The Positive Impact of a High-Fibre Diet and Adequate Fluid Intake on Surgical Outcomes After Posterior Sagittal Anorectoplasty

The Positive Impact of a High-Fibre Diet and Adequate Fluid Intake on Surgical Outcomes After Posterior Sagittal Anorectoplasty | 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 The Positive Impact of a High-Fibre Diet and Adequate Fluid Intake on Surgical Outcomes After Posterior Sagittal Anorectoplasty Hery Poerwosusanta, Mohammad Bakhriansyah, Agung Ary Wibowo, Juhairina Juhairina, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7836026/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 Purpose Posterior Sagittal Anorectoplasty (PSARP) is recognised as the primary surgical intervention for Anorectal Malformations (ARM). However, challenges persist in addressing post-operative incontinence and constipation. Sufficient fibre and fluid intake can mitigate surgical complications, which need to optimise the roles of these factors. This study aims to ascertain the influence of a high-fibre diet and adequate fluid intake on surgical outcomes after PSARP, focusing on voluntary bowel movement, incontinence, and constipation levels. Methods This retrospective observational analytical study encompassed 118 patients who underwent surgery at Ulin or Siaga Banjarmasin Hospital from 2018 to 2023. Data was collected using the Krickenbeck questionnaire to determine the surgical outcome, while the Semi-Quantitative-Food Frequency Questionnaire (SQ-FFQ) guided interviews were used to determine fibre and fluid intake. A logistic regression test determined odds Ratios (ORs) and 95% Confidence Intervals (95% CI). Results Most patients had satisfactory surgical outcomes, with 65 patients (55.08%) achieving this, followed by 41 patients (34.75%) with the best outcomes, and 12 patients (10.17%) with the poorest outcomes. Patients with deficit-fibre intake were 95.4% (Adj. OR = 0.046, 95%CI: 0.005–0.447, p = 0.008) significantly less likely to have an adequate surgical outcome compared to moderate-fibre intake, and the low-fibre intake group was 98.7% (Adj. OR = 0.013, 95%CI: 0.001–0.214, p = 0.002) less likely to have a satisfactory surgical outcome compared to those with moderate-fiber intake. The best surgical outcome occurred in 34.7% of the group with good fluid intake. Conclusion A high-fibre diet and adequate fluid intake positively affect surgical outcomes after Posterior Sagittal Anorectoplasty. Anorectal Malformations Krickenbeck SO-FFQ morbidity surgical outcome Introduction Anorectal malformations (ARMs) are complex congenital anomalies affecting the distal rectum and anus, often accompanied by urogenital or other systemic abnormalities. Posterior Sagittal Anorectoplasty (PSARP) has become the standard surgical technique for anatomical reconstruction in children with ARMs, allowing direct visualization and precise repair of the malformation. Despite enhancements in surgical techniques, functional complications such as constipation, fecal incontinence, and poor voluntary bowel control remain major challenges in post-operative management and long-term quality of life (Rotaru et al., 2025 ). The pathophysiology of these complications is multifactorial, involving neural innervation defects, abnormal rectal positioning, and impaired pelvic floor coordination. However, emerging evidence suggests that nutritional factors particularly dietary fibre and fluid intake may play an essential role in maintaining intestinal motility and supporting anorectal function after surgery (Canzan et al., 2024 ). Fibre contributes to stool formation, microbial balance, and intestinal transit, while adequate hydration ensures optimal stool consistency and prevents constipation. Together, these components may enhance bowel regularity and functional recovery following PSARP (Meldrum & Yakubov, 2025 ; Procházková et al., 2023 ). Previous studies have mainly focused on surgical modifications, anorectal physiology, and post-operative bowel management programs. Few have investigated how nutritional habits, especially fibre and fluid intake, influence functional outcomes after PSARP (MacVicar et al., 2022 ; Utrilla Fornals et al., 2024 ). In paediatric surgical settings, dietary counselling is often underemphasized, even though inadequate fibre and hydration are common in children with anorectal malformations (Bianchi, 2023 ; Owens, 2022 ). This gap in knowledge highlights the need for evidence-based research examining the contribution of nutritional factors to post-surgical prognosis. Following anorectal malformation surgery, faecal incontinence is a common complication, affecting 17% of patients (Danielson et al., 2017 ), 22.73% of patients experienced constipation, and 20.78% suffered from faecal impaction (Upadhyaya et al., 2021 ). Proper surgical and continuous post-operative evaluation are essential for optimal anorectal function and are crucial in mitigating the risk of complications (Rahimi et al., 2022 ). Nutrients, including fibre and fluid, are essential components that support the digestive system's physiology (Brownlee, 2014 ). A high-fibre diet and adequate fluid intake purportedly play a significant role in improving the outcomes of PSARP surgery. Understanding the relationship between diet and surgical outcomes could provide valuable insights for optimizing post-operative care. If high-fibre and sufficient-fluid intake are shown to enhance voluntary bowel movements, reduce constipation, and enhance continence, they could become a simple yet effective adjunct to surgical and rehabilitative protocols (Kurze et al., 2022 ). Furthermore, integrating nutritional education into post-surgery follow-up programs could enhance patient compliance and long-term bowel function (Wali et al., 2024 ; Wang & Pan, 2025 ). Therefore, this study aimed to evaluate the effect of a high-fibre diet and Adequate Fluid intake on the outcomes of Posterior Sagittal Anorectoplasty in patients with anorectal malformations. Specifically, it assessed their influence on voluntary bowel movement, fecal incontinence, and constipation levels. We hypothesized that higher fibre and fluid intake would be associated with more favourable functional outcomes after PSARP surgery. Materials and Methods The retrospective analytic observational research focused on patients who underwent definitive corrective surgery for anorectal malformations at Ulin and Siaga Hospital, Banjarmasin, between 2018 and 2023, with or without a prior colostomy. A nonprobability quota sampling method selected participants with at least six months of post-surgery follow-up and complete medical records. Data collection utilised a hybrid approach from September to October 2023. For local participants, home visits were conducted, while those residing in distant provinces were contacted through video calls and telephone. Gay and Diehl (1992) and Hill (1998) noted that a minimum sample size of 30 per subcategory of the outcome is required for an observational study (TUMIRAN, 2024 ). In our study, we had three subcategories ("poor," "adequate," and "the best"). The minimum sample size we calculated represented a significant population of 90 patients. We aimed for a minimum sample size of 90 patients but recruited 20% more, totalling 118 patients to accommodate potential dropouts. Research variables Data was obtained using Krickenbeck questionnaire-guided interviews, the Semi-Quantitative-Food Frequency Questionnaire (SQ-FFQ), and patient medical records. The Krickenbeck questionnaire focuses on three main areas: voluntary bowel movements, faecal incontinence, and constipation. Voluntary bowel movements were evaluated as good (score 1) or bad (score 0). Faecal incontinence was rated as none (score 3), mild-moderate (score 2), or severe (score 0–1), while constipation was assessed as either present (score 0–2) or absent (score 3). These scores are combined to gauge surgical