Posterior sagittal anorectoplasty (Peña Procedure or psarp). What is an anorectal malformation?

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What is an anorectal malformation?

An anorectal malformation is a birth defect that affects the development of the anus, the urinary system and/or the sexual structures. This malformation can also be associated with defects of the spine, esophagus, trachea, kidneys, heart or limbs.

Who gets anorectal malformations?

They occur in 1 out of 4000 newborns.

How is an anorectal malformation diagnosed?

Commonly it is diagnosed at birth, either by noting an abnormally placed anus or no opening at all.

How is the decision made that surgery is needed?

The type of surgery needed will depend on the type of defect that is present. The defect will either be termed low or high. Other specific terms may be given to further explain exactly where the defect lies. The surgeon will explain your child’s problem in detail before surgery.

What can I expect from surgery?

In newborns with low defects stool can pass through the abnormally located anus. Often this small opening needs to be stretched with dilators. In these cases, a one stage surgical repair will be planned in the near future. This is called an anoplasty, mini Peña Procedure or cutback procedure. In high defects, the baby will need a colostomy within the first 24 to 48 hours of life. This will allow stool to drain through a "stoma" onto the abdomen. Since the baby cannot pass stool through a normal opening, this will allow the intestine to function normally. Weeks after the colostomy, an operation will be planned. This surgery is called a posterior sagittal anorectoplasty , PSARP or "Peña Procedure". This operation will separate the anus from the urinary and/or sexual structures. The colostomy will remain open until healing is completed. Later, your baby will return to the hospital to have the colostomy closed.

Tips for the day of surgery-what to bring, what to leave home:

Bring washable toys that will comfort your child during the hospitalization.

Diapers, pajamas, creams and medications will be provided at the hospital.

When will my child be able to go home?

After the posterior sagittal anorectoplasty your child will be in the hospital for 4 to 5 days. After the closure of the colostomy, approximately 3 to 4 days.

How much time should I plan off work?

You should plan on taking off about two weeks. Afterwards, you will need frequent follow up visits so you may want to prepare your employer for that need.

What care is needed at home after surgery?

Care of the incision: Gentle warm soap and water washes; triple antibiotic ointment to the anus for two weeks.

Diaper area care: If your baby has a colostomy, s/he will have very frequent stools and be at risk for skin breakdown (serious diaper rash) after the colostomy is closed. The use of a barrier cream (i.e. Ilex ® cream) applied to the diaper area three times a day will help prevent this severe rash. Cover the cream with petroleum jelly at each diaper change. Do not scrub creams off. You may remove it with mineral oil and cotton balls.

Activity limitations: Your baby should have nothing by rectum after the posterior sagittal anorectoplasty. Your surgeon will tell you when it is safe to take rectal temperatures or give suppositories.

Diet: Give non-constipating foods such as fruits, vegetables and whole grains as directed by your surgeon. Be sure your baby gets plenty of fluids.

Bathing: Give gentle soap and water baths as directed by the surgeon.

Medication: Give oral Tylenol every four hours as directed. If stronger medication is needed, call the surgery team.

What should I call the surgery team for?

Call for fever over 100.5 F, pain, vomiting, redness or swelling of the incisions, increase or decrease in bowel movements, swollen belly, serious diaper rash or any problems or concerns that you have. The first postoperative visit will be two weeks after discharge.

What should I call my pediatrician for, and when should we see him/her?

Call you pediatrician for feeding problems, colds, earaches, rashes.

When can my child return to daycare?

Your child should be able to return to daycare a few days after discharge from the hospital. Make sure that your facility is comfortable caring for children with special needs. Be sure they know not to put anything in the rectum.

What are the long term consequences?

Based on the child's defect level, the long term consequences will be different. Your surgical team will discuss this with you. A common problem after surgery is constipation. The surgical team will give you instructions on diet, laxatives and possibly enemas, as needed.

Will this affect growth and development?

Children with anorectal malformations should have normal growth and development unless they have other defects as well.

Is there anything else I need to know to care for my child?

Children with anorectal malformations will need follow up care throughout their childhood. Toilet training may be delayed for children after this surgery. Bowel management through diet, laxatives and/or enemas may be a life-long need. Keeping in close contact with the surgical team will provide helpful advice for your child's success with toilet training and preventing bowel accidents.

Please reproduce and distribute this sheet to your surgery families. This teaching sheet can also be downloaded at
Copyright 2006,
Fran Gill. Copied with permission by Jones and Bartlett Publishers, Sudbury, MA.
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