1965, Brit. J.

RadioL, 38, 444-448

Radiological assessment of imperforate anus

By D. A. R. Robertson, M.B., Ch.B., D.M.R.D.,* Eric Samuel M.D., F.R.C.S., F.R.C.P.E., F.F.R., and W. Macleod, M.B., F.R.C.P.E., F.F.R.(R.C.S.L) Radiodiagnostic Departments, Royal Infirmary and Royal Hospital for Sick Children, Edinburgh
{Received August, 1964)

Imperforate anus occurs with a frequency of approximately 1 in 5,000 births. The results of surgical treatment in these cases have been variable and this has largely depended on the type of lesion present. For this reason, the use of radiology in differentiating between a high rectal atresia and a true imperforate anus is more than an academic exercise. The purpose of this study was to carry out an independent radiological assessment of the level of the lesion by a retrospective analysis of the radiographs. This was then compared with the findings at operation. Eighteen cases of imperforate anus admitted to the Royal Hospital for Sick Children were reviewed. As the results of operation are so dependent upon the type of ano-rectal abnormality present, it was felt that this review might offer to the paediatric surgeon a more definite indication of the level of the lesion, and hence a better guide to the choice of surgical approach. Lesions were classified according to their relation to the pelvic floor"high" lesions above the estimated level of the pelvic floor, "low" lesions below the floor. The low lesions are treated by a perineal approach, whilst the high lesions are considered to be treated better by an abdomino-perineal approach. The abdominal approach is advisable in high lesions, as many are complicated by fistula formation, for which extensive rectal mobilisation is necessary. It also avoids an extensive dissection of the pelvic floor from below, with consequent possible damage. Various classifications of rectal and anal malformation have been suggested, but that of Ladd and Gross (1934) has received widest recognition. They described four types as follows: Type I Incomplete rupture of anal membrane or stenosis at 3 point 1-4 cm above the anus. Type II Imperforate anus. Obstruction due to a persistent membrane. Type III Imperforate anus, but with a rectal pouch separated from the anal membrane The rectal pouch ended blindly in or above the pelvis. Type IV Anus and pouch normal. The rectal pouch ended blindly. There was either mem-

branous obstruction or separation of these two pouches. Browne (1955), however, classified imperforate anus into high and low types, i.e. those with rectal agenesis and those without, but with a malformed or misplaced anus. The essential difference is that in the high type of deformity with rectal agenesis the bowel ends above the levator ani (the pelvic floor), whereas in the low type it passes through this muscle, which exercises sphincteric control through the pubo-rectalis. The level of the pelvic floor may be estimated from bony landmarks and thus the classification of high and low types of anomaly can be based on this measurement. Scott and Swenson (1959) stated that the pubo-coccygeal line indicates the position of the pelvic floor; lesions ending above this line were classified as high and those below as low lesions. The line was defined as running from the lower border

Ladd and Gross l5cm Kiesewetter 2-0 cm

Stephens

\ Scott and Swenson

Present address: Kingston General Hospital, Surrey.

FIG. 1. Line drawing of pubo-coccygeal line.

