Analysis of influencing factors on postoperative constipation in patients with Congenital Anorectal Malformations

Analysis of influencing factors on postoperative constipation in patients with Congenital Anorectal Malformations | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Analysis of influencing factors on postoperative constipation in patients with Congenital Anorectal Malformations Cheng-Yan Tang, Ze-Meng Duan, Yuan-Mei Liu, Ze-Bing Zheng, Wan-Kang Zhou, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6768880/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective This study analyzed the clinical data of infants who underwent surgery for congenital anorectal malformations (ARM) and the factors influencing the occurrence of postoperative constipation. Methods This retrospective analysis was conducted using the clinical data of 177 infants with congenital ARM who had been diagnosed and operated on at the authors’ hospital from January 2008 to March 2018. This included 132 cases who underwent a perineal operation (PO), 23 cases of posterior sagittal anorectoplasty (PSARP), and 22 cases of laparoscopic-assisted anorectoplasty (LAARP). The patients were grouped according to clinical type, surgery mode, the presence of other malformations, the duration of surgery, the grade of wound healing, and the presence of ganglion cells at the blind end of the rectum. Results The constipation rate after surgery in patients of the intermediate/high type of ARM was higher than in low-type patients ( P < 0.05). For surgery modes, the constipation rate in patients who underwent PO was higher than for those who received PSARP and LAARP ( P < 0.05). The constipation rate of those with other malformations was higher than those without ( P < 0.05). The constipation rate of those with Grade B and C wound healing was higher than in those with Grade A ( P < 0.05). The constipation rate of those without ganglion cells at the blind end of the rectum was higher than in those with ganglion cells ( P < 0.05). The clinical type (odds ratio [OR] 1.512, 95% confidence interval [CI], 1.301 and 3.551), operation mode (OR 1.586, 95% CI, 1.189 and 3.586), the presence of other malformations (OR 1.187, 95% CI 1.131 and 6.835), grade of wound healing (OR 1.234, 95% CI, 1.159 and 5.961), and the presence of ganglion cells at the blind end of the rectum (OR 1.215, 95% CI, 1.114 and 9.156) were found to be postoperative constipation influencing factors. Conclusions In infants who underwent surgery for congenital ARM, the clinical type, operation mode, the presence of other malformations, operation duration, wound healing grade, and the presence of ganglion cells at the blind end of the rectum were factors influencing postoperative constipation. congenital anorectal malformation constipation logistic regression analysis influencing factors Introduction Congenital Anorectal Malformations(anorectal malformations,ARM) is one of the common digestive tract malformations in children, with a incidence rate of 1/5000 to 1/3500 [ 1 – 3 ]. Postoperative defecation dysfunction is a serious complication of ARM, often causing psychological, physiological development, and social activity disorders in children [ 4 – 7 ]. The main manifestations of postoperative defecation dysfunction in ARM are fecal incontinence and constipation, and more research has focused on the pathological basis of postoperative fecal incontinence and the improvement of treatment methods [ 8 – 11 ]. In recent years, with the continuous improvement of surgical techniques, especially the widespread implementation of posterior sagittal anorectal reconstruction (PSARP) and laparoscopic assisted anorectal reconstruction (LAARP), the incidence of postoperative fecal incontinence has decreased, but the incidence of postoperative constipation has been increasing year by year, ranging from 22.2–86.7% according to incomplete statistics, and has become the main complication of ARM surgery, Arousing people's attention [ 12 – 18 ]. Severe constipation can cause fecal contamination and pseudofecal incontinence, which can be confused with postoperative anal sphincter dysfunction leading to fecal incontinence. These two types of fecal incontinence have different causes and treatment methods. Studying the causes and pathological changes of postoperative constipation, and treating them according to the causes, is of great significance for improving treatment efficacy and improving the quality of life of patients. This study retrospectively analyzed the postoperative constipation of children with congenital anorectal malformations treated in our hospital, and analyzed multiple factors such as clinical classification, presence of malformations, surgical methods, wound healing, and presence or absence of ganglion cells in the blind end of the rectum. Possible factors affecting postoperative constipation were explored. Data and method 1.1 Data 1.1.1 Subjects A total of 225 infants with congenital ARM who had visited the Pediatric Surgery Department of the Zunyi Medical University between January 2008 and March 2018 were retrospectively analyzed. These included 202 cases who had undergone anoplasty. Among these, 25 cases were lost to follow-up; 177 cases were successfully followed up and were included in the study. The follow up was conducted using questionnaires during outpatient visits or through phone calls. The follow-up evaluation for constipation was completed by the pediatric surgery team of the Affiliated Hospital of Zunyi Medical University. 1.1.2 Inclusion criteria The study’s inclusion criteria were as follows: 1) Infants with a confirmed diagnosis of anorectal malformation who had undergone surgery and had been followed up successfully. 2) Infants experiencing constipation as per diagnostic criteria for the condition (Diagnostic Criteria for Constipation: Rome IV, 2016 revision) which included the following: In the age group of newborn infants and children up to the age of 4 years, the presence of at least two of the following symptoms for one month: Defecation twice or less every week; Following the acquisition of toilet skills, at least one episode of fecal incontinence per week; A history of fecal retention; A history of difficult or painful bowel movements; A large fecal mass in the rectum; Large-diameter stools that could clog the toilet Symptoms including irritability, a decreased appetite, or early satiety, which would quickly disappear following defecation of a large volume. For children aged 4 years and older, the presence of at least two or more of the following symptoms for at least two months were considered: Defecation ≤ 2 times per week; At least one episode of fecal incontinence per week; A history of stool-retentive posturing or excessive volitional fecal retention; A history of pain or exertion when defecating; A large fecal mass in the rectum; Large-diameter stool that could clog the toilet and insufficient criteria for the diagnosis of irritable bowel syndrome. 1.1.3 Exclusion criteria The following were considered the exclusion criteria of the study: 1) Patients who did not meet the above-noted diagnostic criteria for constipation; 2) Patients who did not undergo surgical treatment or who were lost to follow up. 1.2 Study content and method 1.2.1 Study content The clinical data of 177 patients were grouped according to the following factors: clinical type (intermediate/high, or low), operation mode (PO, PSARP, or LAARP), the presence of other malformations (yes/no), surgery duration (< 90 or ≥ 90 min), wound-healing grade (A, B, or C), and the presence of ganglion cells at the blind end of the rectum (yes/no). Univariate analysis was performed using each of these factors for the occurrence of constipation. Multivariate logistic regression analysis was also performed for the factors that showed statistical significance to investigate which of them impacted constipation after surgery. 1.2.2 Criteria for clinical types The clinical types of ARMs were classified according to the Wingspread Classification. Anteroposterior and lateral invertograms of the infants were taken between 24ཞ48 hours after birth. The line connecting the superior margin of the pubic symphysis and the sacrococcygeal joint was taken as the pubococcygeal line (PCL). If the gas shadow at the end of the rectum was observed above the PCL, a high ARM was identified; if it was present between the PCL and the ischial line (IL), an intermediate ARM was identified; if it was observed below the IL, a low ARM was identified. The surgical regimens for patients with intermediate and high malformations were similar and, as a result, the data for intermediate and high types were combined for the analysis. 1.2.3 Surgery modes (1) Perineal operation was indicated for infants with a low ARM. (2) Posterior sagittal anorectoplasty was indicated for infants with high and intermediate ARMs, with all procedures completed in three stages as follows: first, fistulization of the sigmoid or transverse colon; PSARP 3–6 months after fistulization; finally, fistula closure. (3) Laparoscopic-assisted anorectoplasty was indicated for infants with high and intermediate ARMs, with all procedures completed in two or three stages as follows: first, fistulization of the sigmoid or transverse colon; some patients underwent LAARP and fistula closure in stage 2; some patients underwent LAARP in stage 2, and fistula closure in stage 3. 1.2.4 The presence of other malformations (1) Malformation in the urogenital system, including cryptorchidism, hypospadias, vesicoureteral reflux, and renal dysplasia. Malformations of the reproductive system for female infants included hydrocolpos and gynatresia. (2) Malformations observed in the cardiovascular system included atrial septal defect, patent foramen ovale, patent ductus arteriosus, tetralogy of Fallot, and ventricular septal defect. (3) Malformation of the motor system included talipes equinus, lumbar hemivertebrae, and tethered cord. 1.2.5 Anal wound healing Postoperative wound healing was classified into grades A, B, and C. Grade A reflected excellent healing with no adverse reactions. Grade B indicated poor healing with an inflammatory reaction at the wound site, e.g., erythema, nodule, hematoma, and hydrops, but without festering. Grade C indicated a festering wound. 1.2.6 The development of ganglion cells on the intestinal wall of the blind end of the rectum Tissue samples at the blind end of the rectum were taken for pathological examination from all the infants who underwent surgery to check for the presence of ganglion cells. The patients were divided into two groups, i.e., those with and those without ganglion cells. 1.2.7 Treatment after operation To prevent anal stenosis, anal dilatation which was performed twice a day was stared 2 weeks after surgery. The size of anal dilator was usually 9 or 10 and was increased by 1 every 1 to 2 weeks till it was suitable for the patient. Intermittent enema treatment was not performed routinely except for one case of severe postoperative constipation. In all cases, probiotics were used for regulating intestinal flora. No other drugs were used in addition. 1.2.8 Study methods The infants were divided into different groups according to the clinical type, surgery mode, the presence of other malformations, operation duration, wound healing grade, and the presence/absence of ganglion cells at the blind end of the rectum. Univariate analysis was performed for the occurrence of constipation, and multivariate logistic analysis was also conducted for factors with statistical significance. 1.3 Statistical method The SPSS Statistics (IBM, Windows, v.19.0., Armonk, NY) software program was used to conduct a statistical analysis of the data. Results 2.1 Demographics 2.1.1 Demographic data statistics A total of 177 infants with congenital ARMs were successfully followed up within a period of 0.5–8 years, with a mean of 3.8 years. There were 114 male patients (64.41%), and 63 female patients (35.59%). The age of the patients at the time of surgery ranged from 1 day to 12 months. There were 36 cases with intermediate/high malformations (20.34%) and 141 cases with low malformations (79.66%). The results are shown in Table 1 . Table 1 Demographic Data Type Number of cases Percentage (%) Rectoperineal fistula 94 53.12 Rectovestibullar fistula 41 23.16 Rectourethral fistula 27 15.25 Rectovaginal fistula 3 1.69 Without fistula (pouch colon) 5 2.82 Rectostenosis 7 3.95 2.1.2 Statistical data on postoperative constipation A total of 132 cases underwent PO (74.58%), 23 cases received PSARP (12.99%), and 22 cases underwent LAARP (12.43%); 91 cases had other malformations (51.41%), and 86 cases had no other malformations (48.59%). For 116 cases, the surgery duration was < 90min (65.54%). In 61 cases, the surgery duration was ≥ 90 min (34.46%). There were 148 cases of grade A wound healing (83.62%), 21 cases with grade B wound healing (11.86%), and 8 cases with grade C wound healing (4.52%). Ganglion cells at the blind end of the rectum were observed in 110 (62.15%) but not in 64 (37.85%) cases. There were 55 cases with postoperative constipation (31.07%) and 122 without constipation (68.93%). Table 2 shows the statistical results. Table 2 Univariate Analysis on Influencing Factors of Constipation after ARM Operation Related factors With constipation Without constipation Total Constipation rate (%) χ 2 P Clinical type Low 30 111 141 21.28 0.987 0.321 Intermediate/high 5 31 36 13.89 Operation mode PO 47 85 132 35.60 9.342 0.035 PSARP 6 17 23 26.08 LAARP 2 20 22 9.09 Presence of other malformations Yes 44 47 91 48.35 4.654 0.032 No 11 75 86 12.79 Operation duration <90min 35 81 116 30.17 1.321 0.251 ≥ 90min 20 43 61 32.79 Wound healing grade A 42 106 148 28.38 6.144 0.024 B 10 11 21 47.62 C 3 5 8 37.50 Presence of ganglion cell at blind end of rectum Yes 41 69 110 37.27 7.562 0.012 No 53 14 67 79.10 2.1.3 Statistics regarding the presence of other malformations There were 91 (51.41%) cases with other malformations, 47 (51.65%) cases with malformations of the urinary system, 26 (28.57%) cases with cardiovascular malformations, 7 (7.69%) cases with malformations of the motor system, 4 cases (4.39%) with malformations of the nervous system, and 7 (7.69%) cases with other malformations. 