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Adv Biomed Res 2023,  12:214

Evaluation of Magnetic Resonance Imaging (MRI) Findings following posterior Sagital Ano-Recto Plasty (PSARP) in Severe Incontinent Children with High Imperforate Anus (IA)

1 Departament of Pediatric Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
2 Departament of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission21-Jun-2022
Date of Acceptance25-Oct-2022
Date of Web Publication31-Aug-2023

Correspondence Address:
Mehrdad Hosseinpour
Dr. Amin Hospital, Ibn Sina Blvd., Isfahan University of Medical Sciences, Isfahan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/abr.abr_207_22

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Background: The aim of this study was to evaluate pelvic MRI accuracy for measurement of anatomical land marks in severe fecal incontinent (FI) children with high imperforate anus (IA).
Materials and Methods: A total of 80 children (40 cases and 40 controls) aged more than 4 years with severe FI were assessed. Magnetic resonance imaging was performed by a radiologist with the same device. For pelvic anatomical land marks measurement, we measured the ano-rectal angel and hiatal/pc ratio.
Results: The mean of ano-rectal angel was 118.67 ± 25.2 mm in cases and 132.07 ± 13.8 mm in control group (P = .004). H/PCR was 0.63 ± 0.05 in cases and 0.62 ± 0.45 in controls (P = NS). There was no significant correlation between [INSIDE:1] (r = 0.25, P = 0.36) or ano-rectal angle measurement (r = 0.16, P = 0.05) and FI score in patients with severe FI.
Conclusions: Pelvic magnetic resonance imaging could be accurately used is measuring the ano-rectal angle is high IA children with severe FI which leads to selected patients who may have benefits of reoperation.

Keywords: Children, fecal incontinency, MRI.

How to cite this article:
Ziyaee B, Nazem M, Riahinezhad M, Hosseinpour M. Evaluation of Magnetic Resonance Imaging (MRI) Findings following posterior Sagital Ano-Recto Plasty (PSARP) in Severe Incontinent Children with High Imperforate Anus (IA). Adv Biomed Res 2023;12:214

How to cite this URL:
Ziyaee B, Nazem M, Riahinezhad M, Hosseinpour M. Evaluation of Magnetic Resonance Imaging (MRI) Findings following posterior Sagital Ano-Recto Plasty (PSARP) in Severe Incontinent Children with High Imperforate Anus (IA). Adv Biomed Res [serial online] 2023 [cited 2023 Sep 26];12:214. Available from:

  Introduction Top

Fecal incontinence (FI) is a common disorder affecting the psychological, social, and mental aspects in children with high imperforate anus (IA).[1] Surgeries at the birth of children with IA can lead to lifelong problems with FI which impact on quality of life.[2]

Although posterior sagittal ano-rectoplasty (PSARP) represents a major advance in surgical management of children with IA, achieving a good postoperative defecatory function remains a major.

Consideration and choosing the best procedure for FI prevention is still a dilemma and unsatisfactory outcome in children with IA can be attributed to the type of anomaly, sacral dysplasia, spinal cord malformations, and technical factors in operation.[3],[4]

Although magnetic resonance imaging (MRI) has been introduced as one of the main methods for evaluation of pelvic soft tissue in children with FI,[5],[6] but assessing the measurement of pelvic hiatus and anatomical alterations following PSARP procedure is necessary for selection of patients who may need reoperation for management of postoperative FI. Therefore, a single-institution cross-sectional study was conducted to evaluate and measure MRI anatomical landmarks in IA children with severe FI. As hypothesis, it was investigated whether pelvic MIR could be accurately used to measure anatomical land marks is children with IA.

  Materials and Methods Top

This prospective cross-sectional study was performed as a pilot study in the department of pediatric surgery of ISFAHAN university of medical sciences from October 2019 to October 2021 after obtaining approval from university ethics committee. Children aged more than 4 years who were referred to the hospital for evaluation of postoperative FI were prospectively included and informed consent was obtained from their parents. Children with pelvic anomalies, re-do cases, spinal cord abnormalities (in clinical examination or previous radiologic reports), and sacral dysplasia were excluded and the patients with abdomino-perineal operations, low to moderate FI score, and low-type IA. Inclusion criteria were aged more than 4 years, parental consent, PSARP operation, high IA, and severe FI. For FI scoring, we used Kyrklund K et al. score as a numerical scoring system.[7] In this study, severe FI was defined as hall score less than 9.