outcomes, categorised as poor (score 0–3), adequate (score 4–6), or excellent (score 7) (Agrawal et al., 2022 ). The fibre intake was measured as deficit (< 70%), low (70%-<80%), moderate (80%-<100%), or good (≥ 100%), and fluid intake was evaluated as either insufficient (< 90%) or good (≥ 90%) (Habibaturochmah & Fitranti, 2014 ). The Krickenbeck questionnaire is a widely recognised tool used to evaluate patients' conditions after surgery, often to determine the success of PSARP (Anita Abdul Aziz et al., 2017 ). We used the SQ-FFQ to examine patients' dietary habits post-operation. The data collected from the SQ-FFQ were analysed with NutriSurvey 2007 software, enhanced by the Indonesian Food Consumption Table, FatSecret, and nilaigizi.com, to assess fibre and fluid intake based on the Indonesian Ministry of Health's criteria (Arini et al., 2022 ). The SQ-FFQ effectively gathers detailed information on an individual's eating habits, particularly how frequently and the food quality consumed per portion. This tool is crucial for understanding the regularity of food consumption within a specific period (Depkes, 2017 ). Notably, the SQ-FFQ helps evaluate long-term dietary patterns and has been applied in studies on nutrient intake in toddlers and children (Hartriyanti et al., 2023 ). It is also a significant instrument for epidemiological studies on unhealthy eating patterns (Sochacka-Tatara & Pac, 2014 ). Data analyses The baseline characteristics of the surgical outcome were analysed using the Chi-square test or the Fisher Exact test for categorical data and one-way ANOVA for numerical data. We then used binomial and multinomial logistic regression tests to calculate crude odds ratios (OR), adjusted OR, and 95% confidence intervals (CI) for the impact of independent variables (high-fibre diet and fluid intake) on the surgical outcome. Our analysis was further stratified based on specific categories of dependent variables, including voluntary bowel movement, faecal incontinence, and constipation. All statistical analyses were conducted at a 95% confidence (α = 0.05) using the Statistical Package for the Social Sciences (SPSS) version 26 for Windows. Results Bivariate analyses for the characteristics Out of 118 patients, 65 had successful outcomes (55.08%), 41 had the best outcomes (34.75%), and 12 had suboptimal outcomes (10.17%). Most patients with successful outcomes (58.5%) had surgery between 0–1 years old. 38 (58.5%) were male among the patients with successful outcomes. In the poor outcome group, three patients (25.0%) had low birth weights, and nine (75.0%) had average birth weights. Anorectal malformations without fistula were the most common type observed in the group with successful outcomes (48 patients, 73.8%). In the same group, anorectal malformations with fistula were found in 17 patients (26.2%). 92.7% of patients without other congenital anomalies experienced the best surgical outcomes. In contrast, 66.7% of patients with additional congenital anomalies, including Down syndrome, congenital heart disease, ankyloglossia, cleft lip palate, combinations of congenital heart disease with an imperforate hymen, Down syndrome, sacral anomalies, prune belly syndrome, polydactyly, and a combination of polydactyly with microtia, had suboptimal surgical outcomes. Most patients, 91.7%, had poor results after multiple-stage operations (colostomy + PSARP + large-to-large intestinal anastomosis) for high-level anorectal malformations. Only one patient (8.3%) with a low-level anorectal malformation (undergoing PSARP surgery without colostomy) had a suboptimal surgical outcome. 84.6% of operations occurred during COVID-19 (2020–2023), contrasting with 15.4% pre-pandemic (2018–2019), resulting in adequate surgical outcomes. Siaga Hospital Banjarmasin was where 89.2% of these patients were treated successfully. 73.2% of these patients came from South Kalimantan, while the remaining 26.8% came from outside of South Kalimantan. 83.3% of the parents were in primary and secondary education, and 16.7% were in college with suboptimal surgical outcomes. One significant finding was that anorectal malformation and other congenital anomalies were statistically associated with different surgical outcome levels (p = 0.000). Insert Table 1 here Potential surgical outcomes with the deficit and less fibre compared to moderate fibre intake Table 2 showed a multinomial logistic regression analysis revealed that 39 out of 41 patients (95.1%) had the best surgical outcome, and 33 out of 65 patients (50.8%) with moderate-fibre intake experienced adequate-surgical outcomes. Eight out of 12 patients (66,7%) with deficit-fibre intake had poor-surgical outcomes. Compared to moderate fibre intake, patients with deficit-fibre intake were 95.4% less likely to have an adequate surgical outcome (Adj. OR = 0.046, 95% CI: 0.005–0.447, p-value = 0.008), and it was statistically significant (p < 0.05). Patients with less fibre intake were 98.7% less likely to have the best-surgical outcome, which was statistically significant (Adj. OR = 0.013, 95% CI: 0.001–0.214, p-value = 0.002). These findings suggest that inadequate fibre intake worsens surgical outcomes. The relationship between fibre consumption and surgical outcomes cannot be analysed due to an absolute value of 0 in some groups. None of the patients had good-fibre intake, and the effects of this level of intake on surgical outcomes were not determined. Insert Table 2 here Potential voluntary bowel movements with the deficit and less-fibre compared to moderate fibre intake Table 3 presents the analysis of the effect of fibre consumption on bowel-voluntary as the dependent variable among PSARP. The binomial logistic regression test proved that compared to moderate fibre intake, deficit-fibre intake was 92.7% less likely to have good voluntary bowel movement (Adj. OR = 0.073, 95%CI: 0.002–3.308, p-value = 0.179), and this finding did not reach statistical significance (p > 0.05). Patients with less-fibre intake were also 99.1% less likely to have a good voluntary bowel movement (Adj. OR = 0.009, 95% CI: 0.000-0.575, p-value = 0.026), and it was statistically significant. These findings strongly indicate reduced fibre intake's influence on achieving satisfactory voluntary bowel movements. None of the patients had a good-fibre intake. The effect of fibre intake on the level of voluntary bowel movement was not calculated. Insert Table 3 here Potential faecal continence with the deficit and less-fibre compared to moderate-fibre intake Table 4 presents the results of the multinomial logistic regression test that individuals with deficit fibre intake were found to be 92.9% less likely to experience faecal incontinence (Adj. OR = 0.071, 95% CI: 0.016–0.309, p-value = 0.000), which was statistically significant. Similarly, those with less fibre intake were 81.5% less likely to experience faecal incontinence (Adj. OR = 0.185, 95% CI: 0.041–0.841, p-value = 0.029). These findings suggest that reducing fibre intake may decrease the likelihood of faecal incontinence. It is important to note that the association of good fibre intake with faecal incontinence could not be analysed due to the absence of patients with good fibre intake. Insert Table 4 here Potential constipation with deficit and less-fibre compared to moderate-fibre intake Table 5 indicates that less- and deficit fibre intake reduces the likelihood of constipation. Patients with lower fibre intake were 95.3% less likely to experience constipation (Adj. OR = 0.047, 95% CI: 0.010–0.228, p = 0.000), while those with deficient fibre intake were 87.4% less likely (Adj. OR = 0.126, 95% CI: 0.042–0.375, p = 0.000). This study suggests that reduced fibre intake increases the risk of constipation. Insert Table 5 here Effect of fluid intake on surgical outcomes All 118 patients had adequate fluid intake. Due to the uniform adequate fluid intake across all patients, it