2.2 Univariate analysis results The univariate analysis for clinical types showed that the constipation rate after surgery in patients with intermediate/high type of ARMs was higher than in patients with the low type ( P < 0.05). For the surgery modes, the constipation rate in patients who underwent PO was higher than those who received PSARP and LAARP ( P < 0.05), whereas the constipation rate among those with other malformations was higher than for those without other malformations ( P < 0.05). For anal wound-healing grade, the constipation rate of those with grades B and C was higher than those with grade A ( P 0.05). The constipation rate for those without ganglion cells in the blind end of the rectum was higher than for patients with ganglion cells ( P 90 min and for those where this was 0.05). 2.3 Multivariate unconditional logistic analysis As shown in the univariate analysis, the factors that were significantly associated with postoperative constipation included the clinical type, surgery mode, the presence of other malformations, wound-healing grade, and the presence of ganglion cells at the blind end of the rectum. Multivariate logistic regression analysis was performed, and the results showed that the clinical type, surgery mode, the presence of other malformations, wound-healing grade, and the presence of ganglion cells at the blind end of the rectum were influencing factors for constipation after surgery. These details are shown in Table 3 . Table 3 Multivariate Unconditional Logistic Regression Analysis of Constipation after ARM Operation Influencing factor Regression coefficient SD of regression coefficient Wald value P value Odds ratio Odds ratio, 95% CI Lower limit Upper limit Clinical type 0.756 0.463 14.52 <0.01 1.512 1.301 3.551 Operation mode 0.578 0.212 10.181 0.001 1.586 1.189 3.586 Presence of other malformations 0.862 0.543 10.896 0.021 1.187 1.131 6.835 Healing grade 0.764 0.125 10.564 0.018 1.234 1.159 5.961 Ganglion cell at blind end of rectum 0.756 0.542 11.491 <0.01 1.215 1.114 9.156 Discussion Postoperative bowel dysfunction in ARM surgery mainly includes fecal incontinence and constipation. With the continuous improvement of surgical techniques, the occurrence of postoperative fecal incontinence. The rate has decreased, and people are gradually shifting their focus to postoperative constipation. The incidence of constipation in normal children is 0.7–29.6% [ 19 ], but the incidence of postoperative constipation in ARM patients is as high as 22.2–86.7%, which is significantly higher than the incidence in the normal population, indicating that the occurrence of postoperative constipation is related to the complex pathological changes of ARM itself. However, there are few literature reports on the factors affecting the defecation function of such children. Defecation control is a complex physiological reflex and regulatory process, which is the result of the interaction of many factors such as the strength and reflex mechanism of the internal and external sphincters, rectal sensation and compliance regulation, and coordinated pelvic floor muscle movement. Any abnormality in any of these links can lead to the occurrence of constipation. To explore the influencing factors of postoperative constipation in ARM patients, this study retrospectively analyzed the clinical classification, presence or absence of malformations, surgical methods, wound healing, and presence or absence of ganglion cells in the blind end of the rectum of children with congenital anorectal malformations who developed constipation after surgery treated in our hospital. Multiple factors were analyzed to explore potential factors that may affect postoperative constipation. 3.1 The relationship between clinical type and postoperative constipation A higher ARM position had a higher rate of constipation. Developmental defects of the anorectum are also associated with pathological changes in the pelvic floor muscles, the sacral nerves, and the perianal skin,[ 20 ] which can seriously affect the postoperative quality of life in infants. According to some studies[ 21 ], the incidence of constipation after surgery for an ARM is 30.7%. A Chinese study reported an incidence of constipation in follow-up visits of 21.87% among infants who underwent surgery for a low ARM[ 22 ] .Laura et al.[ 23 ] reported a postoperative constipation rate of 42–70% for low malformations. Huang[ 16 ] reported constipation as the most common complication among 188 infants who had been followed up, with an incidence of 64.5% in the low ARM group and a higher incidence of constipation in the longer follow up. Huang posited that constipation in infants with a low ARM was chiefly caused by abnormal development of the rectal peripheral nerves. In the present study, there were 55 cases of postoperative constipation with a constipation rate of 31.07%. Constipation occurred in 30 of 141 cases (21.28%) in the low ARM group. Among them, 29 children were able to defecate normally after regular anal dilation and the use of laxatives. Only 1 child developed severe constipation and needed to use glycerin to defecate. At the same time, the postoperative pathological results of the rectal end in this patient showed no ganglion cells. The normal defecation process relies on the cooperation of pelvic floor muscle groups and nerve fibers. Foreign scholars have reported [ 24 ] that children with high-level deformities have poor pelvic floor muscle development. Zhang et al. [ 25 ] found significant developmental abnormalities in the pelvic floor muscle group of the ARM group by observing the development of rectal smooth muscle. Domestic and foreign scholars [ 26 – 27 ] found through animal experiments that there are varying degrees of abnormalities in the extraintestinal and intraintestinal nervous systems of the blind end of the ARM rectum, including abnormalities in the size and density of nerve fibers, as well as abnormalities in related neurotransmitters and transmission mechanisms [ 28 – 29 ], which are related to postoperative constipation. There are reports [ 30 – 31 ] that the more severe the pelvic floor muscle and nerve fiber lesions are in children with high classification, the higher the incidence of postoperative constipation. Scholars have reported [ 21 ] that according to the Krinkenbeck classification, the constipation rate of rectoperineal fistula is the lowest, at 14.5%, while the postoperative constipation rate of rectobladder fistula and rectovaginal fistula is the highest, at 100%. This is also in line with the data presented in this article, where rectoperineal fistula is classified as a low level anomaly, while rectobladder fistula and vaginal fistula are high level anomalies; For postoperative constipation, especially for families of patients with mid to high levels, it is necessary to instruct them to strictly and regularly dilate the anus, promote the development of nerves around the anus and pelvic floor, and form a normal defecation reflex arc. For stubborn constipation, it is necessary to regularly go to the hospital for biofeedback and other treatments. It is also important to pay attention to whether congenital megacolon is present and promptly detect and treat it. 3.2 The relationship between surgery mode and postoperative constipation As indicated in this study, the constipation rate after PO was 35.60%, after PSARP this was 26.08%, and the rate after LAARP was 9.09%. In this study, the constipation rate post-LAARP was consistent with the results in other studies,[ 32 ] likely due to the application of a laparoscopic technique, which significantly reduced surgical wounds. Abnormal nerve function that innervates the anal, rectal, and pelvic floor muscles can lead to an increase in rectal sensory threshold, prolonged sensory contraction time, and abnormal bowel motility, resulting in the occurrence of constipation. In order to investigate whether there are neurological abnormalities in children with postoperative constipation after ARM surgery, studies have conducted neurophysiological tests[ 33 ]. The results showed that the perineal anal reflex latency, spinal cord anal reflex latency, and reflex arc central conduction time, which reflect the nerve conduction function of the external anal sphincter, were significantly prolonged in the ARM constipation positive group, indicating more significant neurological damage in the children. For children with mid to high level anorectal malformations combined with fistulas, laparoscopy can clearly observe the location of the fistula and accurately separate and ligate the fistula, thereby reducing surgical trauma. At the same time, avoid extensive dissociation to reduce damage to surrounding blood vessels and nerves. Few studies involving long-term follow-ups on LAARPs have been reported, but the procedure is currently highly valued by pediatric surgeons for its significant advantages, i.e., a small wound, quick recovery, aesthetics, and a good effect on short-term follow-up. 3.3 The relationship between the presence of other malformations and postoperative constipation Anorectal malformations are often associated with other deformities, with an occurrence rate of approximately 40–70%[ 34 – 36 ] .The most common concomitant malformations are those that occur in the urogenital system, followed by spinal (mainly sacral) malformations, as well as digestive tract, cardiac, and other malformations. The lumbosacral vertebrae and sacral nerves participate in the control of the defecation process; therefore, the presence of malformations to the lumbosacral vertebrae and sacral nerves may to some degree be associated with postoperative constipation. In this study, 5 of 7 cases with malformations to the nervous system experienced a significantly higher constipation rate after surgery. Sensory neurons innervating the levator ani muscle are mainly distributed in the dorsal root ganglion of the spinal cord at the L5-S1 segment. Therefore, lumbosacral vertebrae and sacral nerve malformations may lead to abnormal conduction of sensory impulses of the levator ani muscle, which may affect the brain's control of spinal cord defecation reflex and lead to postoperative constipation[ 37 – 38 ]. For many years, the abnormality of the lumbosacral nerve in children with ARM has attracted people's attention. Li et al. [ 39 ] found significant abnormalities in the sensory and motor nerve endings of the children during the histological examination of the pelvic floor muscles in ARM. Scholars have used an ARM rat model induced by ethylene thiourea for embryonic neural tracing research, and found significant developmental abnormalities in the spinal motor and sensory neurons that innervate the pelvic floor muscles, as well as the spinal parasympathetic neurons that innervate the rectum [ 8 , 9 , 19 ]. Tunell [ 40 ] found through X-ray examination that 35% of anorectal infants were accompanied by bone abnormalities in the lumbosacral vertebrae, and 53% had spinal cord or spinal canal abnormalities, which gradually worsened with age. Capitanucci [ 41 ] found that individuals with spinal cord abnormalities rarely experience symptoms at a young age, while older children experience a significant increase. The researcher believes that early diagnosis and treatment of spinal cord lesions are crucial before symptoms appear. Samuk [ 42 ] conducted MRI examinations on 790 children with ARM and found that 36% of the patients could be diagnosed with tethered cord syndrome. Kyrklund K [ 43 ] conducted MRI examinations on 89 children with normal spinal appearance in ARM, and found that 34% of the children had spinal cord abnormalities. These research results all suggest serious neurological dysfunction in children with ARM. In order to improve postoperative treatment effectiveness, it should be considered to perform nerve function repair and reconstruction treatment simultaneously with anal reconstruction surgery [ 44 , 45 ]. 