The Star Malaysia

My baby doesn’t have an anus

Anorec­tal mal­for­ma­tions are birth de­fects where the anus and rec­tum (the lower end of the di­ges­tive tract) do not de­velop prop­erly.

- By Dr NADA SUDHAKARAN Dr Nada Sudhakaran is a pae­di­atric sur­geon. This ar­ti­cle is cour­tesy of the Malaysian As­so­ci­a­tion of Pae­di­atric Surgery. For fur­ther in­for­ma­tion, e-mail starhealth@thes­ The in­for­ma­tion pro­vided is for ed­u­ca­tional and commu Medicine · Austria · Iceland · Turkey · Belgium · Belarus

ANO-rec­tal mal­for­ma­tion (ARM) refers to an ab­nor­mal­ity in the for­ma­tion of the rec­tum or anus of a new­born.

These ba­bies of­ten present with no open­ing to their bot­tom end at birth.

When I give lec­tures to med­i­cal stu­dents on this topic, I will jok­ingly com­ment, “No one is per­fect, we are all born with a crack, so these kids are per­fect!”

To ex­plain the cause of this con­di­tion, I will re­fer to the evo­lu­tion of the species.

Rep­tiles and birds have a com­mon chan­nel for fae­ces and uri­nary ex­cre­ment from which these are ex­pelled.

The next time you get bird drop­pings on your car, note that the white, more liq­uid sub­stance is the uri­nary con­cen­trate, while the darker, more solid sub­stance that cor­rodes paint­work and is mixed into the uri­nary con­cen­trate, is the fae­ces.

Sim­i­larly, the house­hold lizard pro­duces dark, neatly com­pacted fae­ces, and “del­i­cately” dec­o­rated on top, is a white spot, which is the uri­nary con­cen­trate.

In mam­mals, how­ever, the uri­nary sys­tem and the ano-rec­tal pas­sage is sep­a­rated and func­tions in­de­pen­dently. Fail­ure of this sep­a­ra­tion process be­fore the child is born re­sults in ARM in ba­bies.

Hence, the “poo” and “wee” pipes re­main ab­nor­mally con­nected in these kids.

The most com­mon ab­nor­mal­ity in a girl child with ARM is when the rec­tum opens into the en­trance of the vagina, with no other open­ing on the bot­tom.

In a boy child, the com­mon­est form is when the rec­tum opens into the ure­thra (uri­nary tube con­nect­ing the blad­der to the tip of the pe­nis), close to the prostate gland and again with no other dis­cernible open­ing on the bot­tom.

The con­nec­tion be­tween the rec­tum and the above-men­tioned struc­tures are of­ten small, and hence, the baby will not be able to open his or her bow­els, which will sub­se­quently be ob­structed.

It is im­per­a­tive that a pae­di­atric sur­geon cre­ate a stoma (bowel open­ing into a bag on the ab­domen) to pre­vent bowel ob­struc­tion.

Once a stoma is formed, the child can feed and grow un­til de­fin­i­tive surgery can be planned to con­struct a new open­ing for the anus, usu­ally af­ter a few months.

Smelly peo­ple don’t make many friends, so most of us try to re­main so­cially con­ti­nent of fae­ces, un­less a mishap oc­curs af­ter eat­ing dodgy food at the ma­mak stall the night be­fore.

Our mech­a­nism of con­ti­nence is a vol­un­tary con­trol of our anal sphinc­ter, which is shut tightly most of the time un­til one re­laxes it when safely po­si­tioned over the toi­let bowl, ready to defe­cate.

In a child with ARM, these sphinc­ter mus­cles sur­round the anal canal and are usu­ally still present in the cor­rect place de­spite the rec­tum con­nect­ing to other struc­tures.

The de­fin­i­tive surgery would in­volve dis­con­nect­ing the rec­tum from what­ever it’s at­tached to, and “re-plumb” it through the sphinc­ter mus­cle.

The surgery would hope to achieve a good cal­i­bre new anus, which is cen­trally placed within the sphinc­ter mus­cle and can func­tion to main­tain fae­cal con­ti­nence.

As you can imag­ine, the surgery it­self is a del­i­cate process of try­ing to pre­serve the pre­cious sphinc­ter mus­cles and care­fully plac­ing the new anus in the pre­cise lo­ca­tion.

A pae­di­atric sur­geon should per­form this com­plex surgery, as it is cru­cial that surgery is done cor­rectly the first time round.

Once the re­con­struc­tive work is done, the stoma can then be closed, so that the “new bot­tom” can then be used.

The surgery may in­volve a larger in­ci­sion near where the new anus is to be lo­cated, and some sur­geons of­fer key­hole surgery for boys, which means smaller in­ci­sions.

Most chil­dren do well in the long term. How­ever, some may be con­sti­pated, re­quir­ing long term use of lax­a­tives to help them with their bowel open­ing.

Some chil­dren may have the op­po­site prob­lem of in­con­ti­nence, of­ten dirty­ing their un­der­pants.

This may be­come a so­cial hin­drance. How­ever there are bowel man­age­ment pro­grammes, which are suc­cess­ful in main­tain­ing so­cial con­ti­nence, so that these kids are not re­jected by so­ci­ety.

The key point is that this con­di­tion re­quires spe­cialised treat­ment.

Pae­di­atric surgery is a highly spe­cialised field. The out­comes for such con­di­tions are bet­ter if treated ap­pro­pri­ately at the right time, the right place and by the right per­son.

 ??  ?? The in­ci­dence of anorec­tal mal­for­ma­tions is re­ported as 2.0–2.5 per 10,000 live births. — AFP
The in­ci­dence of anorec­tal mal­for­ma­tions is re­ported as 2.0–2.5 per 10,000 live births. — AFP

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