Rectal cancer in anorectal malformation with rectovestibular fistula - Sphincter-restoring surgery by anterior resection and dynamic vaginoanograciloplasty

PURPOSE: The aim of this study was to describe and discuss the anosphincter -restoring procedure adopted in an adult patient with rectal cancer, affect ed by anorectal atresia and rectovestibular fistula not previously treated. METHODS: After anterior resection and transverse dissection of the rectova ginal septum, a straight double-staple low colorectal anastomosis was perfo rmed. A subcutaneous tunnel was extended from the inter-rectovaginal space, surrounding the pseudoanal orifice. The tunnel housed a left gracilis musc le arranged counter-clockwise and connected to an implanted stimulator. The vaginal and anorectal flaps were sutured longitudinally, thereby spacing o ut the two orifices and creating an anorectal angle. A temporary loop right colostomy was performed. RESULTS: The postoperative course was uneventful. After continuous electrostimulation training and colostomy takedown, the p atient had improved continence (stimulator on) and normal defecation (stimu lator off). CONCLUSIONS: The solution described seemed a suitable alternati ve to a pull-through procedure, which would have involved a colocutaneous a nastomosis and the loss of the anorectal sensory function. Any previous ana l transposition or pull-through procedures would have prevented the saving of the pre-existing "anus," because of the interruption of the residual mes enteric vascular supply to the anorectal remnant secondary to mesorectal ex cision.