was not feasible to perform statistical analyses to examine the impact of fluid intake on surgical outcomes and elucidate this influence through graphical representation. In patients with adequate fluid intake, a majority experienced adequate-surgical outcomes (65 patients, 55.1%), followed by best outcomes (41 patients, 34.7%), and to a lesser extent, suboptimal surgical outcomes (12 patients, 10.2%) (Fig. 1). A hundred and thirteen patients (96.0%) with good fluid intake reported good voluntary bowel movements and only five patients (4.2%) with adequate fluid intake had bad voluntary bowel movements (Fig. 2). Patients exhibiting good fluid intake demonstrated a notable absence of faecal incontinence (76 patients, 64.4%). Conversely, 23 patients (19.5%) with good fluid intake experienced mild to moderate faecal incontinence, while 19 patients (16.1%) suffered from severe incontinence (Fig. 3). Out of the 118 patients, 60 (50.8%) with adequate fluid intake did not experience constipation, while the remaining 58 patients (49.2%) reported constipation (Fig. 4). These graphical representations emphasise the association between good fluid intake and favourable surgical outcomes, regular voluntary bowel movements, absence of faecal incontinence, and reduced incidence of constipation (Appendix Fig. 1–4). Discussion Definitive surgery at 0–1 years old tends to have the best surgery results and an excellent functional prognosis due to easier anal dilatation, appropriate rectal placement, better sensory improvisation, and more quick stoma release (Hakalmaz & Tekant, 2023 ; Nasr & Etchill, 2024 ). Low-birth-weight babies with significant congenital anomalies tend to have suboptimal outcomes due to their small size. Delicate procedures pose a high potential risk to the function of surrounding tissues, nerves, and organs and a risk of wound infection due to their immature immunological status. The type of malformation, including recto-vestibular or recto-urethral fistula, hind-gut hypo-function, and developmental innervation, can also affect the surgery results (Rocourt et al., 2019 ). Fibre can enhance the composition of the gut microbiota, which in turn modulates the immune system and protects against pathogenic microorganisms (Cui et al., 2019 ). Fibre also acts as a prebiotic for developing good bacteria (Ali et al., 2022 ; Bedford et al., 2024 ). Adequate fibre intake can reduce the risk of constipation by forming ideal stool mass and texture (Bellini et al., 2021 ). A high-fibre diet is also beneficial for improving intestinal motility and preventing the risk of functional obstruction (Barber et al., 2020 ; Jaacks et al., 2014 ). Besides fibre, adequate fluid is vital to prevent constipation and faecal incontinence (El-Sharkawy et al., 2014 ; Shen et al., 2019 ). Adequate fluid intake significantly aids the absorption process in the intestines (Greenwood-Van Meerveld et al., 2017 ). In dehydration, the absorption of fluid increases, resulting in hard stool and constipation (Shen et al., 2019 ). Consuming adequate fibre and fluid can enhance post-operative prognosis (Colavita & Andy, 2016 ). Constipation is a problem that makes patients difficult to defecate due to hard stool or obstruction in the gastrointestinal tract. On the other hand, faecal incontinence is a loss of control of defecation resistance, leading to the spontaneous release of faeces. Both conditions directly impact the ability to have normal bowel movements. Faecal incontinence occurs due to damage to anatomical structures, especially the anal sphincter muscles, pelvic floor muscles, or the motoric nervous system of the anorectal region, anomalies formed and complications during surgical procedures. Monitoring constipation and faecal incontinence is essential for assessing the patient's prognosis. If left untreated, these conditions can significantly affect the patient's quality of life (Kyrklund et al., 2018 ). The defecation process encompasses four distinct phases: the basal, pre-expulsive, expulsive, and final. Due to its complex anomalies, defecation cannot be performed flawlessly in anorectal malformations. Relying on definitive procedures to reconstruct damaged structures, fibre, and fluid intake support is needed to maintain the physiology of the gastrointestinal system. Fibre promotes post-operative wound healing by eliciting immune responses and modulating inflammatory cytokines, neutrophils, lymphocytes, and mast cells (Poerwosusanta et al., 2022 ). Fibre can protect the surgical site from inflammation. High-quality dietary fibre can effectively modulate the immune system by balancing pro- and anti-inflammatory cytokines (Barrea et al., 2021 ). Adequate fibre and fluid intake reduces the risk of constipation and faecal incontinence. Fibre has proven beneficial as a non-pharmacological management of constipation (Staller et al., 2018 ). The potential of fibre as an essential nutrient has yet to be optimised as a critical component of post-operative care in anorectal malformations. In addition to its role as a prebiotic in improving the function of the gastrointestinal system, adequate-fibre intake can increase stool volume, promote smooth stool texture, and reduce transit time, ensuring proper intestinal motility (Weber et al., 2014 ). Adequate fluid intake is needed for food absorption. Insufficient fluid intake can lead to constipation and worsen faecal incontinence symptoms. In dehydrated conditions, the colon's absorption of food and fluid increases. Dehydration can cause an increase in food and fluid absorption by the colon, making faeces' consistency challenging to pass (Segal et al., 2013 ). The present study demonstrated that dietary fibre and adequate fluid intake significantly influence the functional outcomes of Posterior Sagittal Anorectoplasty (PSARP) in patients with anorectal malformations (ARMs). Patients with low or deficient fibre intake were substantially less likely to achieve satisfactory surgical outcomes, as reflected in poorer voluntary bowel control and higher constipation scores. These findings underscore the critical role of nutritional factors particularly dietary fibre in maintaining bowel function and ensuring favourable post-operative recovery in children with ARMs. Our results are consistent with previous research indicating that dietary fibre enhances intestinal motility and stool consistency, thereby reducing the incidence of constipation and faecal incontinence. A study found that children who maintained a fibre-rich diet after ARM repair demonstrated better continence scores and fewer gastrointestinal complaints compared to those with inadequate fibre intake (Rajindrajith et al., 2024 ). Similarly, other studies reported that sufficient fibre consumption promoted bowel regularity and enhanced stool passage among paediatric patients with chronic constipation (Salvatore et al., 2023 ). These studies support our findings that optimal dietary fibre intake is essential for achieving long-term bowel functionality following reconstructive surgery. From a physiological standpoint, fibre acts as a prebiotic that modulates the gut microbiota, promotes the growth of beneficial bacteria, and regulates short-chain fatty acid production. These processes enhance intestinal peristalsis and enhance stool quality. Adequate fluid intake complements these effects by maintaining stool hydration and facilitating smooth defecation. Dehydration increases colonic fluid reabsorption, leading to hard stool and exacerbating constipation. This mechanism aligns with the observations of (Evans et al., 2024 ), who highlighted that sufficient hydration mitigates constipation by optimizing the water balance in the gastrointestinal tract. Therefore, combining high-fibre foods with proper hydration may represent an effective non-pharmacological approach to enhance post-surgical bowel regulation. Beyond its physiological impact, dietary management