Using the same device, all the pelvic imaging were performed by a radiologist. We used 1.5T magnet (GE, USA) multiple pulse sequences were acquired (T2W1, T1W1) in sagittal axial and coronal planes. In nonco-operative children, study was done under general anesthesia. Images were evaluated by DICOM viewer (K-PACS) for pelvic anatomical land marks measurement; we measured the ano-rectal angel and hiatal/pc ratio as described by Abo Zeid et al.[8] The ano-rectal angel was measured as the angel between the longitudinal axis of the anal canal and the posterior rectal wall on the levator plate [Figure 1].
Figure 1: The ano-rectal angel measurement

Click here to view

Hiatal/pc ratio, was measured as below:

Pelvic hiatus (PH) [Figure 2] = distance between the mid of the back of the pubic symphysis and a point corresponding to puborectalis sling at the back of anorectal junction pubococcygeal line (pc) (fig2) = distance between the mid of the back of the pubic symphysis.
Figure 2: Pelvic hiatus measurement

Click here to view

In the axial planes, centrality of neorectum symmetry and status of muscle complex were assessed. Primary end point was collected; the data included the compliance of pelvic MRI landmarks with FI severity. Secondary end points of study were comparison of MRI land marks in both genders.

Statistical analysis

The statistical package for social science (SPSS 24, Chicago, Illinois) software was used for data analysis. Variables were not normally distributed and the Mann-Whitney was used to determine any differences in the mean scores of the groups. Data were expressed as mean ± SD and P value less than .05 was statistically significant based on preliminary results; α = 0.05 and L-β = 0 sample size was calculated as 80.

  Results Top

In this study, a total of 80 children (40 as severe FI, 40 as normal) were included; the mean age was 4.8 ± 0.09 years in case group and 6.72 ± 0.63 years in the control group (p = NS). There was no significant differences in the gender of subjects in cases, in controls) (P = NS); the mean of ano-rectal angel was 118.67 ± 25.2 mm in case group and 132.07 ± 13.8 mm in the control group (P = 0.004). H/PCR was 0.63 ± 0.05 in the cases and 0.62 ± 0.45 in the controls (P = NS). There was no significant correlation between (r = 0.25, P = .36) or anorectal angle measurement (r = -0.16, P = .05) and FI score in patients with severe FI. In 8 patients, neorectum was not located centrally, and in 12 patients, muscle complex was not homogeneous bilaterally.

  Discussion Top

FI is a debilitating and embarrassing problem facing of the children population that predisposes them to stigmatization, rejection, school avoidance, and social withdrawal.[8] Although the most common reasons of FI are attributed to functional causes, but organic reasons such as Anorecat malformatiom (ARM) and spinal cord diseases are also common in communities.[9] Surgeries at the birth for IA can lead to lifelong problems with FI.[10] Although the main aim of surgery is reconstruction of rectum in the mid-way of muscle complex to facilitate normal defecation,[11] but uncorrectable factors such as spinal cord anomalies, sacral dysplasia, and type of ARM can affect the outcome of operation.

On the other hand, some surgical notes such as proper position of rectum in muscle complex and proper angling of ano-rectal region can be the major tricks of operation to reduce postoperative FI.

It was shown that pelvic MRI could study the development of pelvic floor muscle, morphology and location of the rectum, and anal canal in children with FI after anoplasty.[12],[13]

The MRI finding of this study showed that the use of MRI landmarks for IA children with severe FI can be a usable method to select patients who may have benefits for reoperation.

Our study showed that ano-rectal angle is the main significant measure in ARM children in comparison to normal group; this finding is in contrast of Penninckx et al.[14] study that questioned the reliability of this angle for different observer bias. In our study, the mean of angle was 118.67 that was lower than the measurement of Abou Zeid et al.[8] study and normal population. It seems that in children with severe FI, re-establishment of this angle can decrease the severity of FI; however, this hypothesis should be investigated in further studies. Our findings are consistent with other investigators as well.[15],[16] The results of our study suggested that PH measurement as an MRI parameter is not significantly different is ARM children with saver FI and normal population. It is in contrast to Abou Zeid et al.[8] study that showed the significance of this parameter in children with FI. It seems that this difference should be attributed to study population.

In our study, we selected the children with severe FI and our results showed that with increase of FI severity, the significance of this parameter disappeared.

