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Rectal Problems

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Patients can experience dehiscence, retraction, infection and/or acquired atresia of the rectum related to technical problems arising during the pull-through procedure. These are usually the result of excessive tension or inadequate blood supply. In addition, anal strictures may result when families do not follow the prescribed protocol of dilatations.

Reoperation for these patients proceeds posterior sagittally. In cases of retraction, dehiscence, and acquired atresia, the rectum is usually located somewhere high in the pelvis and is surrounded by a significant amount of fibrosis. Multiple 6-0 silk sutures are placed in the rectal wall in order to exert uniform traction and facilitate a circumferential dissection of the rectum, again trying to stay as close as possible to the rectal wall without injuring it. Bands and extrinsic vessels surrounding the rectum are divided and cauterized circumferentially until enough rectal length is gained so as to place the rectum within the limits of the sphincter mechanism.

Short ring-like rectal strictures can be treated with a Heineke-Mikulicz type of plasty. Strictures that are longer than 1 cm must be resected, with the rectum mobilized until the fibrotic portion can be removed, and a fresh nonscarred portion of rectum pulled down, creating a new anus.

Based on our anatomic findings during these re-operations, we speculate that retraction, dehiscence, and acquired rectal atresia were most likely due to a poor technique used to mobilize the rectum. During a primary procedure, the rectum, when seen posterior sagittally, is covered by a very characteristic white fascia that contains vessels to the rectum. The surgeon must dissect this fascia off the rectum, remaining as close as possible to the rectal wall. Uniform traction provided by multiple silk sutures is imperative to facilitate the dissection. Bands and the extrinsic rectal blood supply must be divided to gain rectal length. The intramural blood supply of the rectum is excellent; and the rectum can be dissected to gain significant length provided the rectal wall is not injured. The most likely cause for difficulty in dissection of the rectum is working outside the fascia. Alternatively, dissection too close to the rectum can injure the rectal wall, interfere with the intramural blood supply, and provoke ischemia. The result of all this is an incomplete mobilization, rectal ischemia, and a rectal-to-skin anastomosis under tension, which may explain most of these complications.

We speculate that rectal strictures are also most likely due to ischemia of the distal part of the rectum. When the rectum is correctly mobilized and the blood supply kept intact, it is extremely unlikely to see an anal stricture. A few patients of ours who were operated on primarily failed to follow our protocol of dilatations and returned months after their operation with strictures. These patients had a thin fibrotic ring in the area of the anoplasty, which was easy to treat either with an anoplasty or dilatations. A long narrow stricture is most likely due to rectal ischemia.

Some surgeons do not have their patients follow a protocol of anal dilatations. In order to avoid painful maneuvers to the patient, they follow a specific plan consisting of taking the patient to the operating room every week and under anesthesia performing forceful dilatations. Those dilatations can actually provoke lacerations in the anal verge, which then heal with scarring, only to be reopened during the next forceful dilatation, leading ultimately to an intractable ring of fibrosis.