plays an important psychosocial role in post-PSARP care. Many children with ARMs experience dietary restrictions due to fear of constipation or incontinence, often leading to poor fibre and fluid intake. Educating caregivers about the importance of balanced nutrition can significantly enhance compliance and post-operative outcomes. Our findings resonate with those of (Fitzpatrick et al., 2022 ), who emphasized that structured dietary guidance should be integrated into follow-up visits to reduce long-term bowel dysfunction in ARM patients. Furthermore, considering the high prevalence of low-vegetable consumption among Indonesian children, the present study also highlights the cultural aspect of dietary habits as a potential barrier to recovery. The present findings also add to the growing body of evidence supporting comprehensive, multidisciplinary post-operative management in paediatric surgery. While surgical precision remains fundamental, non-surgical interventions such as diet optimization, bowel training, and lifestyle education should not be overlooked. Incorporating dietary assessment tools, such as the Semi-Quantitative Food Frequency Questionnaire (SQ-FFQ) used in this study, allows clinicians to monitor nutritional adequacy and tailor interventions accordingly. This approach aligns with the holistic model proposed by (Pasarón et al., 2024 ), which advocates for individualized bowel management programs combining medical, surgical, and behavioural components. Nevertheless, this study has several limitations. The retrospective design may introduce recall bias, particularly regarding dietary assessment, as respondents’ memory may influence the accuracy of reported intake. Additionally, all participants in this study had uniformly good fluid intake, limiting our ability to analyse variations in hydration status statistically. Future studies should adopt a prospective or cohort design with larger sample sizes and include biochemical markers of hydration to strengthen causal inference. It would also be beneficial to explore the long-term impact of consistent dietary interventions on bowel continence, quality of life, and nutritional status. In summary, the current study provides strong evidence that sufficient fibre and fluid intake are critical determinants of successful surgical outcomes in ARM patients following PSARP. These findings not only reinforce the physiological basis of gastrointestinal recovery but also emphasize the practical importance of dietary counselling in post-operative care. By integrating nutritional management into routine follow-up protocols, clinicians can enhance bowel function, prevent complications, and ultimately enhance the quality of life of children undergoing anorectal reconstruction. Potential impact This study scientifically proves that insufficient fibre intake in post-operative anorectal malformation patients may lead to suboptimal surgical outcomes in the field of pediatric surgery. Conversely, sufficient fibre and fluid intake is significantly associated with good voluntary bowel movement, faecal continence, and no constipation. Educating patients and their families about the importance of consuming sufficient fibre and fluids is crucial. This study could enhance guidelines and treatments in the future. Strengths and limitations This study is believed to be the first to analyse the impact of a high-fibre diet and adequate fluid intake on definitive anorectal malformation surgery outcomes. However, it is essential to acknowledge some limitations, including the small sample size and the hybrid data collection method used. The hybrid data collection method may lead to differences in respondents' perceptions of the questionnaire during online data collection. Although the SQ-FFQ is an ideal tool for collecting dietary pattern data over time compared to other questionnaires, respondents' memory may still significantly impact the results due to information recall bias. Future cohort studies with a larger sample size and inclusion of risk factor variables that influence the lifestyles of Kalimantan people, who may not like vegetables, are needed. Conclusion This study found that the crucial role of consuming enough fibre and fluids enhances the outcomes of PSARP surgery. Inadequate intake of fibre and fluids is significantly associated with suboptimal surgical outcomes, while adequate intake is linked to better bowel movements and faecal continence. It is firmly established that a high-fibre diet and adequate fluid intake positively affect surgical outcomes.This study highlights the crucial role of dietary fibre and adequate fluid intake in improving the functional outcomes of Posterior Sagittal Anorectoplasty (PSARP) among patients with anorectal malformations. Children who maintained sufficient fibre intake exhibited significantly better voluntary bowel movement, lower constipation rates, and enhanced faecal continence compared to those with poor fibre intake. These findings affirm that nutritional factors are essential components of post-operative recovery and should be considered alongside surgical precision and bowel management protocols. Despite these encouraging results, several limitations should be acknowledged. First, the retrospective design of this study relied on self-reported dietary data, which may introduce recall bias and inaccuracies in estimating nutrient intake. Second, the relatively small sample size and single-region population limit the generalizability of the findings to broader demographic or cultural contexts. Third, the uniformity of good fluid intake among participants precluded statistical comparison of different hydration levels, which could have provided a more comprehensive understanding of the fluid fibre interaction. Lastly, other potential confounders such as physical activity, psychological stress, or socioeconomic status were not evaluated, though they may influence bowel function outcomes. Future research should employ a prospective cohort or interventional design to confirm these findings and establish causal relationships between nutrition and post-surgical bowel function. Expanding the study across multiple centres with larger, more diverse populations would strengthen external validity. Moreover, integrating objective biomarkers such as hydration status, stool transit time, and gut microbiota analysis could provide deeper insight into the underlying physiological mechanisms. Longitudinal studies assessing dietary adherence and long-term quality of life after PSARP are also warranted. In conclusion, a high-fibre diet and sufficient fluid intake represent simple yet powerful non-pharmacological strategies to enhance bowel function and reduce complications after PSARP surgery. Incorporating structured dietary education into post-operative care plans could serve as an effective adjunct to surgical and rehabilitative interventions, ultimately improving patient outcomes and quality of life. These findings may serve as a foundation for developing standardized dietary guidelines for children recovering from anorectal malformation surgery. Declarations Ethical Approval: This study was approved by the Ethics Committee of Ulin and Siaga Hospitals, Banjarmasin, Indonesia. Written informed consent was obtained from all participants or their guardians. Funding Statement This research was self-funded by the authors. No external financial support, grant, or sponsorship was received from any individual, institution, or organization during the planning, execution, or publication of this study. Author Contribution H.P. and M.B. conceptualized and designed the study. A.A.W. and J. were responsible for data collection and patient recruitment. M.I.K. and C.K.N. performed data analysis and statistical interpretation. R.P. contributed to the manuscript drafting, critical revision, and interpretation of the results. Z.N. supervised the study and provided final