  Conclusion Top

In conclusion, our finding showed pelvic MRI could be accurately used in measuring the ano-rectal angle in high IA children with severe FI which leads to selected patients who may have benefits of reoperation.

Ethics approval and consent to participate

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


We thank Ahmadi B. for her co-operation in data collection of this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rajindrajith S, Devanarayana NM, Thapar N, Benninga MA. Functional fecal incontinence in children: Epidemiology, pathophysiology, evaluation, and management. J Pediatr Gastroenterol Nutr 2021;72:794-801.  Back to cited text no. 1
Shahba Z, Ahmadi B, Haji Bandeh S, Hosseinpour M. Evaluation of bowel management program on quality of life in children with fecal incontinence. Adv Biomed Res 2022;11:69.  Back to cited text no. 2
  [Full text]  
Kilpatrick JA, Zobell S, Leeflang EJ, Cao D, Mammen L, Rollins MD. Intermediate and long-term outcomes of a bowel management program for children with severe constipation or fecal incontinence. J Pediatr Surg 2020;55:545-8.  Back to cited text no. 3
Dewberry L, Trecartin A, Pena A, Pierre MS, Bischoff A. Systematic review: Sacral nerve stimulation in the treatment of constipation and fecal incontinence in children with emphasis in anorectal malformation. Pediatr Surg Int 2019;35:1009-12.  Back to cited text no. 4
Jarboe M, Ladino-Torres M, Wild L, Spremo D, Elkins S, Ladouceur R, et al. Imaged-guided and muscle sparing laparoscopic anorectoplasty using real-time magnetic resonance imaging. Pediatric Surg Int 2020;36:1255-60.  Back to cited text no. 5
Han Y, Xia Z, Guo S, Yu X, Li Z. Laparoscopically assisted anorectal pull-through vs posterior sagittal anorectoplasty for high and intermediate anorectal malformation: A systematic review and meta-analysis. PLOS One 2017;12:e017042.  Back to cited text no. 6
Kyrklund K, Koivusalo A, Rintala RJ, Pakarinen MP. Evaluation of bowel function and fecal continence in 594 Finnish individuals aged 4 to 26 years. Dis Colon Rectum 2012;55:671-6.  Back to cited text no. 7
Abou Zeid AA, Ibrahim SE, Mohammad SA, Radwan AB, Eldebeiky M, Zaki AM. Anatomical alterations following the 'PSARP' procedure: Correlating MRI findings with continence scores. J Pediatr Surg 2019;54:471-8.  Back to cited text no. 8
Muddasani S, Moe A, Semmelrock C, Gilbert CL, Enemuo V, Chiou EH, et al. Physical therapy for fecal incontinence in children with pelvic floor dyssynergia. J Pediatr 2017;190:74-8.  Back to cited text no. 9
Takahashi T, Fukumoto K, Yamoto M, Nakaya K, Sekioka A, Nomura A, et al. Long-term follow-up for anorectal function after anorectoplasty in patients with high/intermediate imperforate anus: A single center experience. Surg Today 2020;50:889-94.  Back to cited text no. 10
Wood RJ, Levitt MA. Anorectal malformations. Clin Colon Rectal Surg 2018;3:61-70.  Back to cited text no. 11
Madhusmita, Ghasi RG, Mittal MK, Bagga D. Anorectal malformations: Role of MRI in preoperative evaluation. Indian J Radiol Imaging 2018;28:187-94.  Back to cited text no. 12
Desai SN, Choudhury H, Joshi P, Pargewar S. Magnetic resonance imaging evaluation after anorectal pull-through surgery for anorectal malformations: A comprehensive review. Pol J Radiol 2018;83:e348-52.  Back to cited text no. 13
Penninckx F, Debruyne C, Lestar B. Observer variation in the radiological measurement of the anorectal angle. Int J Colorectal Dis 1990;5:94-7.  Back to cited text no. 14
Eltomey MA, Donnelly LF, Emery KH, Levitt MA, Peña A. Postoperative pelvic MRI of anorectal malformations. AJR Am J Roentgenol 2008;191:1469-76.  Back to cited text no. 15
Yong C, Ruo-yi W, Yuan Z, Shu-hui Z, Guang-Rui S. MRI findings in patients with defecatory dysfunction after surgical correction of anorectal malformation. Pediatr Radiol 2013;43:964-70.  Back to cited text no. 16


  [Figure 1], [Figure 2]


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