3.4 The relationship between anal healing grade and postoperative constipation Anoplasty requires a category II incision, which can easily be contaminated by feces after the procedure. Due to the young age of the patients in the present study, they were more prone to wound infection. Regardless of the surgery mode, healing of the incision is an important factor in the success of the operation. In this study, the postoperative constipation rate was 28.38% for grade A, 47.62% for grade B, and 37.5% for grade C healing (no grade B or grade C healing was observed after PSARP and LAARP surgeries). Three cases of grade C healing occurred after PO; Two patients were cured by perineal caring, which included cleaning of incision secretion and local application of silver ion dressing. One case required surgery for postoperative cicatricial stricture, suggesting that the operation mode also affected the grade of postoperative anal healing. Univariate and multivariate regression analyses indicated a close association between incision healing grade and constipation. In this study, patients with intermediate/high ARMs underwent colostomy surgery in the neonatal period, and thereafter PSARP or LAARP in stage 2; accordingly, feces did not contaminate the incision, thus decreasing the risk of infection and ensuring quick healing of the incision (this was also the reason why there was no grade B or C healing after these surgeries, and the constipation rate was the lowest among these patients). Therefore, for patients with intermediate/high ARMs, it is still recommended that colostomy surgery be performed first so that feces will not be discharged from the newly constructed anus during the stage 2 operation. For infants undergoing PO, post-operative wound nursing must be enhanced to avoid wound infection and an impact on bowel functions. 3.5 The relationship between ganglion cells at the rectum end and postoperative constipation Defecation is controlled by the autonomic nervous system (ANS), the somatic nervous system (SNS), and the enteric nervous system (ENS). The ENS is independent of the brain and comprises ganglion cells and nervous processes that commonly exist in the form of a special nerve plexus in the gastrointestinal wall. Ganglion cells are distributed in the submucosal and myenteric nerve plexus on the intestinal wall, where they serve to promote intestinal tract development and maintain intestinal function[ 46 – 49 ]. They are controlled by the ANS and the SNS. Hence, the development of ganglion cells is directly associated with defecation function[ 50 ]. The ENS provides the necessary trophic factors for the development of ganglion cells, i.e., glial cell-derived neurotrophic factor, which promotes ENS development[ 51 ]. It is chiefly expressed in the submucosal and myenteric nerve plexus on the intestinal wall, and animal tests have shown that their expression in fetal rats with ARMs is lower compared with a normal test group. Hypoplasia of the ENS may cause a lack of development of intestinal ganglion cells and may also be associated with postoperative constipation[ 52 ]. According to the results of this study, the postoperative constipation rate of patients with ganglion cells was 37.27%, significantly lower than those without ganglion cells (79.10%). The presence of ganglion cells is thus an influencing factor for postoperative constipation. Congenital anorectal malformation combined with hirschsprung disease is rare in clinical practice and often misdiagnosed. For patients with congenital anorectal malformations, if constipation persists and worsens after surgery and conservative treatment is ineffective, they should be vigilant about the possibility of coexisting with congenital megacolon; The pathological diagnosis based on rectal mucosal biopsy remains the gold standard for diagnosis. If diagnosed with hirschsprung disease, surgery is required to remove the affected intestinal tract. Conclusion In summary,the clinical classification, surgical method, comorbidities, wound healing grade, and the presence or absence of ganglion cells in the blind end of the rectum are the influencing factors for postoperative constipation in congenital anorectal malformations. The limitation of this study is that it did not conduct tests such as rectal and anal pressure measurement, anal sphincter nerve electrophysiology, and electromyography. In the future, we will conduct a comprehensive, systematic, and dynamic evaluation of the anorectal and nerve function in children with postoperative constipation after ARM surgery, clarify the specific causes and pathological changes of defecation dysfunction, which is of great significance for the formulation of treatment plans and the prediction of therapeutic effects. Declarations Ethics approval and consent to participate This study was conducted with approval from the Ethics Committee of affiliated Hospital of Zunyi Medical University. This study was conducted in accordance with the declaration of Helsinki. Due to the retrospective nature of the study, the requirement of patient consent for inclusion was waived by the Ethics Committee of affiliated Hospital of Zunyi Medical University. Consent for publication Not applicable Funding National Natural Science Foundation of China(82060100) Competing interests The authors declare that they have no competing interests. Availability of data and materials All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author. Acknowledgements We would like to acknowledge the hard and dedicated work of all the staff that implemented the intervention and evaluation components of the study. Authors’ contributions Conception and design of the research: YL, ZJ Acquisition of data: ZD, CT, ZZ, XX Analysis and interpretation of the data: ZD, CT Statistical analysis: ZD, CT, WZ Obtaining financing: YL Writing of the manuscript: CT Critical revision of the manuscript for intellectual content: YL, ZJ References Rigueros Springford L,Connor MJ,Jones K, et al. Prevalence of active long-term problems in patients with anorectal malformations: a systematic review. Dis Colon Rectum, 2016, 59(6): 570–580. DOI: 10. 1097 /DCR. 0000000000000576. Han Y, Xia Z, Guo S, et al. Laparoscopically assisted anorectal pull-through versus posterior sagittal anorectoplasty for high and intermediate anorectal malformations: a systematic review and meta-analysi. PLoS One,2017,12 (1): e0170421. DOI: 10. 1371 /journal. pone. 0170421. Yuan ZW. Recent advances in etiologies of congenital anorectal malformations.Journal of Developmental Medicine,2016,4(1): 8–12. Bai YZ. Preventions and treatments of dysporia for young children after anorectal orthopedic procedure.J Clin Ped Sur,2004,3 (3): 200–201. DOI: 10. 3969 /j.Issn. 1671–6353. 2004. 03. 012. Kyrklund K, Pakarinen MP, Koivusalo A, et al. Long-term bowel functional outcomes in rectourethral fistula treated with PSARP: controlled results after 4–29 years of followup: a single-institution,cross-sectional study. J Pediatr Surg,2014,49(11): 1635–1642.DOI: 10. 1016 /j. jpedsurg. 2014. 04. 017. Fabbro MA, Chiarenza F, D'Agostino S, et al. Anorectal malformations (ARM): quality of life assessed in the functional,urologic and neurologic short and long term follow-up.Pediatr Med Chir,2011, 33(4) : 182–192. Kyrklund K, Pakarinen MP, Rintala RJ. Long-term bowel function,quality of life and sexual function in patients with anorectal malformations treated during the PSARP era Semin Pediatr Surg,2017,26(5): 336–342. DOI: 10.1053 / j. Sempedsurg. 2017. 09. 010. Yuan ZW, Lui VC, Tam PK. Deficient motor innervation to the sphincter mechanism in fetal rats with anorectal malformation: a quantitative study by Fluorogold retrograde tracing.J Paediatr Surg,2003,38 (9): 1383–1388. DOI: 10. 1016 /s0022-3468(03) 00401-9. Jia H, Zhang K, Zhang S, et al. Quantitative analysis of sacral parasympathetic nucleus innervating the rectum in rats with anorectal malformation. J Pediatr Surg. 2007, 42 (9): 1544–1548.DOI: 10.1016 /j.jpedsurg.2007. 04. 034. Yang Z, Geng Y, Yao Z, et al. Spatiotemporal expression of Bcl-2 /Bax and neural cell apoptosis in the developing lumbosacral spinal cord of rat fetuses with anorectal malformations.Neurochem Res,2017,42 (11): 3160–3169.DOI: 10. 1007 /s11064-017-2354-1. Lagares-Tena L, Millán-Paredes L, Lázaro-García L, et al. Sacral neuromodulation in patients with congenital faecal incontinence Special issues and review of the literature.Tech Coloproctol,2018,22 (2): 89–95.DOI: 10. 1007 / s10151-017-1742-5. Santos-Jasso KA, Arredondo-García JL, Maza-Vallejos J, et al. Effectiveness of senna vs polyethylene glycol as laxative therapy in children with constipation related to anorectal malformation. J Pediatr Surg,2017,52 (1): 84–88. DOI: 10. 1016 /j. jpedsurg. 2016. 10. 021. Van Meegdenburg MM, Heineman E, Broens PM. Dyssynergic defecation may aggravate constipation: results of mostly pediatric cases with congenital anorectal malformation. Am J Surg, 2015, 210(2): 357–364. DOI: 10.1016 /j. amjsurg. 2014. 09. 038. Kyrklund K, Pakarinen MP, Koivusalo A, et al. Long-term bowel functional outcomes in rectourethral fistula treated with PSARP: controlled results after 4–29 years of followup: a single-institution,cross-sectional study. J Pediatr Surg, 2014,49 (11): 1635–1642. DOI: 10.1016 /j.jped surg.2014.04.017. Stenström P, Kockum CC, Emblem R, et al. Bowel symptoms in children with anorectal malformation-a follow-up with a gender and age perspective. J Pediatr Surg, 2014, 49 (7): 1122–1130. DOI:10. 1016/j. jpedsurg. 2013.10.022. Huang CF,Lee HC,Yeung CY,et al. Constipation is a major complication after posterior sagittal anorectoplasty for anorectal malformations in childre. Pediatr Neonatol, 2012, 53 (4): 252–256. DOI: 10. 1016 /j. pedneo. 2012. 06. 007. Levitt MA, Kant A, Peña A. The morbidity of constipation in patients with anorectal malformations.J Pediatr Surg,2010,45(6): 1228–1233.DOI: 10. 1016 /j. jpedsurg.2010. 02. 096. Rintala R, Lindahl H, Marttinen E, et al. Constipation is a major functional complication after internal sphicter-saving posterior sagittal anorectoplasty for high and intermediate anorectal malformations. J Pediatr Surg, 1993, 28 (8):1054–1058. DOI: 10. 1016 /0022-3468(93) 90518-p. Mugie SM, Benninga MA, Di Lorenzo C. Epidemiology of constipation in children and adults: a systematic review. Best Pract Res Clin Gastroenterol. Best Pract Res Clin Gastroenterol,2011,25 (1): 3–18. DOI: 10. 1016 /j. bpg. 2010. 12. 010. Boemers TM, Ludwikowski B, Forstner R, Schimke C, Ardelean MA. Dynamic magnetic resonance imaging of the pelvic floor in children and adolescents with vesical and anorectal malformations. J Pediatr Surg. 2006;41(7):1267–1271. DOI: 10. 1016/ j. jpedsurg. 2006. 03. 006 Nam SH, Kim DY, Kim SC. Can we expect a favorable outcome after surgical treatment for an anorectal malformation?. J Pediatr Surg. 2016;51(3):421–424. DOI: 10.1016/j.jpedsurg . 2015. 08. 048 Zheng S, Zhang P, Dong K, et al. Retrospective study of reoperation for congenital anorectal malformation. Chinese Journal of Pediatric Surgery, 2012, 33(4): 296–299 Lombardi L, Bruder E, Caravaggi F, Del Rossi C, Martucciello G. Abnormalities in "low" anorectal malformations (ARMs) and functional results resecting the distal 3 cm. J Pediatr Surg. 2013; 48(6): 1294–1300. DOI: 10. 1016/ j. jpedsurg. 2013. 03. 026 Iwanaka T, Arai M, Kawashima H, et al. Findings of pelvic musculature and efficacy of laparoscopic muscle stimulator in laparoscopy-assisted anorectal pull-through for high imperforate anus. Surgical Endoscopy and Other Interventional Techniques, 2003, 17(2): 278–281. Zhang SW, Bai YZ, Zhang SC, et al. Morphological researches of embryogenesis of striated muscle complex on anorectal malformation in mice.Chinese Journal of Pediatric Surgery, 2008, 29(5): 301–305. DOI: 10.3760/cma . j. issn. 0253–3006. 2008. 05. 013 Zhu JY, Zhan JH, Zhao SL, et al. Distributions of Ganglia and Cajal Cells in Congenital Imperforate Anus. Tianjin Pharmaceutical, 2010, 38(6): 486–488. DOI: 10. 3969/j.i ssn. 0253–9896. 2010. 06. 013. Zhang HL, Zhang SC, Zhang ZB, et al. Study of intestinal interstitial cells of Cajai in later stage embryos of rats with anorectal malformations. Chinese Journal of Pediatric Surgery, 2009, 30(10): 718–721. DOI: 10.3760/cma . j. issn. 0253–3006. 2009. 10. 016 Yuan ZW, Wang WL, Tan GH, et al. Quantitative analysis of motoneurons innervating the muscle levator ani in rats with anorectal malformation. Chinese Medical Journal, 2003, 83(14): 1266–1269. DOI: 10. 3760/ j: issn: 0376–2491. 2003. 14. 