approval of the version to be published. All authors reviewed and approved the final manuscript. Acknowledgement The authors would like to express their sincere gratitude to the medical staff of the Pediatric Surgery Department at RSUD Ulin Banjarmasin, whose support and collaboration made this study possible. We also thank the Dietitian and Nutrition Unit for their valuable assistance in dietary monitoring and patient education during the study. Finally, the authors acknowledge the contribution of Universitas Lambung Mangkurat for providing research facilities and ethical oversight. References Agrawal V, Gupta S, Liêm NT, Acharya H, Sharma D (2022) Laparoscopic-Assisted Modified Posterior Sagittal Anorectoplasty for Rectobulbar Urethral Fistula of Anorectal Malformation: A Prospective Study. J Indian Association Pediatr Surg 27(2):216–222 Ali Q, Ma S, La S, Guo Z, Liu B, Gao Z, Farooq U, Wang Z, Zhu X, Cui Y (2022) Microbial short-chain fatty acids: a bridge between dietary fibers and poultry gut health—a review. Anim Bioscience 35(10):1461 Anita Abdul Aziz D, Velayutham R, Osman M, Latiff ZA, Lim FSK, Nor MM (2017) Anorectal anomaly with rectovestibular fistula: a historical comparison of neonatal anterior sagittal anorectoplasty without covering colostomy and postoperative anal dilatation to the classical three-stage posterior sagittal anorectoplasty. Open Access Surg, 33–44 Arini HRB, Hadju V, Thomas P, Ferguson M (2022) Nutrient and food intake of Indonesian children under 5 years of age: a systematic review. Asia Pac J Public Health 34(1):25–35 Barber TM, Kabisch S, Pfeiffer AFH, Weickert MO (2020) The health benefits of dietary fibre. Nutrients 12(10):3209 Barrea L, Muscogiuri G, Frias-Toral E, Laudisio D, Pugliese G, Castellucci B, Garcia-Velasquez E, Savastano S, Colao A (2021) Nutrition and immune system: from the Mediterranean diet to dietary supplementary through the microbiota. Crit Rev Food Sci Nutr 61(18):3066–3090 Bedford MR, Svihus B, Cowieson AJ (2024) Dietary fibre effects and the interplay with exogenous carbohydrases in poultry nutrition. Anim Nutr 16:231–240 Bellini M, Tonarelli S, Barracca F, Rettura F, Pancetti A, Ceccarelli L, Ricchiuti A, Costa F, de Bortoli N, Marchi S (2021) Chronic constipation: is a nutritional approach reasonable? Nutrients 13(10):3386 Bianchi A (2023) The Surgical Management of Children with Intestinal Failure. Frailty in Children: From the Perioperative Management to the Multidisciplinary Approach. Springer, pp 89–107 Brownlee I (2014) The impact of dietary fibre intake on the physiology and health of the stomach and upper gastrointestinal tract. Bioactive Carbohydr Diet Fibre 4(2):155–169 Canzan F, Longhini J, Caliaro A, Cavada ML, Mezzalira E, Paiella S, Ambrosi E (2024) The effect of early oral postoperative feeding on the recovery of intestinal motility after gastrointestinal surgery: a systematic review and meta-analysis of randomized clinical trials. Front Nutr 11:1369141 Colavita K, Andy UU (2016) Role of diet in fecal incontinence: a systematic review of the literature. Int Urogynecol J 27(12):1805–1810 Cui J, Lian Y, Zhao C, Du H, Han Y, Gao W, Xiao H, Zheng J (2019) Dietary fibers from fruits and vegetables and their health benefits via modulation of gut microbiota. Compr Rev Food Sci Food Saf 18(5):1514–1532 Danielson J, Karlbom U, Graf W, Wester T (2017) Outcome in adults with anorectal malformations in relation to modern classification—which patients do we need to follow beyond childhood? J Pediatr Surg 52(3):463–468 Depkes RI (2017) Profil kesehatan republik indonesia. Jakarta: Badan Penelitian Dan Pengembangan Kesehatan Kemenkes RI El-Sharkawy AM, Sahota O, Maughan RJ, Lobo DN (2014) The pathophysiology of fluid and electrolyte balance in the older adult surgical patient. Clin Nutr 33(1):6–13 Evans GH, James LJ, Maughan RJ, Shirreffs SM (2024) Effects of an active lifestyle on water balance and water requirements. Lifestyle Medicine, Fourth Edition. CRC, pp 123–132 Fitzpatrick JA, Melton SL, Yao CK, Gibson PR, Halmos EP (2022) Dietary management of adults with IBD—the emerging role of dietary therapy. Nat Reviews Gastroenterol Hepatol 19(10):652–669 Greenwood-Van Meerveld B, Johnson AC, Grundy D (2017) Gastrointestinal physiology and function. Gastrointest Pharmacol, 1–16 Habibaturochmah H, Fitranti DY (2014) Hubungan Konsumsi Air, Asupan Zat Gizi, Dan Aktivitas Fisik Dengan Persen Lemak Tubuh Pada Remaja Putri. J Nutr Coll 3(4):595–603 Hakalmaz AE, Tekant GT (2023) Anorectal malformations and late-term problems. Turkish Archives Pediatr 58(6):572 Hartriyanti Y, Melindha ND, Wardani RK, Ermamilia A, Lestari SK (2023) The Valid and Reliable Semi-Quantitative Food Frequency Questionnaire among the Sleman Under Five Children. INQUIRY: J Health Care Organ Provis Financing 60:00469580231152323 Jaacks LM, Crandell J, Liese AD, Lamichhane AP, Bell RA, Dabelea D, D’Agostino RB Jr, Dolan LM, Marcovina S, Reynolds K (2014) No association of dietary fiber intake with inflammation or arterial stiffness in youth with type 1 diabetes. J Diabetes Complicat 28(3):305–310 Kurze I, Geng V, Böthig R (2022) Guideline for the management of neurogenic bowel dysfunction in spinal cord injury/disease. Spinal Cord 60(5):435–443 Kyrklund K, Neuvonen MI, Pakarinen MP, Rintala RJ (2018) Social morbidity in relation to bowel functional outcomes and quality of life in anorectal malformations and Hirschsprung’s disease. Eur J Pediatr Surg 28(06):522–528 MacVicar E, Cullen F, Kastora SL, Parnaby C, Mackay C, Ramsay G (2022) A systematic review of the impact of post-operative oral fluid intake on ileus following elective colorectal surgery. Int J Surg 103:106651 Meldrum OW, Yakubov GE (2025) Journey of dietary fiber along the gastrointestinal tract: role of physical interactions, mucus, and biochemical transformations. Crit Rev Food Sci Nutr 65(22):4264–4292 Nasr IW, Etchill EW (2024) Congenital Anorectal Malformations and Hirschsprung Disease in the Neonate. Principles of Neonatology. Elsevier, pp 738–744 Owens E (2022) The qualitative and quantitative outcomes of children with Hirschsprung’s Disease and Anorectal Malformations. The University of Liverpool (United Kingdom) Pasarón R, Calisto JL, Gurucharri BP, Levitt MA (2024) Health Literacy Implementation Principles: Pediatric Colorectal Program Development. J Pediatr Surg Nurs 13(1):36–42 Poerwosusanta H, Gunadi G, Gunawan P, Fauzi AR, Budi AS, Poerwosusanta AR, Esmeralda E, Aditia D, Oktavianti IK, Kania N (2022) Mast Cell Essential Roles: Will it be a Novel Tool for Differentiating the Severity of Pediatric Appendicitis? Open Access Macedonian J Med Sci 10(A):812–816 Procházková N, Falony G, Dragsted LO, Licht TR, Raes J, Roager HM (2023) Advancing human gut microbiota research by considering gut transit time. Gut 72(1):180–191 Rahimi M, Shamsi A, Hasan AA (2022) Comparison of Various Analgesic Protocols for Control of Postoperative Pain Following Anorectal Surgery. Archives of Anesthesia and Critical Care Rajindrajith S, Gordon M, Dovey TM, Benninga MA, Sinopoulou V (2024) Dietary interventions for the management of chronic constipation in children. Cochrane Database Syst Rev 2024(2):CD014865 Rocourt DV, Kulaylat AS, Kulaylat AN, Leung S, Cilley RE (2019) Primary posterior sagittal anorectoplasty outcomes for rectovestibular and perineal fistulas using an accelerated pathway: a single institution study. J Pediatr Surg 54(9):1778–1781 Rotaru V, Chitoran E, Gelal A, Gullo G, Stefan D-C, Simion L (2025) Living After Pelvic Exenteration: A Mixed-Methods Synthesis of Quality-of-Life Outcomes and Patient Perspectives. J Clin Med 14(18):6541 Salvatore S, Battigaglia MS, Murone E, Dozio E, Pensabene L, Agosti M (2023) Dietary fibers in healthy children and in pediatric gastrointestinal disorders: a practical guide. Nutrients 15(9):2208 Segal S, Saks EK, Asfaw TS, Arya LA (2013) Increased fluid intake is associated with bothersome bowel