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Radiological Assessment of Imperforate Anus of the pubis to the sacro-coccygeal junction (Fig. 1.) Stephens (1953), on the other hand, located the pubo-coccygeal line from the upper border of the pubis to the sacro-coccygeal junction. He considered this is the common level at which the rectal lumen is narrowed or obliterated at its junction with the upper cloacal canal, due to failure of subdivision of rectum from cloaca. This line is the approximate anatomical level of the verumontanum, peritoneal pouch, the external os of the cervix and Houston's third valve of the rectum. Ladd and Gross (1934) stated that lesions 1-5 cm or more from the anal dimple should be considered high lesions and that an abdomino-perineal approach should be used in their surgical treatment. Kiesewetter and Turner (1963) accepted 2 cm as the measurement from the anal dimple that corresponded to the level of the pelvic floor. Since the pubo-coccygeal line of Scott and Swenson (1959) gives the position of the pelvic floor and corresponds to the classification of Browne (1955), this line has been taken as the division between high and low lesions in the present study. Radiography The basis of the radiological examination, employing the Wangensteen-Rice principle (1930), is a lateral radiograph of the pelvis with the infant inverted. The level of air in the distal pouch of bowel in relation to the pubo-coccygeal line can thus be determined. Air on or above the line indicates a high lesion and below the line a low lesion (Figs. 2, 3, 4 and 5). A metallic marker is placed at the anal dimple and the distance from marker to distal pouch of bowel is measured. Certain criteria should be followed when taking the films. The centring point is the upper aspect of the greater trochanter with the inverted infant in the true lateral position. Some authors recommend an A.F.D. distance of as much as 6 ft. to minimise magnification. Films taken before 8-12 hours are unlikely to show gas at the true level of the distal pouch and serial films at three-hour intervals have been advocated until no further distal movement of gas is noted (Figs. 6 and 7). Accurate placement of the marker at the anal pit is important. An antero-posterior film of the pelvis is of value to demonstrate the degree of distension of proximal bowel and possible associated sacral bone anomalies. Method The films were examined before the surgical approach used in each case was known and the following observations made: (i) The relation of gas to the pubo-coccygeal line of Scott and Swenson (1959); (ii) the distance of gas from the anal marker; (iii) the presence of gas in the genito-urinary tract; (iv) associated congenital abnormalities. The results were recorded as follows: Firstly, using the pubo-coccygeal line as the sole indication

FIG.

2.

FIG. 3. FIG. 2. High lesion. FIG. 3. High lesion. Gas at S3 level. FIG. 4. High lesion. Gas at pubo-coccygeal line. Sacral anomaly.

FIG.

4.

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FIG. 5. Low lesion. FIG. 6. Low lesion. Incomplete descent of gas. FIG. 7. After three hours gas outlines true level of lesion. FIG. 8. Apparent low lesion. High surgical approach. Fistula present.

of the level of the lesion. Secondly, an assessment of our own using the pubo-coccygeal line in conjunction with the distance of gas from the anal marker and the presence of gas in the genitourinary tract. On these three premises it was thought that a perineal or abdomino-perineal surgical approach could be suggested. Our suggested surgi-

cal approach was then compared with that actually used. The anatomical findings at operation or postmortem were also recorded. Results From 18 cases reviewed, five were excluded from the final correlation for lack of precise information.

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Radiological Assessment of Imperf orate Anus

FIG. 9. Gas in bladder. Low surgical approach. ? Fistula present. FIG. 10. Antero-posterior view of gas in bladder. FIG. 11. Cloaca formation. Gas in uterus and Fallopian tubes. FIG. 12. Antero-posterior view of cloaca. FIG. 13. High lesion. Gas in bladder. Wide fistula to posterior urethra. FIG. 14. Sacral anomaly. Rectal atresia and fistula.

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38, No. 450 D. A. R. Robertson, Eric Samuel and W. Macleod (iii) internal rectal sphincters not relaxed at the time of X-ray examinations, (iv) difficulty in defining bony end points, especially when there are sacral anomalies; (v) distortion due to radiological magnification. Other authors (Winslow, Litt and Altman, 1961) have found that similar errors in interpretation could arise from these factors. Gas in the genitourinary tract is a valuable sign as it indicates a fistula with a high lesion and an abdomino-perineal operative approach would be indicated (Fig. 9). Occasionally difficulty may be experienced in determining whether gas lies in bowel or bladder. The posterior border of the rectum lies in relation to the anterior aspect of the sacrum, whilst the bladder lies anteriorly, behind and above the pubic bones (Fig. 13). The use of the Ladd and Gross (1934) method of measurement from anal marker to bowel gave a fallacious indication of the level of the lesion in two of 13 cases. In these, high lesions were indicated, as the gas shadows were over 2 cm from the anal marker, when low lesions were in fact present. The same points hold as above when gas fails to outline the distal pouch of bowel. The presence of sacral anomalies is of importance as severe sacral agenesis deprives the bladder and lower rectum of its full sensory supply and is associated with a poorly developed pelvic floor (Fig. 14).
CONCLUSION