016 Zurbuchen U, Groene J, Otto S D, et al. Sacral neuromodulation for fecal incontinence and constipation in adult patients with anorectal malformation-a feasibility study in patients with or without sacral dysgenesis. International Journal of Colorectal Disease, 2014, 29(10): 1297–1302. Yang Z, Geng Y, Yao Z, et al. Spatiotemporal Expression of Bcl-2/Bax and Neural Cell Apoptosis in the Developing Lumbosacral Spinal Cord of Rat Fetuses with Anorectal Malformations. Neurochemical Research, 2017, 42(11): 3160–3169. Wijers C H, Van Rooij I A, Marcelis C L, et al. Genetic and nongenetic etiology of nonsyndromic anorectal malformations: a systematic review. Birth Defects Research Part C Embryo Today Reviews, 2015, 102(4): 382–400. Koga H, Miyano G, Takahashi T, et al. Comparison of anorectal angle and continence after Georgeson and Peña procedures for high/intermediate imperforate anus. J Pediatr Surg. 2010;45(12):2394–2397. DOI: 10. 1016/j. jpedsurg. 2010. 08. 041. Yang ZH, Wang DB, Liu D, et al. Comprehensive assessments of defecation functions in anorectal malformation children with postoperative constipatio. J Clin Ped Sur, 2020, 19(1): 18–25. DOI: 10. 3969 /j. Issn. 1671–6353. 2020. 01. 004. Wong KK, Wu X, Chan IH, Tam PK. Evaluation of defecative function 5 years or longer after laparoscopic-assisted pull-through for imperforate anus. J Pediatr Surg. 2011; 46(12): 2313–2315. DOI: 10. 1016/ j. jpedsurg. 2011. 09. 021. Zhang M, Sun J, Wang Z, et al. Clinical analysis for associated congenital anomalies in congenital complex anorectal malformation. Journal of Third Military Medical University, 2018,40(17):1590–1594. Bai Y. Long-term follow-up and multicenter study of anorectal malformations in children. Chinese Journal of Pediatric Surgery, 2018, 39(12):881–882. Van der Steeg HJ, Schmiedeke E, Bagolan P, et al. European consensus meeting of ARM-Net members concerning diagnosis and early management of newborns with anorectal malformations. Tech Coloproctol. 2015; 19(3): 181–185. DOI: 10. 1007/ s10151-015-1267-8 Chen L, Chen X, Ren H. Research progress on etiology of postoperative defecation dysfunction in children with congenital anorectal malformation. Chinese Journal of Pediatric Surgery,2012,33(07): 541–543. Li L, Li Z, Hou HS, et al. Sensory nerve endings in puborectalis and anal region: normal findings in the newborn and changes in anorectal anomalis. J Pediatr Surg,1990,25 (6): 658–664. DOI: 10. 1016 /0022-3468(90) 90357-f. Tunell WP, Austin JC, Barnes PD, et al. Neuroradiologic evaluation of sacral abnormalities in imperforate anus complex. J Pediatr Surg, 1987, 22 (1): 58–61. DOI: 10. 1016 /s0022-3468(87) 80016-7. Capitanucci ML, Rivosecchi M, Silveri M, et al. Neurovesical dysfunction due to spinal dysraphia in anorectal anomalies. Eur J Pediatr Surg,1996,6 (3): 159–162. DOI: 10. 1055 /s-2008-1066496. Samuk I, Bischoff A, Freud E, et al. Tethered cord in children with anorectal malformations with emphasis on rectobladder neck fistula. Pediatr Surg Int,2019,35(2): 221–226. DOI: 10. 1007 /s00383-018-4399-x. Kyrklund K, Pakarinen MP, Taskinen S, et al. Spinal cord anomalies in patients with anorectal malformations without severe sacral abnormalities or meningomyelocele: outcomes after expectant conservative management. J Neurosurg Spine,2016,25 (6): 782–789.DOI: 10.3171 /2016. 4.SPINE1641. Zhengwei Y, Weilin W, Yuzuo B, et al. Long-term outcomes of individualized biofeedback training based on the underlying dysfunction for patients with imperforate anus.J Pediatr Surg,2005,40(3): 555–561. DOI: 10.1016 /j.jpedsurg.2004.11 034. Sulkowski JP, Nacion KM, Deans KJ, et al. Sacral nerve stimulation: a promising therapy for fecal and urinary incontinence and constipation in children.J Pediatr Surg,2015,50 (10): 1644–1647.DOI: 10.1016 /j.Jpedsurg. 2015. 03. 043. van den Hondel D, Sloots CE, Bolt JM, Wijnen RM, de Blaauw I, IJsselstijn H. Psychosexual Well-Being after Childhood Surgery for Anorectal Malformation or Hirschsprung's Disease. J Sex Med. 2015; 12(7):1616–1625. DOI: 10.1111/jsm.12886 . Minaev SV, Kirgizov IV, Gladkyy A, Shishkin I, Gerasimenko I. Outcome of Laparoscopic Treatment of Anorectal Malformations in Children. World J Surg. 2017;41(2):625–629. DOI: 10. 1007/ s00268-016-3699-3 Das BC, Thapa P, Karki R, et al. Retinoic acid signaling pathways in development and diseases. Bioorg Med Chem. 2014;22(2):673–683. DOI: 10. 1016/ j. bmc.2013. 11. 025 Meier-Ruge WA, Holschneider AM. Histopathologic observations of anorectal abnormalities in anal atresia. Pediatr Surg Int. 2000; 16(1–2): 2–7. DOI: 10. 1007/ s003830050002 Paka C, Kamisan Atan I, Rios R, Dietz HP. Relationship of Anatomy and Function: External Anal Sphincter on Transperineal Ultrasound and Anal Incontinence. Female Pelvic Med Reconstr Surg. 2017; 23(4): 238–243. DOI: 10. 1097/ SPV. 0000000000000350 Qu Y, Liu Y, Mao Y, et al. Expressions of glial cell line -derived neurotrophic factor and its tyrosine kinase receptor RET in the terminal rectum of fetal rats with congenital anorectal malformations at different gestational ages. Chinese Journal of Applied Clinical Pediatrics, 2016, 31(23):1829–1833. Wang W, Jia H, Zhang H, et al. Abnormal innervation patterns in the anorectum of ETU-induced fetal rats with anorectal malformations. Neurosci Lett. 2011; 495(2): 88–92. DOI: 10. 1016/ j. neulet. 2011. 02. 057 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6768880","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":468159294,"identity":"59805d43-f0d1-41d2-8089-cf197854fee6","order_by":0,"name":"Cheng-Yan Tang","email":"","orcid":"","institution":"Affiliated Hospital of Zunyi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Cheng-Yan","middleName":"","lastName":"Tang","suffix":""},{"id":468159295,"identity":"3c08f654-9bd1-45ac-abfb-ee7112365f80","order_by":1,"name":"Ze-Meng Duan","email":"","orcid":"","institution":"Fuyang Women and Children Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ze-Meng","middleName":"","lastName":"Duan","suffix":""},{"id":468159296,"identity":"99210c6b-00f9-4efb-8e75-f96387dd7f2d","order_by":2,"name":"Yuan-Mei Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYPACCR429uYDDA8MSNAiw8dzLIEhgQQtDDZyEj4GDAnEKDW4kfzs0Y0KCx42CZ6PHxIKDiduZ2B++OgGXi1p5sY5Z4B+ke7dLJFgcDhxZwObsXEOXi0JZtK5bUAtMmc3gLVsOADUjl9L+jfp3H9ALRI5j38QqSUHaEsDWAsbcbZInnlTJp1zDKiF55iZRYJBuvGGwwT8wnc8fZt0Tk2dvXx78+MbH/5Yy2443vzwMT4tCgdQ+c0MDMx4lIOAfAMqv46A+lEwCkbBKBiJAABQ2UwO4ZFa8QAAAABJRU5ErkJggg==","orcid":"","institution":"Affiliated Hospital of Zunyi Medical University","correspondingAuthor":true,"prefix":"","firstName":"Yuan-Mei","middleName":"","lastName":"Liu","suffix":""},{"id":468159297,"identity":"4a01a9e8-f34f-40e0-a388-d963b825137e","order_by":3,"name":"Ze-Bing Zheng","email":"","orcid":"","institution":"Affiliated Hospital of Zunyi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ze-Bing","middleName":"","lastName":"Zheng","suffix":""},{"id":468159298,"identity":"00d48831-2ad1-4033-b201-967350c69ba4","order_by":4,"name":"Wan-Kang Zhou","email":"","orcid":"","institution":"Affiliated Hospital of Zunyi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wan-Kang","middleName":"","lastName":"Zhou","suffix":""},{"id":468159299,"identity":"94de4e86-c221-4804-a4c7-7612191d4aa0","order_by":5,"name":"Xing-Rong Xia","email":"","orcid":"","institution":"Affiliated Hospital of Zunyi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xing-Rong","middleName":"","lastName":"Xia","suffix":""},{"id":468159300,"identity":"87e26066-60f0-4c58-8c05-8d4aafa3096f","order_by":6,"name":"Zhu Jin","email":"","orcid":"","institution":"Affiliated Hospital of Zunyi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhu","middleName":"","lastName":"Jin","suffix":""}],"badges":[],"createdAt":"2025-05-28 14:08:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6768880/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6768880/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109422135,"identity":"668b0402-a782-4a35-a15d-b6bc986520be","added_by":"auto","created_at":"2026-05-18 00:39:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":272563,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6768880/v1/04c82675-1c7e-4729-aed6-bd12c27e9e1b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Analysis of influencing factors on postoperative constipation in patients with Congenital Anorectal Malformations","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCongenital Anorectal Malformations(anorectal malformations,ARM) is one of the common digestive tract malformations in children, with a incidence rate of 1/5000 to 1/3500 [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Postoperative defecation dysfunction is a serious complication of ARM, often causing psychological, physiological development, and social activity disorders in children [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The main manifestations of postoperative defecation dysfunction in ARM are fecal incontinence and constipation, and more research has focused on the pathological basis of postoperative fecal incontinence and the improvement of treatment methods [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In recent years, with the continuous improvement of surgical techniques, especially the widespread implementation of posterior sagittal anorectal reconstruction (PSARP) and laparoscopic assisted anorectal reconstruction (LAARP), the incidence of postoperative fecal incontinence has decreased, but the incidence of postoperative constipation has been increasing year by year, ranging from 22.2\u0026ndash;86.7% according to incomplete statistics, and has become the main complication of ARM surgery, Arousing people's attention [\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Severe constipation can cause fecal contamination and pseudofecal incontinence, which can be confused with postoperative anal sphincter dysfunction leading to fecal incontinence. These two types of fecal incontinence have different causes and treatment methods. Studying the causes and pathological changes of postoperative constipation, and treating them according to the causes, is of great significance for improving treatment efficacy and improving the quality of life of patients. This study retrospectively analyzed the postoperative constipation of children with congenital anorectal malformations treated in our hospital, and analyzed multiple factors such as clinical classification, presence of malformations, surgical methods, wound healing, and presence or absence of ganglion cells in the blind end of the rectum. Possible factors affecting postoperative constipation were explored.\u003c/p\u003e"},{"header":"Data and method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Data\u003c/h2\u003e \u003cp\u003e1.1.1 Subjects\u003c/p\u003e \u003cp\u003eA total of 225 infants with congenital ARM who had visited the Pediatric Surgery Department of the Zunyi Medical University between January 2008 and March 2018 were retrospectively analyzed. These included 202 cases who had undergone anoplasty. Among these, 25 cases were lost to follow-up; 177 cases were successfully followed up and were included in the study. The follow up was conducted using questionnaires during outpatient visits or through phone calls. The follow-up evaluation for constipation was completed by the pediatric surgery team of the Affiliated Hospital of Zunyi Medical University.\u003c/p\u003e \u003cp\u003e1.1.2 Inclusion criteria\u003c/p\u003e \u003cp\u003eThe study\u0026rsquo;s inclusion criteria were as follows:\u003c/p\u003e \u003cp\u003e1) Infants with a confirmed diagnosis of anorectal malformation who had undergone surgery and had been followed up successfully.\u003c/p\u003e \u003cp\u003e2) Infants experiencing constipation as per diagnostic criteria for the condition (Diagnostic Criteria for Constipation: Rome IV, 2016 revision) which included the following:\u003c/p\u003e \u003cp\u003eIn the age group of newborn infants and children up to the age of 4 years, the presence of at least two of the following symptoms for one month:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDefecation twice or less every week;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFollowing the acquisition of toilet skills, at least one episode of fecal incontinence per week;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eA history of fecal retention;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eA history of difficult or painful bowel movements;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eA large fecal mass in the rectum;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLarge-diameter stools that could clog the toilet\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSymptoms including irritability, a decreased appetite, or early satiety, which would quickly disappear following defecation of a large volume.