symptoms among women with urinary incontinence. Urogynecology 19(3):152–156 Shen L, Huang C, Lu X, Xu X, Jiang Z, Zhu C (2019) Lower dietary fibre intake, but not total water consumption, is associated with constipation: a population-based analysis. J Hum Nutr Dietetics 32(4):422–431 Sochacka-Tatara E, Pac A (2014) Relative validity of a semi-quantitative FFQ in 3-year-old Polish children. Public Health Nutr 17(8):1738–1744 Staller K, Song M, Grodstein F, Whitehead WE, Matthews CA, Kuo B, Chan AT (2018) Increased long-term dietary fiber intake is associated with a decreased risk of fecal incontinence in older women. Gastroenterology 155(3):661–667 TUMIRAN MA (2024) How to deal with insufficient sample size due to non-response in surveys? Quantum J Social Sci Humanit 5(2):70–86 Upadhyaya VD, Bharti LK, Mishra A, Yousuf M, Mishra P, Kumar B (2021) Constipation after surgery for anorectal malformations: Unrecognised problem until it is a problem. Afr J Pediatr Surg 18(1):67–71 Utrilla Fornals A, Costas-Batlle C, Medlin S, Menjón-Lajusticia E, Cisneros-González J, Saura-Carmona P, Montoro-Huguet MA (2024) Metabolic and nutritional issues after lower digestive tract surgery: The important role of the dietitian in a multidisciplinary setting. Nutrients 16(2):246 Wali MH, Bekova K, Abdulla N, Gurugubelli S, Lin YM, Banoth D, Butt SR (2024) Adherence to nutritional supplementation, follow-up care, and lost to follow-up in post bariatric surgery patients. J Ayub Med Coll Abbottabad 36(2):417–426 Wang G, Pan S (2025) Optimizing postoperative recovery in colorectal cancer patients through integrated psychological and nutritional interventions. J Cancer Surviv, 1–10 Weber TK, Toporovski MS, Tahan S, Neufeld CB, de Morais MB (2014) Dietary fiber mixture in pediatric patients with controlled chronic constipation. J Pediatr Gastroenterol Nutr 58(3):297–302 Figures Figures 1-4 and Appendix Figures 1-4 are not available with this version. 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17:23:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":700710,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7836026/v1/c356ec7e-4f1b-46a7-9ccc-46b96b48bdce.pdf"},{"id":96251118,"identity":"2806ed84-519c-46d1-98ee-e16a3a46d959","added_by":"auto","created_at":"2025-11-19 07:39:20","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":7131529,"visible":true,"origin":"","legend":"","description":"","filename":"Picture1.png","url":"https://assets-eu.researchsquare.com/files/rs-7836026/v1/a568d967f45101c45d8e605e.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Positive Impact of a High-Fibre Diet and Adequate Fluid Intake on Surgical Outcomes After Posterior Sagittal Anorectoplasty","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAnorectal malformations (ARMs) are complex congenital anomalies affecting the distal rectum and anus, often accompanied by urogenital or other systemic abnormalities. Posterior Sagittal Anorectoplasty (PSARP) has become the standard surgical technique for anatomical reconstruction in children with ARMs, allowing direct visualization and precise repair of the malformation. Despite enhancements in surgical techniques, functional complications such as constipation, fecal incontinence, and poor voluntary bowel control remain major challenges in post-operative management and long-term quality of life (Rotaru et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe pathophysiology of these complications is multifactorial, involving neural innervation defects, abnormal rectal positioning, and impaired pelvic floor coordination. However, emerging evidence suggests that nutritional factors particularly dietary fibre and fluid intake may play an essential role in maintaining intestinal motility and supporting anorectal function after surgery (Canzan et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Fibre contributes to stool formation, microbial balance, and intestinal transit, while adequate hydration ensures optimal stool consistency and prevents constipation. Together, these components may enhance bowel regularity and functional recovery following PSARP (Meldrum \u0026amp; Yakubov, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Proch\u0026aacute;zkov\u0026aacute; et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePrevious studies have mainly focused on surgical modifications, anorectal physiology, and post-operative bowel management programs. Few have investigated how nutritional habits, especially fibre and fluid intake, influence functional outcomes after PSARP (MacVicar et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Utrilla Fornals et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In paediatric surgical settings, dietary counselling is often underemphasized, even though inadequate fibre and hydration are common in children with anorectal malformations (Bianchi, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Owens, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This gap in knowledge highlights the need for evidence-based research examining the contribution of nutritional factors to post-surgical prognosis.\u003c/p\u003e\u003cp\u003eFollowing anorectal malformation surgery, faecal incontinence is a common complication, affecting 17% of patients (Danielson et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), 22.73% of patients experienced constipation, and 20.78% suffered from faecal impaction (Upadhyaya et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Proper surgical and continuous post-operative evaluation are essential for optimal anorectal function and are crucial in mitigating the risk of complications (Rahimi et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Nutrients, including fibre and fluid, are essential components that support the digestive system's physiology (Brownlee, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). A high-fibre diet and adequate fluid intake purportedly play a significant role in improving the outcomes of PSARP surgery.\u003c/p\u003e\u003cp\u003eUnderstanding the relationship between diet and surgical outcomes could provide valuable insights for optimizing post-operative care. If high-fibre and sufficient-fluid intake are shown to enhance voluntary bowel movements, reduce constipation, and enhance continence, they could become a simple yet effective adjunct to surgical and rehabilitative protocols (Kurze et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Furthermore, integrating nutritional education into post-surgery follow-up programs could enhance patient compliance and long-term bowel function (Wali et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Wang \u0026amp; Pan, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTherefore, this study aimed to evaluate the effect of a high-fibre diet and Adequate Fluid intake on the outcomes of Posterior Sagittal Anorectoplasty in patients with anorectal malformations. Specifically, it assessed their influence on voluntary bowel movement, fecal incontinence, and constipation levels. We hypothesized that higher fibre and fluid intake would be associated with more favourable functional outcomes after PSARP surgery.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThe retrospective analytic observational research focused on patients who underwent definitive corrective surgery for anorectal malformations at Ulin and Siaga Hospital, Banjarmasin, between 2018 and 2023, with or without a prior colostomy. A nonprobability quota sampling method selected participants with at least six months of post-surgery follow-up and complete medical records. Data collection utilised a hybrid approach from September to October 2023. For local participants, home visits were conducted, while those residing in distant provinces were contacted through video calls and telephone. Gay and Diehl (1992) and Hill (1998) noted that a minimum sample size of 30 per subcategory of the outcome is required for an observational study (TUMIRAN, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In our study, we had three subcategories (\"poor,\" \"adequate,\" and \"the best\"). The minimum sample size we calculated represented a significant population of 90 patients. We aimed for a minimum sample size of 90 patients but recruited 20% more, totalling 118 patients to accommodate potential dropouts.