Of the remaining 13 cases, seven were high lesions and six were low lesions. Using the pubo-coccygeal line as the sole indication, the level was correct in nine and incorrect in four cases. Using our assessment with the additional factors taken into account, the level was correct in ten instances of the 13 considered. The cases in which radiological errors arose as compared with the surgical findings were reviewed. The first case indicated a low lesion radiologically, but an abdomino-perineal approach was used (Fig. 8). The rectum was brought through levator ani and by dissection a small recto-prostatic urethral fistula found. The second case showed gas on the pubococcygeal line and at a distance of 2-2 cm from the anal marker. A high lesion was diagnosed. A low recto-perineal fistula, evident at clinical examination, was present and a perineal approach made. The third case indicated a high lesion and gas was present in the bladder, though not appreciated at the time of examination of the films (Figs. 9 and 10). An anal skin flap was removed using a low approach. An abdomino-perineal approach should have been undertaken since the high level of bowel and the presence of gas in the bladder pointed to a high lesion with fistula formation. Gas was present in the genito-urinary tract in five cases, though a total of eight fistulae were demonstrated. In one case, gas was present in the bladder with a recto-urethral fistula, whilst in two other such fistulae, no gas could be demonstrated. In one child there was a persistent cloaca with grossly distended bilobed uterus and Fallopian tubes (Figs. 11 and 12). The gas shadows in cloaca and Fallopian tubes are characteristic. Anomalies such as oesophageal atresia, congenital pyloric stenosis, hyaline membrane disease and renal disease were present in nine of the 18 cases. They were occasionally the governing factor in the type of operation performed, e.g. warranting only a gastrostomy or colostomy.
DISCUSSION

It is felt that a relatively firm indication of the level of an ano-rectal anomaly can be given in the majority of cases, bearing in mind the possible causes of error and the precautions which can be taken to minimise these errors. The presence of gas in the genito-urinary tract is a valuable adjunct in the diagnosis of internal fistulae and in placing the defect at its proper level.
ACKNOWLEDGMENTS

Whilst the relation of the distal pouch to the pubococcygeal line indicates correctly the type of lesion REFERENCES in the majority of cases, it is not infallible. In one BROWNE, D., 1955, Arch. Dis. Child., 30, 42. child in this series, gas below this line was asso- KIESEWETTER, W. B., and TURNER, C. R., 1963, Ann. Surg., 158, 498. ciated with a high lesion with a recto-urethral LADD, W. E., and GROSS, R. E., 1934, Amer. J. Surg., 23, fistula. 167. Conversely, gas above the line does not exclude a SCOTT, J. E. S., and SWENSON, O., 1959, Ann. Surg., 150, 477. low lesion. The reasons for this may be: STEPHENS, F. D., 1953, Aust. N. Z.J. Surg., 22, 161. (i) insufficient time to allow gas to reach the distal WANGENSTEEN, O. H., and RICE, C. O., 1930, Ann. Surg., 92, 77. pouch; WINSLOW, O., LITT, R., and ALTMAN, D., 1961, Amer. J. (ii) a meconium plug in the distal pouch; Roentgenol., 85, 719. 448

We acknowledge gratefully the generosity of the Surgeons-in-charge at the Royal Hospital for Sick Children, Edinburgh, for allowing us to refer to and extract information from the operative notes of the cases reviewed. We should like to acknowledge also the assistance of the radiographers at the above hospital and Miss H. Garvie and Miss P. Hoban for their assistance with the manuscript.