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eFor children aged 4 years and older, the presence of at least two or more of the following symptoms for at least two months were considered:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDefecation\u0026thinsp;\u0026le;\u0026thinsp;2 times per week;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAt least one episode of fecal incontinence per week;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eA history of stool-retentive posturing or excessive volitional fecal retention;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eA history of pain or exertion when defecating;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eA large fecal mass in the rectum;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLarge-diameter stool that could clog the toilet and insufficient criteria for the diagnosis of irritable bowel syndrome.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e1.1.3 Exclusion criteria\u003c/p\u003e \u003cp\u003eThe following were considered the exclusion criteria of the study:\u003c/p\u003e \u003cp\u003e1) Patients who did not meet the above-noted diagnostic criteria for constipation;\u003c/p\u003e \u003cp\u003e2) Patients who did not undergo surgical treatment or who were lost to follow up.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e1.2 Study content and method\u003c/h3\u003e\n\u003cp\u003e1.2.1 Study content\u003c/p\u003e \u003cp\u003eThe clinical data of 177 patients were grouped according to the following factors: clinical type (intermediate/high, or low), operation mode (PO, PSARP, or LAARP), the presence of other malformations (yes/no), surgery duration (\u0026lt;\u0026thinsp;90 or \u0026ge;\u0026thinsp;90 min), wound-healing grade (A, B, or C), and the presence of ganglion cells at the blind end of the rectum (yes/no). Univariate analysis was performed using each of these factors for the occurrence of constipation. Multivariate logistic regression analysis was also performed for the factors that showed statistical significance to investigate which of them impacted constipation after surgery.\u003c/p\u003e \u003cp\u003e1.2.2 Criteria for clinical types\u003c/p\u003e \u003cp\u003eThe clinical types of ARMs were classified according to the Wingspread Classification. Anteroposterior and lateral invertograms of the infants were taken between 24ཞ48 hours after birth. The line connecting the superior margin of the pubic symphysis and the sacrococcygeal joint was taken as the pubococcygeal line (PCL). If the gas shadow at the end of the rectum was observed above the PCL, a high ARM was identified; if it was present between the PCL and the ischial line (IL), an intermediate ARM was identified; if it was observed below the IL, a low ARM was identified. The surgical regimens for patients with intermediate and high malformations were similar and, as a result, the data for intermediate and high types were combined for the analysis.\u003c/p\u003e \u003cp\u003e1.2.3 Surgery modes\u003c/p\u003e \u003cp\u003e(1) Perineal operation was indicated for infants with a low ARM.\u003c/p\u003e \u003cp\u003e(2) Posterior sagittal anorectoplasty was indicated for infants with high and intermediate ARMs, with all procedures completed in three stages as follows: first, fistulization of the sigmoid or transverse colon; PSARP 3\u0026ndash;6 months after fistulization; finally, fistula closure.\u003c/p\u003e \u003cp\u003e(3) Laparoscopic-assisted anorectoplasty was indicated for infants with high and intermediate ARMs, with all procedures completed in two or three stages as follows: first, fistulization of the sigmoid or transverse colon; some patients underwent LAARP and fistula closure in stage 2; some patients underwent LAARP in stage 2, and fistula closure in stage 3.\u003c/p\u003e \u003cp\u003e1.2.4 The presence of other malformations\u003c/p\u003e \u003cp\u003e(1) Malformation in the urogenital system, including cryptorchidism, hypospadias, vesicoureteral reflux, and renal dysplasia. Malformations of the reproductive system for female infants included hydrocolpos and gynatresia.\u003c/p\u003e \u003cp\u003e(2) Malformations observed in the cardiovascular system included atrial septal defect, patent foramen ovale, patent ductus arteriosus, tetralogy of Fallot, and ventricular septal defect.\u003c/p\u003e \u003cp\u003e(3) Malformation of the motor system included talipes equinus, lumbar hemivertebrae, and tethered cord.\u003c/p\u003e \u003cp\u003e1.2.5 Anal wound healing\u003c/p\u003e \u003cp\u003ePostoperative wound healing was classified into grades A, B, and C. Grade A reflected excellent healing with no adverse reactions. Grade B indicated poor healing with an inflammatory reaction at the wound site, e.g., erythema, nodule, hematoma, and hydrops, but without festering. Grade C indicated a festering wound.\u003c/p\u003e \u003cp\u003e1.2.6 The development of ganglion cells on the intestinal wall of the blind end of the rectum\u003c/p\u003e \u003cp\u003eTissue samples at the blind end of the rectum were taken for pathological examination from all the infants who underwent surgery to check for the presence of ganglion cells. The patients were divided into two groups, i.e., those with and those without ganglion cells.\u003c/p\u003e \u003cp\u003e1.2.7 Treatment after operation\u003c/p\u003e \u003cp\u003eTo prevent anal stenosis, anal dilatation which was performed twice a day was stared 2 weeks after surgery. The size of anal dilator was usually 9 or 10 and was increased by 1 every 1 to 2 weeks till it was suitable for the patient. Intermittent enema treatment was not performed routinely except for one case of severe postoperative constipation. In all cases, probiotics were used for regulating intestinal flora. No other drugs were used in addition.\u003c/p\u003e \u003cp\u003e1.2.8 Study methods\u003c/p\u003e \u003cp\u003eThe infants were divided into different groups according to the clinical type, surgery mode, the presence of other malformations, operation duration, wound healing grade, and the presence/absence of ganglion cells at the blind end of the rectum. Univariate analysis was performed for the occurrence of constipation, and multivariate logistic analysis was also conducted for factors with statistical significance.\u003c/p\u003e\n\u003ch3\u003e1.3 Statistical method\u003c/h3\u003e\n\u003cp\u003eThe SPSS Statistics (IBM, Windows, v.19.0., Armonk, NY) software program was used to conduct a statistical analysis of the data.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Demographics\u003c/h2\u003e \u003cp\u003e2.1.1 Demographic data statistics\u003c/p\u003e \u003cp\u003eA total of 177 infants with congenital ARMs were successfully followed up within a period of 0.5\u0026ndash;8 years, with a mean of 3.8 years. There were 114 male patients (64.41%), and 63 female patients (35.59%). The age of the patients at the time of surgery ranged from 1 day to 12 months. There were 36 cases with intermediate/high malformations (20.34%) and 141 cases with low malformations (79.66%). The results are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectoperineal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectovestibullar fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectourethral fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectovaginal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithout fistula (pouch colon)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectostenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e2.1.2 Statistical data on postoperative constipation\u003c/p\u003e \u003cp\u003eA total of 132 cases underwent PO (74.58%), 23 cases received PSARP (12.99%), and 22 cases underwent LAARP (12.43%); 91 cases had other malformations (51.41%), and 86 cases had no other malformations (48.59%). For 116 cases, the surgery duration was \u0026lt;\u0026thinsp;90min (65.54%). In 61 cases, the surgery duration was \u0026ge;\u0026thinsp;90 min (34.46%). There were 148 cases of grade A wound healing (83.62%), 21 cases with grade B wound healing (11.86%), and 8 cases with grade C wound healing (4.52%). Ganglion cells at the blind end of the rectum were observed in 110 (62.15%) but not in 64 (37.85%) cases. There were 55 cases with postoperative constipation (31.07%) and 122 without constipation (68.93%). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the statistical results.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate Analysis on Influencing Factors of Constipation after ARM Operation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelated factors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWith constipation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWithout constipation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eConstipation rate (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eClinical type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e21.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.987\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntermediate/high\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eOperation mode\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e9.342\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePSARP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e26.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLAARP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePresence of other malformations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e48.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e4.654\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOperation duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;90min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.321\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.251\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;90min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e32.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWound healing grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e28.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e6.144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e37.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePresence of ganglion cell at blind end of rectum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e37.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e7.562\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e79.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e2.1.3 Statistics regarding the presence of other malformations\u003c/p\u003e \u003cp\u003eThere were 91 (51.41%) cases with other malformations, 47 (51.65%) cases with malformations of the urinary system, 26 (28.57%) cases with cardiovascular malformations, 7 (7.69%) cases with malformations of the motor system, 4 cases (4.39%) with malformations of the nervous system, and 7 (7.69%) cases with other malformations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Univariate analysis results\u003c/h2\u003e \u003cp\u003eThe univariate analysis for clinical types showed that the constipation rate after surgery in patients with intermediate/high type of ARMs was higher than in patients with the low type (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). For the surgery modes, the constipation rate in patients who underwent PO was higher than those who received PSARP and LAARP (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), whereas the constipation rate among those with other malformations was higher than for those without other malformations (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). For anal wound-healing grade, the constipation rate of those with grades B and C was higher than those with grade A (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and a comparison between grades B and C showed no statistical significance (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The constipation rate for those without ganglion cells in the blind end of the rectum was higher than for patients with ganglion cells (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The constipation rate among patients for whom the surgery duration was \u0026gt;\u0026thinsp;90 min and for those where this was \u0026lt;\u0026thinsp;90 min showed no statistical significance (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e2.3 Multivariate unconditional logistic analysis\u003c/h3\u003e\n\u003cp\u003eAs shown in the univariate analysis, the factors that were significantly associated with postoperative constipation included the clinical type, surgery mode, the presence of other malformations, wound-healing grade, and the presence of ganglion cells at the blind end of the rectum. Multivariate logistic regression analysis was performed, and the results showed that the clinical type, surgery mode, the presence of other malformations, wound-healing grade, and the presence of ganglion cells at the blind end of the rectum were influencing factors for constipation after surgery. These details are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate Unconditional Logistic Regression Analysis of Constipation after ARM Operation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eInfluencing factor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRegression coefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSD of regression coefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWald value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOdds ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eOdds ratio, 95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLower limit\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUpper limit\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.756\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.463\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.512\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3.551\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation mode\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.578\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.586\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3.586\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresence of other malformations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.862\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.543\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.896\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6.835\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealing grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.764\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.564\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.234\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e5.961\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGanglion cell at blind end of rectum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.756\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.542\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.491\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e9.156\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePostoperative bowel dysfunction in ARM surgery mainly includes fecal incontinence and constipation. With the continuous improvement of surgical techniques, the occurrence of postoperative fecal incontinence. The rate has decreased, and people are gradually shifting their focus to postoperative constipation. The incidence of constipation in normal children is 0.7\u0026ndash;29.6% [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], but the incidence of postoperative constipation in ARM patients is as high as 22.2\u0026ndash;86.7%, which is significantly higher than the incidence in the normal population, indicating that the occurrence of postoperative constipation is related to the complex pathological changes of ARM itself. However, there are few literature reports on the factors affecting the defecation function of such children. Defecation control is a complex physiological reflex and regulatory process, which is the result of the interaction of many factors such as the strength and reflex mechanism of the internal and external sphincters, rectal sensation and compliance regulation, and coordinated pelvic floor muscle movement. Any abnormality in any of these links can lead to the occurrence of constipation. To explore the influencing factors of postoperative constipation in ARM patients, this study retrospectively analyzed the clinical classification, presence or absence of malformations, surgical methods, wound healing, and presence or absence of ganglion cells in the blind end of the rectum of children with congenital anorectal malformations who developed constipation after surgery treated in our hospital. Multiple factors were analyzed to explore potential factors that may affect postoperative constipation.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.1 The relationship between clinical type and postoperative constipation\u003c/h2\u003e \u003cp\u003eA higher ARM position had a higher rate of constipation. Developmental defects of the anorectum are also associated with pathological changes in the pelvic floor muscles, the sacral nerves, and the perianal skin,[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] which can seriously affect the postoperative quality of life in infants. According to some studies[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], the incidence of constipation after surgery for an ARM is 30.7%. A Chinese study reported an incidence of constipation in follow-up visits of 21.87% among infants who underwent surgery for a low ARM[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] .Laura et al.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] reported a postoperative constipation rate of 42\u0026ndash;70% for low malformations. Huang[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] reported constipation as the most common complication among 188 infants who had been followed up, with an incidence of 64.5% in the low ARM group and a higher incidence of constipation in the longer follow up. Huang posited that constipation in infants with a low ARM was chiefly caused by abnormal development of the rectal peripheral nerves.\u003c/p\u003e \u003cp\u003eIn the present study, there were 55 cases of postoperative constipation with a constipation rate of 31.07%. Constipation occurred in 30 of 141 cases (21.28%) in the low ARM group. Among them, 29 children were able to defecate normally after regular anal dilation and the use of laxatives. Only 1 child developed severe constipation and needed to use glycerin to defecate. At the same time, the postoperative pathological results of the rectal end in this patient showed no ganglion cells.\u003c/p\u003e \u003cp\u003eThe normal defecation process relies on the cooperation of pelvic floor muscle groups and nerve fibers. Foreign scholars have reported [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] that children with high-level deformities have poor pelvic floor muscle development. Zhang et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] found significant developmental abnormalities in the pelvic floor muscle group of the ARM group by observing the development of rectal smooth muscle. Domestic and foreign scholars [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] found through animal experiments that there are varying degrees of abnormalities in the extraintestinal and intraintestinal nervous systems of the blind end of the ARM rectum, including abnormalities in the size and density of nerve fibers, as well as abnormalities in related neurotransmitters and transmission mechanisms [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], which are related to postoperative constipation. There are reports [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] that the more severe the pelvic floor muscle and nerve fiber lesions are in children with high classification, the higher the incidence of postoperative constipation.\u003c/p\u003e \u003cp\u003eScholars have reported [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] that according to the Krinkenbeck classification, the constipation rate of rectoperineal fistula is the lowest, at 14.5%, while the postoperative constipation rate of rectobladder fistula and rectovaginal fistula is the highest, at 100%. This is also in line with the data presented in this article, where rectoperineal fistula is classified as a low level anomaly, while rectobladder fistula and vaginal fistula are high level anomalies; For postoperative constipation, especially for families of patients with mid to high levels, it is necessary to instruct them to strictly and regularly dilate the anus, promote the development of nerves around the anus and pelvic floor, and form a normal defecation reflex arc. For stubborn constipation, it is necessary to regularly go to the hospital for biofeedback and other treatments. It is also important to pay attention to whether congenital megacolon is present and promptly detect and treat it.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.2 The relationship between surgery mode and postoperative constipation\u003c/h2\u003e \u003cp\u003eAs indicated in this study, the constipation rate after PO was 35.60%, after PSARP this was 26.08%, and the rate after LAARP was 9.09%. In this study, the constipation rate post-LAARP was consistent with the results in other studies,[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] likely due to the application of a laparoscopic technique, which significantly reduced surgical wounds. Abnormal nerve function that innervates the anal, rectal, and pelvic floor muscles can lead to an increase in rectal sensory threshold, prolonged sensory contraction time, and abnormal bowel motility, resulting in the occurrence of constipation. In order to investigate whether there are neurological abnormalities in children with postoperative constipation after ARM surgery, studies have conducted neurophysiological tests[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The results showed that the perineal anal reflex latency, spinal cord anal reflex latency, and reflex arc central conduction time, which reflect the nerve conduction function of the external anal sphincter, were significantly prolonged in the ARM constipation positive group, indicating more significant neurological damage in the children. For children with mid to high level anorectal malformations combined with fistulas, laparoscopy can clearly observe the location of the fistula and accurately separate and ligate the fistula, thereby reducing surgical trauma. At the same time, avoid extensive dissociation to reduce damage to surrounding blood vessels and nerves. Few studies involving long-term follow-ups on LAARPs have been reported, but the procedure is currently highly valued by pediatric surgeons for its significant advantages, i.e., a small wound, quick recovery, aesthetics, and a good effect on short-term follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.3 The relationship between the presence of other malformations and postoperative constipation\u003c/h2\u003e \u003cp\u003eAnorectal malformations are often associated with other deformities, with an occurrence rate of approximately 40\u0026ndash;70%[\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] .The most common concomitant malformations are those that occur in the urogenital system, followed by spinal (mainly sacral) malformations, as well as digestive tract, cardiac, and other malformations. The lumbosacral vertebrae and sacral nerves participate in the control of the defecation process; therefore, the presence of malformations to the lumbosacral vertebrae and sacral nerves may to some degree be associated with postoperative constipation. In this study, 5 of 7 cases with malformations to the nervous system experienced a significantly higher constipation rate after surgery. Sensory neurons innervating the levator ani muscle are mainly distributed in the dorsal root ganglion of the spinal cord at the L5-S1 segment. Therefore, lumbosacral vertebrae and sacral nerve malformations may lead to abnormal conduction of sensory impulses of the levator ani muscle, which may affect the brain's control of spinal cord defecation reflex and lead to postoperative constipation[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. For many years, the abnormality of the lumbosacral nerve in children with ARM has attracted people's attention. Li et al. [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] found significant abnormalities in the sensory and motor nerve endings of the children during the histological examination of the pelvic floor muscles in ARM. Scholars have used an ARM rat model induced by ethylene thiourea for embryonic neural tracing research, and found significant developmental abnormalities in the spinal motor and sensory neurons that innervate the pelvic floor muscles, as well as the spinal parasympathetic neurons that innervate the rectum [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Tunell [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] found through X-ray examination that 35% of anorectal infants were accompanied by bone abnormalities in the lumbosacral vertebrae, and 53% had spinal cord or spinal canal abnormalities, which gradually worsened with age. Capitanucci [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] found that individuals with spinal cord abnormalities rarely experience symptoms at a young age, while older children experience a significant increase. The researcher believes that early diagnosis and treatment of spinal cord lesions are crucial before symptoms appear. Samuk [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] conducted MRI examinations on 790 children with ARM and found that 36% of the patients could be diagnosed with tethered cord syndrome. Kyrklund K [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] conducted MRI examinations on 89 children with normal spinal appearance in ARM, and found that 34% of the children had spinal cord abnormalities. These research results all suggest serious neurological dysfunction in children with ARM. In order to improve postoperative treatment effectiveness, it should be considered