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eResearch variables\u003c/h2\u003e\u003cp\u003eData was obtained using Krickenbeck questionnaire-guided interviews, the Semi-Quantitative-Food Frequency Questionnaire (SQ-FFQ), and patient medical records. The Krickenbeck questionnaire focuses on three main areas: voluntary bowel movements, faecal incontinence, and constipation. Voluntary bowel movements were evaluated as good (score 1) or bad (score 0). Faecal incontinence was rated as none (score 3), mild-moderate (score 2), or severe (score 0\u0026ndash;1), while constipation was assessed as either present (score 0\u0026ndash;2) or absent (score 3). These scores are combined to gauge surgical outcomes, categorised as poor (score 0\u0026ndash;3), adequate (score 4\u0026ndash;6), or excellent (score 7) (Agrawal et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The fibre intake was measured as deficit (\u0026lt;\u0026thinsp;70%), low (70%-\u0026lt;80%), moderate (80%-\u0026lt;100%), or good (\u0026ge;\u0026thinsp;100%), and fluid intake was evaluated as either insufficient (\u0026lt;\u0026thinsp;90%) or good (\u0026ge;\u0026thinsp;90%) (Habibaturochmah \u0026amp; Fitranti, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). The Krickenbeck questionnaire is a widely recognised tool used to evaluate patients' conditions after surgery, often to determine the success of PSARP (Anita Abdul Aziz et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). We used the SQ-FFQ to examine patients' dietary habits post-operation. The data collected from the SQ-FFQ were analysed with NutriSurvey 2007 software, enhanced by the Indonesian Food Consumption Table, FatSecret, and nilaigizi.com, to assess fibre and fluid intake based on the Indonesian Ministry of Health's criteria (Arini et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The SQ-FFQ effectively gathers detailed information on an individual's eating habits, particularly how frequently and the food quality consumed per portion. This tool is crucial for understanding the regularity of food consumption within a specific period (Depkes, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Notably, the SQ-FFQ helps evaluate long-term dietary patterns and has been applied in studies on nutrient intake in toddlers and children (Hartriyanti et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). It is also a significant instrument for epidemiological studies on unhealthy eating patterns (Sochacka-Tatara \u0026amp; Pac, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData analyses\u003c/h3\u003e\n\u003cp\u003eThe baseline characteristics of the surgical outcome were analysed using the Chi-square test or the Fisher Exact test for categorical data and one-way ANOVA for numerical data. We then used binomial and multinomial logistic regression tests to calculate crude odds ratios (OR), adjusted OR, and 95% confidence intervals (CI) for the impact of independent variables (high-fibre diet and fluid intake) on the surgical outcome. Our analysis was further stratified based on specific categories of dependent variables, including voluntary bowel movement, faecal incontinence, and constipation. All statistical analyses were conducted at a 95% confidence (α\u0026thinsp;=\u0026thinsp;0.05) using the Statistical Package for the Social Sciences (SPSS) version 26 for Windows.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eBivariate analyses for the characteristics\u003c/h2\u003e\u003cp\u003eOut of 118 patients, 65 had successful outcomes (55.08%), 41 had the best outcomes (34.75%), and 12 had suboptimal outcomes (10.17%). Most patients with successful outcomes (58.5%) had surgery between 0\u0026ndash;1 years old. 38 (58.5%) were male among the patients with successful outcomes. In the poor outcome group, three patients (25.0%) had low birth weights, and nine (75.0%) had average birth weights. Anorectal malformations without fistula were the most common type observed in the group with successful outcomes (48 patients, 73.8%). In the same group, anorectal malformations with fistula were found in 17 patients (26.2%).\u003c/p\u003e\u003cp\u003e92.7% of patients without other congenital anomalies experienced the best surgical outcomes. In contrast, 66.7% of patients with additional congenital anomalies, including Down syndrome, congenital heart disease, ankyloglossia, cleft lip palate, combinations of congenital heart disease with an imperforate hymen, Down syndrome, sacral anomalies, prune belly syndrome, polydactyly, and a combination of polydactyly with microtia, had suboptimal surgical outcomes.\u003c/p\u003e\u003cp\u003eMost patients, 91.7%, had poor results after multiple-stage operations (colostomy\u0026thinsp;+\u0026thinsp;PSARP\u0026thinsp;+\u0026thinsp;large-to-large intestinal anastomosis) for high-level anorectal malformations. Only one patient (8.3%) with a low-level anorectal malformation (undergoing PSARP surgery without colostomy) had a suboptimal surgical outcome. 84.6% of operations occurred during COVID-19 (2020\u0026ndash;2023), contrasting with 15.4% pre-pandemic (2018\u0026ndash;2019), resulting in adequate surgical outcomes. Siaga Hospital Banjarmasin was where 89.2% of these patients were treated successfully. 73.2% of these patients came from South Kalimantan, while the remaining 26.8% came from outside of South Kalimantan. 83.3% of the parents were in primary and secondary education, and 16.7% were in college with suboptimal surgical outcomes. One significant finding was that anorectal malformation and other congenital anomalies were statistically associated with different surgical outcome levels (p\u0026thinsp;=\u0026thinsp;0.000).\u003c/p\u003e\u003cp\u003eInsert Table\u0026nbsp;1 here\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePotential surgical outcomes with the deficit and less fibre compared to moderate fibre intake\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;2 showed a multinomial logistic regression analysis revealed that 39 out of 41 patients (95.1%) had the best surgical outcome, and 33 out of 65 patients (50.8%) with moderate-fibre intake experienced adequate-surgical outcomes. Eight out of 12 patients (66,7%) with deficit-fibre intake had poor-surgical outcomes. Compared to moderate fibre intake, patients with deficit-fibre intake were 95.4% less likely to have an adequate surgical outcome (Adj. OR\u0026thinsp;=\u0026thinsp;0.046, 95% CI: 0.005\u0026ndash;0.447, p-value\u0026thinsp;=\u0026thinsp;0.008), and it was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Patients with less fibre intake were 98.7% less likely to have the best-surgical outcome, which was statistically significant (Adj. OR\u0026thinsp;=\u0026thinsp;0.013, 95% CI: 0.001\u0026ndash;0.214, p-value\u0026thinsp;=\u0026thinsp;0.002). These findings suggest that inadequate fibre intake worsens surgical outcomes. The relationship between fibre consumption and surgical outcomes cannot be analysed due to an absolute value of 0 in some groups. None of the patients had good-fibre intake, and the effects of this level of intake on surgical outcomes were not determined.