
Postoperative
CT
patient
was
incontinent

Scan

demonstrates

that

scan

of
after

case
sur-

pulled-through

intestine
(arrowheads)
is in an adequate
position
within
the levator
sling.
But the sling
itself
(arrows)
is very
poorly
developed,

which

can be a cause

coccygeus
puborectal
have
an

(Fig.
1). Among
these,
the
muscle
is considered
to
important
role in the control

of bowel
function
of the
anorectal
the way
in which
tions
is not totally
On

Volume

of incontinence.

axial

157

CT

after
surgical
repair
anomaly,
although
the sphincter
funcunderstood.
sections,

Number

the

anal

8.

Postoperative

The
pulled-through
levator
sling
(arrows).

CT scan
intestine

of case

is outside

sphincter
is seen
as a ring-shaped
soft-tissue
mass.
This
mass
is cornposed
of internal
and external
sphincten muscles;
however,
it is impossible
for each
muscle
layer
to be differentiated
on
the
scans.
The
puborectal
muscle
is seen
as a band
surrounding
this
ring,
extending
anteriorly
to the
pubic
bone
(Figs.
2 and
3). It is difficult
to differentiate
the
levaton
ani
from
other
muscles
on axial
sections
in neonates.

Effect

of Muscle

Anatomy

on

Continence
Defecation
pontant
result

control
is the most
following
surgery

can

malformations.
be obtained

Good
contiin patients

with
low
and
intermediate
types
of
anorectal
anomalies.
It is known
that
high-type
anomaly
results
in rather
poor
continence
(5),
and
surgeons
have
been
focusing
on
how
to im-

Muscle

Low
Low
Low
Low
Low
Low

19.
the

13.

anorectal
nence

1.

imfor

prove

continence

by

surgical

methods

in these
patients.
Generally
speaking,
there
are several factors
related
to continence:
passive
forces;
the
motor
action
of the
sphincter;
the sensitivity
of the skin,
mucosa,
and
sphincter;
the functioning of the intestine;
and
nervous
system pathways
(6). The first two factors
are
rather
important
in anorectal
anomaly
and
can be correlated
with
the amount
of the muscle
mass
present
in the sphincter.
In our
series,
well-developed
sphincter
muscles
were
seen
on CT
scans
in all patients
with
low and
intermediate
types
of the
anomaly.
However,
in
those
with
high-type
anomaly,
these
muscles
were
poorly
seen
or not identified.
Our
CT findings
also
suggest
that
there
is a difference
in sphincter-muscle
development
between
patients
with
rectourethral
fistulas
and
those
with
the
other
high-type
anomalies.
Most
of
the rectourethral
fistulas
seen
in our
series
were
associated
with
poor
but
some
development
of sphincter
musdes,
which
may
contribute
to continence,
whereas
nectovesical
or hightype
cloacal
anomalies
were
associated with
almost
deficient
sphincter
muscle.
This
finding
appears
to be
well
correlated
with
the
reported
good
results
following
surgical
nepairs
in cases
of rectourethral
fistula
where
there
was substantial
sphincter
muscle
(4, 7). Pathologic
examination
also
showed
the
existence
of the
sphincter
muscles
in our
patients
with
rectourethral
fistulas
(Fig.
3).
Therefore,
management
may
have
to
differ
in each
type
of anomaly
depending
on the presence
and
development
of the
sphincter
muscles.
When
sphincter
muscles
are
recognizable
on CT scans,
surgical
procedunes
using
the
patients
original
sphincter
muscles
may give
sufficient
continence
after
surgery.
When
CT
scans
reveal
only
a strand-like
or no
structure
representing
the
sphincter
muscle,
other
procedures
may have
to
be considered
to augment
the
pullthrough
operation,
such
as levatorplasty
or muscle
transplantation.
Another
important
factor
for continence
in postoperative
patients
is correct
placement
of the
intestine
that
is
pulled
through
within
the
levator
sling
at surgery.
Kiesewetten
(8)
stressed
that
the pubonectal
muscle
is
missed
in pull-through
surgery
with

Radiology

351

greater

frequency

than

is

generally

appreciated,
necessitating
a second
operation
(8).
Therefore,
surgeons
now
focus
on the
technique
of pulling the intestine
correctly
into
the levaton
sling.
However,
it is not
easy
during
surgery
to find
the correct
location
through
which
to pass
the intestine.
This is now
done
by direct
observation
and
by digital
evaluation,
although
some
surgeons
prefer
to utilize an electronic
stimulation
method
for this
purpose.
Whether
the intestine
has correctly
passed
through
the
levator
sling
can
be well
evaluated
postoperatively
by
CT
scanning.
Therefore,
the
use
of postoperative
CT scans
may give
the incontinent
pa-

352.

Radiology

tient
after

a chance
a second

to be
operation.

fully

continent

4.

Send correspondence
Ehiichi
Kohda,
M.D.,

Radiology,

Keio

35 Shinanomachi,
pan.

and reprint
requests
to:
Department
of Diagnostic
University
School
of Medicine,
Shinjuku-ku,
Tokyo,
160 Ja-

5.

6.
7.

References
1.

2.

3.

Kiesewetter
WB.
Rectum
and anus.
In: Ravitch MM, Welch
KJ, Benson
OD, Aberdeen
E, Randolph
JG, eds. Pediatric
surgery.
3d
ed. Chicago:
Year Book, 1979; 1059-1072.
Stephens
FD, Smith
ED.
Classification.
In:
Stephens
FD, Smith
ED, eds. Anorecta!
malformations
in children.
Chicago:
Year
Book, 1971; 133-159.
Millard
DR,
Rowe
MI.
Plastic
surgical
principles
in high
imperforate
anus.
Plast
Reconstr
Surg 1982; 69:399-411.

8.

Pena A, Dervies
PA.
Posterior
sagittal
anorectoplasty:
important
technical
considerations
and new application.
J Pediatr
Surg
1982; 17:796-811.
Nixon
NH, Pun P. The results
of treatment
of anorectal
anomalies:
a thirteen
to twenty
year
follow-up.
J Pediatr
Surg
1977;
12:27-37.
Schaerl
AF.
Analysis
of anal incontinence.
Prog Pediatr
Surg 1984; 17:93-104.
Yokoyama
J. Hayashi
A, Ikawa
H, et al. Abdominal
extended
sacroperineal
approach
for high
type anorectal
malformation
and
our new operative
method.
Z Kinderchirurgie (in press).
Kiesewetter
WB, Jefferies
MR.
Secondary
anorectal
surgery
for the missed
puborectalis muscle.
J Pediatr
Surg 1981; 16:921-927.

November

1985