to perform nerve function repair and reconstruction treatment simultaneously with anal reconstruction surgery [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.4 The relationship between anal healing grade and postoperative constipation\u003c/h2\u003e \u003cp\u003eAnoplasty requires a category II incision, which can easily be contaminated by feces after the procedure. Due to the young age of the patients in the present study, they were more prone to wound infection. Regardless of the surgery mode, healing of the incision is an important factor in the success of the operation. In this study, the postoperative constipation rate was 28.38% for grade A, 47.62% for grade B, and 37.5% for grade C healing (no grade B or grade C healing was observed after PSARP and LAARP surgeries). Three cases of grade C healing occurred after PO; Two patients were cured by perineal caring, which included cleaning of incision secretion and local application of silver ion dressing. One case required surgery for postoperative cicatricial stricture, suggesting that the operation mode also affected the grade of postoperative anal healing. Univariate and multivariate regression analyses indicated a close association between incision healing grade and constipation. In this study, patients with intermediate/high ARMs underwent colostomy surgery in the neonatal period, and thereafter PSARP or LAARP in stage 2; accordingly, feces did not contaminate the incision, thus decreasing the risk of infection and ensuring quick healing of the incision (this was also the reason why there was no grade B or C healing after these surgeries, and the constipation rate was the lowest among these patients). Therefore, for patients with intermediate/high ARMs, it is still recommended that colostomy surgery be performed first so that feces will not be discharged from the newly constructed anus during the stage 2 operation. For infants undergoing PO, post-operative wound nursing must be enhanced to avoid wound infection and an impact on bowel functions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.5 The relationship between ganglion cells at the rectum end and postoperative constipation\u003c/h2\u003e \u003cp\u003eDefecation is controlled by the autonomic nervous system (ANS), the somatic nervous system (SNS), and the enteric nervous system (ENS). The ENS is independent of the brain and comprises ganglion cells and nervous processes that commonly exist in the form of a special nerve plexus in the gastrointestinal wall. Ganglion cells are distributed in the submucosal and myenteric nerve plexus on the intestinal wall, where they serve to promote intestinal tract development and maintain intestinal function[\u003cspan additionalcitationids=\"CR47 CR48\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. They are controlled by the ANS and the SNS. Hence, the development of ganglion cells is directly associated with defecation function[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. The ENS provides the necessary trophic factors for the development of ganglion cells, i.e., glial cell-derived neurotrophic factor, which promotes ENS development[\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. It is chiefly expressed in the submucosal and myenteric nerve plexus on the intestinal wall, and animal tests have shown that their expression in fetal rats with ARMs is lower compared with a normal test group. Hypoplasia of the ENS may cause a lack of development of intestinal ganglion cells and may also be associated with postoperative constipation[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. According to the results of this study, the postoperative constipation rate of patients with ganglion cells was 37.27%, significantly lower than those without ganglion cells (79.10%). The presence of ganglion cells is thus an influencing factor for postoperative constipation. Congenital anorectal malformation combined with hirschsprung disease is rare in clinical practice and often misdiagnosed. For patients with congenital anorectal malformations, if constipation persists and worsens after surgery and conservative treatment is ineffective, they should be vigilant about the possibility of coexisting with congenital megacolon; The pathological diagnosis based on rectal mucosal biopsy remains the gold standard for diagnosis. If diagnosed with hirschsprung disease, surgery is required to remove the affected intestinal tract.\u003c/p\u003e \u003c/div\u003e "},{"header":"Conclusion","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003cp\u003eIn summary,the clinical classification, surgical method, comorbidities, wound healing grade, and the presence or absence of ganglion cells in the blind end of the rectum are the influencing factors for postoperative constipation in congenital anorectal malformations. The limitation of this study is that it did not conduct tests such as rectal and anal pressure measurement, anal sphincter nerve electrophysiology, and electromyography. In the future, we will conduct a comprehensive, systematic, and dynamic evaluation of the anorectal and nerve function in children with postoperative constipation after ARM surgery, clarify the specific causes and pathological changes of defecation dysfunction, which is of great significance for the formulation of treatment plans and the prediction of therapeutic effects.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted with approval from the Ethics Committee of affiliated Hospital of Zunyi Medical University. This study was conducted in accordance with the declaration of Helsinki. Due to the retrospective nature of the study, the requirement of patient consent for inclusion was waived by the Ethics Committee of affiliated Hospital of Zunyi Medical University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNational Natural Science Foundation of China(82060100)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the hard and dedicated work of all the staff that implemented the intervention and evaluation components of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and design of the research: YL, ZJ\u003c/p\u003e\n\u003cp\u003eAcquisition of data: ZD, CT, ZZ, XX\u003c/p\u003e\n\u003cp\u003eAnalysis and interpretation of the data: ZD, CT\u003c/p\u003e\n\u003cp\u003eStatistical analysis: ZD, CT, WZ\u003c/p\u003e\n\u003cp\u003eObtaining financing: YL\u003c/p\u003e\n\u003cp\u003eWriting of the manuscript: CT\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCritical revision of the manuscript for intellectual content: YL, ZJ\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRigueros Springford L,Connor MJ,Jones K, et al. Prevalence of active long-term problems in patients with anorectal malformations: a systematic review. Dis Colon Rectum, 2016, 59(6): 570\u0026ndash;580. DOI: 10. 1097 /DCR. 0000000000000576.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan Y, Xia Z, Guo S, et al. Laparoscopically assisted anorectal pull-through versus posterior sagittal anorectoplasty for high and intermediate anorectal malformations: a systematic review and meta-analysi. PLoS One,2017,12 (1): e0170421. DOI: 10. 1371 /journal. pone. 0170421.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuan ZW. Recent advances in etiologies of congenital anorectal malformations.Journal of Developmental Medicine,2016,4(1): 8\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBai YZ. Preventions and treatments of dysporia for young children after anorectal orthopedic procedure.J Clin Ped Sur,2004,3 (3): 200\u0026ndash;201. DOI: 10. 3969 /j.Issn. 1671\u0026ndash;6353. 2004. 03. 012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKyrklund K, Pakarinen MP, Koivusalo A, et al. Long-term bowel functional outcomes in rectourethral fistula treated with PSARP: controlled results after 4\u0026ndash;29 years of followup: a single-institution,cross-sectional study. J Pediatr Surg,2014,49(11): 1635\u0026ndash;1642.DOI: 10. 1016 /j. jpedsurg. 2014. 04. 017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFabbro MA, Chiarenza F, D'Agostino S, et al. Anorectal malformations (ARM): quality of life assessed in the functional,urologic and neurologic short and long term follow-up.Pediatr Med Chir,2011, 33(4) : 182\u0026ndash;192.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKyrklund K, Pakarinen MP, Rintala RJ. Long-term bowel function,quality of life and sexual function in patients with anorectal malformations treated during the PSARP era Semin Pediatr Surg,2017,26(5): 336\u0026ndash;342. DOI: 10.1053 / j. Sempedsurg. 2017. 09. 010.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuan ZW, Lui VC, Tam PK. Deficient motor innervation to the sphincter mechanism in fetal rats with anorectal malformation: a quantitative study by Fluorogold retrograde tracing.J Paediatr Surg,2003,38 (9): 1383\u0026ndash;1388. DOI: 10. 1016 /s0022-3468(03) 00401-9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJia H, Zhang K, Zhang S, et al. Quantitative analysis of sacral parasympathetic nucleus innervating the rectum in rats with anorectal malformation. J Pediatr Surg. 2007, 42 (9): 1544\u0026ndash;1548.DOI: 10.1016 /j.jpedsurg.2007. 04. 034.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang Z, Geng Y, Yao Z, et al. Spatiotemporal expression of Bcl-2 /Bax and neural cell apoptosis in the developing lumbosacral spinal cord of rat fetuses with anorectal malformations.Neurochem Res,2017,42 (11): 3160\u0026ndash;3169.DOI: 10. 1007 /s11064-017-2354-1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLagares-Tena L, Mill\u0026aacute;n-Paredes L, L\u0026aacute;zaro-Garc\u0026iacute;a L, et al. Sacral neuromodulation in patients with congenital faecal incontinence Special issues and review of the literature.Tech Coloproctol,2018,22 (2): 89\u0026ndash;95.DOI: 10. 1007 / s10151-017-1742-5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSantos-Jasso KA, Arredondo-Garc\u0026iacute;a JL, Maza-Vallejos J, et al. Effectiveness of senna vs polyethylene glycol as laxative therapy in children with constipation related to anorectal malformation. J Pediatr Surg,2017,52 (1): 84\u0026ndash;88. DOI: 10. 1016 /j. jpedsurg. 2016. 10. 021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Meegdenburg MM, Heineman E, Broens PM. Dyssynergic defecation may aggravate constipation: results of mostly pediatric cases with congenital anorectal malformation. Am J Surg, 2015, 210(2): 357\u0026ndash;364. DOI: 10.1016 /j. amjsurg. 2014. 09. 038.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKyrklund K, Pakarinen MP, Koivusalo A, et al. Long-term bowel functional outcomes in rectourethral fistula treated with PSARP: controlled results after 4\u0026ndash;29 years of followup: a single-institution,cross-sectional study. J Pediatr Surg, 2014,49 (11): 1635\u0026ndash;1642. DOI: 10.1016 /j.jped surg.2014.04.017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStenstr\u0026ouml;m P, Kockum CC, Emblem R, et al. Bowel symptoms in children with anorectal malformation-a follow-up with a gender and age perspective. J Pediatr Surg, 2014, 49 (7): 1122\u0026ndash;1130. DOI:10. 1016/j. jpedsurg. 2013.10.022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang CF,Lee HC,Yeung CY,et al. Constipation is a major complication after posterior sagittal anorectoplasty for anorectal malformations in childre. Pediatr Neonatol, 2012, 53 (4): 252\u0026ndash;256. DOI: 10. 1016 /j. pedneo. 2012. 06. 007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevitt MA, Kant A, Pe\u0026ntilde;a A. The morbidity of constipation in patients with anorectal malformations.J Pediatr Surg,2010,45(6): 1228\u0026ndash;1233.DOI: 10. 1016 /j. jpedsurg.2010. 02. 096.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRintala R, Lindahl H, Marttinen E, et al. Constipation is a major functional complication after internal sphicter-saving posterior sagittal anorectoplasty for high and intermediate anorectal malformations. J Pediatr Surg, 1993, 28 (8):1054\u0026ndash;1058. DOI: 10. 1016 /0022-3468(93) 90518-p.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMugie SM, Benninga MA, Di Lorenzo C. Epidemiology of constipation in children and adults: a systematic review. Best Pract Res Clin Gastroenterol. Best Pract Res Clin Gastroenterol,2011,25 (1): 3\u0026ndash;18. DOI: 10. 1016 /j. bpg. 2010. 12. 010.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoemers TM, Ludwikowski B, Forstner R, Schimke C, Ardelean MA. Dynamic magnetic resonance imaging of the pelvic floor in children and adolescents with vesical and anorectal malformations. J Pediatr Surg. 2006;41(7):1267\u0026ndash;1271. DOI: 10. 1016/ j. jpedsurg. 2006. 03. 006\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNam SH, Kim DY, Kim SC. Can we expect a favorable outcome after surgical treatment for an anorectal malformation?. J Pediatr Surg. 2016;51(3):421\u0026ndash;424. DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jpedsurg\u003c/span\u003e\u003cspan address=\"10.1016/j.jpedsurg\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 2015. 08. 048\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZheng S, Zhang P, Dong K, et al. Retrospective study of reoperation for congenital anorectal malformation. Chinese Journal of Pediatric Surgery, 2012, 33(4): 296\u0026ndash;299\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLombardi L, Bruder E, Caravaggi F, Del Rossi C, Martucciello G. Abnormalities in \"low\" anorectal malformations (ARMs) and functional results resecting the distal 3 cm. J Pediatr Surg. 2013; 48(6): 1294\u0026ndash;1300. DOI: 10. 1016/ j. jpedsurg. 2013. 03. 026\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIwanaka T, Arai M, Kawashima H, et al. Findings of pelvic musculature and efficacy of laparoscopic muscle stimulator in laparoscopy-assisted anorectal pull-through for high imperforate anus. Surgical Endoscopy and Other Interventional Techniques, 2003, 17(2): 278\u0026ndash;281.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang SW, Bai YZ, Zhang SC, et al. Morphological researches of embryogenesis of striated muscle complex on anorectal malformation in mice.Chinese Journal of Pediatric Surgery, 2008, 29(5): 301\u0026ndash;305. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3760/cma\u003c/span\u003e\u003cspan address=\"10.3760/cma\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. j. issn. 0253\u0026ndash;3006. 2008. 05. 013\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu JY, Zhan JH, Zhao SL, et al. Distributions of Ganglia and Cajal Cells in Congenital Imperforate Anus. Tianjin Pharmaceutical, 2010, 38(6): 486\u0026ndash;488. DOI: 10. 3969/j.i ssn. 0253\u0026ndash;9896. 2010. 06. 013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang HL, Zhang SC, Zhang ZB, et al. Study of intestinal interstitial cells of Cajai in later stage embryos of rats with anorectal malformations. Chinese Journal of Pediatric Surgery, 2009, 30(10): 718\u0026ndash;721. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3760/cma\u003c/span\u003e\u003cspan address=\"10.3760/cma\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. j. issn. 0253\u0026ndash;3006. 2009. 10. 016\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuan ZW, Wang WL, Tan GH, et al. Quantitative analysis of motoneurons innervating the muscle levator ani in rats with anorectal malformation. Chinese Medical Journal, 2003, 83(14): 1266\u0026ndash;1269. DOI: 10. 3760/ j: issn: 0376\u0026ndash;2491. 2003. 14. 016\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZurbuchen U, Groene J, Otto S D, et al. Sacral neuromodulation for fecal incontinence and constipation in adult patients with anorectal malformation-a feasibility study in patients with or without sacral dysgenesis. International Journal of Colorectal Disease, 2014, 29(10): 1297\u0026ndash;1302.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang Z, Geng Y, Yao Z, et al. Spatiotemporal Expression of Bcl-2/Bax and Neural Cell Apoptosis in the Developing Lumbosacral Spinal Cord of Rat Fetuses with Anorectal Malformations. Neurochemical Research, 2017, 42(11): 3160\u0026ndash;3169.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWijers C H, Van Rooij I A, Marcelis C L, et al. Genetic and nongenetic etiology of nonsyndromic anorectal malformations: a systematic review. Birth Defects Research Part C Embryo Today Reviews, 2015, 102(4): 382\u0026ndash;400.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoga H, Miyano G, Takahashi T, et al. Comparison of anorectal angle and continence after Georgeson and Pe\u0026ntilde;a procedures for high/intermediate imperforate anus. J Pediatr Surg. 2010;45(12):2394\u0026ndash;2397. DOI: 10. 1016/j. jpedsurg. 2010. 08. 041.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang ZH, Wang DB, Liu D, et al. Comprehensive assessments of defecation functions in anorectal malformation children with postoperative constipatio. J Clin Ped Sur, 2020, 19(1): 18\u0026ndash;25. DOI: 10. 3969 /j. Issn. 1671\u0026ndash;6353. 2020. 01. 004.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong KK, Wu X, Chan IH, Tam PK. Evaluation of defecative function 5 years or longer after laparoscopic-assisted pull-through for imperforate anus. J Pediatr Surg. 2011; 46(12): 2313\u0026ndash;2315. DOI: 10. 1016/ j. jpedsurg. 2011. 09. 021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang M, Sun J, Wang Z, et al. Clinical analysis for associated congenital anomalies in congenital complex anorectal malformation. Journal of Third Military Medical University, 2018,40(17):1590\u0026ndash;1594.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBai Y. Long-term follow-up and multicenter study of anorectal malformations in children. Chinese Journal of Pediatric Surgery, 2018, 39(12):881\u0026ndash;882.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan der Steeg HJ, Schmiedeke E, Bagolan P, et al. European consensus meeting of ARM-Net members concerning diagnosis and early management of newborns with anorectal malformations. Tech Coloproctol. 2015; 19(3): 181\u0026ndash;185. DOI: 10. 1007/ s10151-015-1267-8\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen L, Chen X, Ren H. Research progress on etiology of postoperative defecation dysfunction in children with congenital anorectal malformation. Chinese Journal of Pediatric Surgery,2012,33(07): 541\u0026ndash;543.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi L, Li Z, Hou HS, et al. Sensory nerve endings in puborectalis and anal region: normal findings in the newborn and changes in anorectal anomalis. J Pediatr Surg,1990,25 (6): 658\u0026ndash;664. DOI: 10. 1016 /0022-3468(90) 90357-f.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTunell WP, Austin JC, Barnes PD, et al. Neuroradiologic evaluation of sacral abnormalities in imperforate anus complex. J Pediatr Surg, 1987, 22 (1): 58\u0026ndash;61. DOI: 10. 1016 /s0022-3468(87) 80016-7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCapitanucci ML, Rivosecchi M, Silveri M, et al. Neurovesical dysfunction due to spinal dysraphia in anorectal anomalies. Eur J Pediatr Surg,1996,6 (3): 159\u0026ndash;162. DOI: 10. 1055 /s-2008-1066496.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSamuk I, Bischoff A, Freud E, et al. Tethered cord in children with anorectal malformations with emphasis on rectobladder neck fistula. Pediatr Surg Int,2019,35(2): 221\u0026ndash;226. DOI: 10. 1007 /s00383-018-4399-x.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKyrklund K, Pakarinen MP, Taskinen S, et al. Spinal cord anomalies in patients with anorectal malformations without severe sacral abnormalities or meningomyelocele: outcomes after expectant conservative management. J Neurosurg Spine,2016,25 (6): 782\u0026ndash;789.DOI: 10.3171 /2016. 4.SPINE1641.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhengwei Y, Weilin W, Yuzuo B, et al. Long-term outcomes of individualized biofeedback training based on the underlying dysfunction for patients with imperforate anus.J Pediatr Surg,2005,40(3): 555\u0026ndash;561. DOI: 10.1016 /j.jpedsurg.2004.11 034.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSulkowski JP, Nacion KM, Deans KJ, et al. Sacral nerve stimulation: a promising therapy for fecal and urinary incontinence and constipation in children.J Pediatr Surg,2015,50 (10): 1644\u0026ndash;1647.DOI: 10.1016 /j.Jpedsurg. 2015. 03. 043.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan den Hondel D, Sloots CE, Bolt JM, Wijnen RM, de Blaauw I, IJsselstijn H. Psychosexual Well-Being after Childhood Surgery for Anorectal Malformation or Hirschsprung's Disease. J Sex Med. 2015; 12(7):1616\u0026ndash;1625. DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jsm.12886\u003c/span\u003e\u003cspan address=\"10.1111/jsm.12886\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinaev SV, Kirgizov IV, Gladkyy A, Shishkin I, Gerasimenko I. Outcome of Laparoscopic Treatment of Anorectal Malformations in Children. World J Surg. 2017;41(2):625\u0026ndash;629. DOI: 10. 1007/ s00268-016-3699-3\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDas BC, Thapa P, Karki R, et al. Retinoic acid signaling pathways in development and diseases. Bioorg Med Chem. 2014;22(2):673\u0026ndash;683. DOI: 10. 1016/ j. bmc.2013. 11. 025\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeier-Ruge WA, Holschneider AM. Histopathologic observations of anorectal abnormalities in anal atresia. Pediatr Surg Int. 2000; 16(1\u0026ndash;2): 2\u0026ndash;7. DOI: 10. 1007/ s003830050002\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaka C, Kamisan Atan I, Rios R, Dietz HP. Relationship of Anatomy and Function: External Anal Sphincter on Transperineal Ultrasound and Anal Incontinence. Female Pelvic Med Reconstr Surg. 2017; 23(4): 238\u0026ndash;243. DOI: 10. 1097/ SPV. 0000000000000350\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQu Y, Liu Y, Mao Y, et al. Expressions of glial cell line -derived neurotrophic factor and its tyrosine kinase receptor RET in the terminal rectum of fetal rats with congenital anorectal malformations at different gestational ages. Chinese Journal of Applied Clinical Pediatrics, 2016, 31(23):1829\u0026ndash;1833.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang W, Jia H, Zhang H, et al. Abnormal innervation patterns in the anorectum of ETU-induced fetal rats with anorectal malformations. Neurosci Lett. 2011; 495(2): 88\u0026ndash;92. DOI: 10. 1016/ j. neulet. 2011. 02. 057\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"congenital anorectal malformation, constipation, logistic regression analysis, influencing factors","lastPublishedDoi":"10.21203/rs.3.rs-6768880/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6768880/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study analyzed the clinical data of infants who underwent surgery for congenital anorectal malformations (ARM) and the factors influencing the occurrence of postoperative constipation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective analysis was conducted using the clinical data of 177 infants with congenital ARM who had been diagnosed and operated on at the authors\u0026rsquo; hospital from January 2008 to March 2018. This included 132 cases who underwent a perineal operation (PO), 23 cases of posterior sagittal anorectoplasty (PSARP), and 22 cases of laparoscopic-assisted anorectoplasty (LAARP). The patients were grouped according to clinical type, surgery mode, the presence of other malformations, the duration of surgery, the grade of wound healing, and the presence of ganglion cells at the blind end of the rectum.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe constipation rate after surgery in patients of the intermediate/high type of ARM was higher than in low-type patients (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). For surgery modes, the constipation rate in patients who underwent PO was higher than for those who received PSARP and LAARP (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The constipation rate of those with other malformations was higher than those without (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The constipation rate of those with Grade B and C wound healing was higher than in those with Grade A (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The constipation rate of those without ganglion cells at the blind end of the rectum was higher than in those with ganglion cells (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The clinical type (odds ratio [OR] 1.512, 95% confidence interval [CI], 1.301 and 3.551), operation mode (OR 1.586, 95% CI, 1.189 and 3.586), the presence of other malformations (OR 1.187, 95% CI 1.131 and 6.835), grade of wound healing (OR 1.234, 95% CI, 1.159 and 5.961), and the presence of ganglion cells at the blind end of the rectum (OR 1.215, 95% CI, 1.114 and 9.156) were found to be postoperative constipation influencing factors.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn infants who underwent surgery for congenital ARM, the clinical type, operation mode, the presence of other malformations, operation duration, wound healing grade, and the presence of ganglion cells at the blind end of the rectum were factors influencing postoperative constipation.\u003c/p\u003e","manuscriptTitle":"Analysis of influencing factors on postoperative constipation in patients with Congenital Anorectal Malformations","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-09 10:21:37","doi":"10.21203/rs.3.rs-6768880/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c0a460bb-7f78-4464-be27-fdbc22727ab2","owner":[],"postedDate":"June 9th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Withdrawn","date":"2026-05-18T00:34:52+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T00:38:53+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-09 10:21:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6768880","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6768880","identity":"rs-6768880","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}