\u003c/p\u003e\u003cp\u003eInsert Table\u0026nbsp;2 here\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePotential voluntary bowel movements with the deficit and less-fibre compared to moderate fibre intake\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;3 presents the analysis of the effect of fibre consumption on bowel-voluntary as the dependent variable among PSARP. The binomial logistic regression test proved that compared to moderate fibre intake, deficit-fibre intake was 92.7% less likely to have good voluntary bowel movement (Adj. OR\u0026thinsp;=\u0026thinsp;0.073, 95%CI: 0.002\u0026ndash;3.308, p-value\u0026thinsp;=\u0026thinsp;0.179), and this finding did not reach statistical significance (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Patients with less-fibre intake were also 99.1% less likely to have a good voluntary bowel movement (Adj. OR\u0026thinsp;=\u0026thinsp;0.009, 95% CI: 0.000-0.575, p-value\u0026thinsp;=\u0026thinsp;0.026), and it was statistically significant. These findings strongly indicate reduced fibre intake's influence on achieving satisfactory voluntary bowel movements. None of the patients had a good-fibre intake. The effect of fibre intake on the level of voluntary bowel movement was not calculated.\u003c/p\u003e\u003cp\u003eInsert Table\u0026nbsp;3 here\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePotential faecal continence with the deficit and less-fibre compared to moderate-fibre intake\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;4 presents the results of the multinomial logistic regression test that individuals with deficit fibre intake were found to be 92.9% less likely to experience faecal incontinence (Adj. OR\u0026thinsp;=\u0026thinsp;0.071, 95% CI: 0.016\u0026ndash;0.309, p-value\u0026thinsp;=\u0026thinsp;0.000), which was statistically significant. Similarly, those with less fibre intake were 81.5% less likely to experience faecal incontinence (Adj. OR\u0026thinsp;=\u0026thinsp;0.185, 95% CI: 0.041\u0026ndash;0.841, p-value\u0026thinsp;=\u0026thinsp;0.029). These findings suggest that reducing fibre intake may decrease the likelihood of faecal incontinence. It is important to note that the association of good fibre intake with faecal incontinence could not be analysed due to the absence of patients with good fibre intake.\u003c/p\u003e\u003cp\u003eInsert Table\u0026nbsp;4 here\u003c/p\u003e\n\u003ch3\u003ePotential constipation with deficit and less-fibre compared to moderate-fibre intake\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;5 indicates that less- and deficit fibre intake reduces the likelihood of constipation. Patients with lower fibre intake were 95.3% less likely to experience constipation (Adj. OR\u0026thinsp;=\u0026thinsp;0.047, 95% CI: 0.010\u0026ndash;0.228, p\u0026thinsp;=\u0026thinsp;0.000), while those with deficient fibre intake were 87.4% less likely (Adj. OR\u0026thinsp;=\u0026thinsp;0.126, 95% CI: 0.042\u0026ndash;0.375, p\u0026thinsp;=\u0026thinsp;0.000). This study suggests that reduced fibre intake increases the risk of constipation.\u003c/p\u003e\u003cp\u003eInsert Table\u0026nbsp;5 here\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eEffect of fluid intake on surgical outcomes\u003c/h2\u003e\u003cp\u003eAll 118 patients had adequate fluid intake. Due to the uniform adequate fluid intake across all patients, it was not feasible to perform statistical analyses to examine the impact of fluid intake on surgical outcomes and elucidate this influence through graphical representation. In patients with adequate fluid intake, a majority experienced adequate-surgical outcomes (65 patients, 55.1%), followed by best outcomes (41 patients, 34.7%), and to a lesser extent, suboptimal surgical outcomes (12 patients, 10.2%) (Fig.\u0026nbsp;1). A hundred and thirteen patients (96.0%) with good fluid intake reported good voluntary bowel movements and only five patients (4.2%) with adequate fluid intake had bad voluntary bowel movements (Fig.\u0026nbsp;2). Patients exhibiting good fluid intake demonstrated a notable absence of faecal incontinence (76 patients, 64.4%). Conversely, 23 patients (19.5%) with good fluid intake experienced mild to moderate faecal incontinence, while 19 patients (16.1%) suffered from severe incontinence (Fig.\u0026nbsp;3). Out of the 118 patients, 60 (50.8%) with adequate fluid intake did not experience constipation, while the remaining 58 patients (49.2%) reported constipation (Fig.\u0026nbsp;4). These graphical representations emphasise the association between good fluid intake and favourable surgical outcomes, regular voluntary bowel movements, absence of faecal incontinence, and reduced incidence of constipation (Appendix Fig.\u0026nbsp;1\u0026ndash;4).\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDefinitive surgery at 0\u0026ndash;1 years old tends to have the best surgery results and an excellent functional prognosis due to easier anal dilatation, appropriate rectal placement, better sensory improvisation, and more quick stoma release (Hakalmaz \u0026amp; Tekant, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Nasr \u0026amp; Etchill, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Low-birth-weight babies with significant congenital anomalies tend to have suboptimal outcomes due to their small size. Delicate procedures pose a high potential risk to the function of surrounding tissues, nerves, and organs and a risk of wound infection due to their immature immunological status. The type of malformation, including recto-vestibular or recto-urethral fistula, hind-gut hypo-function, and developmental innervation, can also affect the surgery results (Rocourt et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFibre can enhance the composition of the gut microbiota, which in turn modulates the immune system and protects against pathogenic microorganisms (Cui et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Fibre also acts as a prebiotic for developing good bacteria (Ali et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Bedford et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Adequate fibre intake can reduce the risk of constipation by forming ideal stool mass and texture (Bellini et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). A high-fibre diet is also beneficial for improving intestinal motility and preventing the risk of functional obstruction (Barber et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Jaacks et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBesides fibre, adequate fluid is vital to prevent constipation and faecal incontinence (El-Sharkawy et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Shen et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Adequate fluid intake significantly aids the absorption process in the intestines (Greenwood-Van Meerveld et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). In dehydration, the absorption of fluid increases, resulting in hard stool and constipation (Shen et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Consuming adequate fibre and fluid can enhance post-operative prognosis (Colavita \u0026amp; Andy, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Constipation is a problem that makes patients difficult to defecate due to hard stool or obstruction in the gastrointestinal tract. On the other hand, faecal incontinence is a loss of control of defecation resistance, leading to the spontaneous release of faeces. Both conditions directly impact the ability to have normal bowel movements. Faecal incontinence occurs due to damage to anatomical structures, especially the anal sphincter muscles, pelvic floor muscles, or the motoric nervous system of the anorectal region, anomalies formed and complications during surgical procedures. Monitoring constipation and faecal incontinence is essential for assessing the patient's prognosis. If left untreated, these conditions can significantly affect the patient's quality of life (Kyrklund et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe defecation process encompasses four distinct phases: the basal, pre-expulsive, expulsive, and final. Due to its complex anomalies, defecation cannot be performed flawlessly in anorectal malformations. Relying on definitive procedures to reconstruct damaged structures, fibre, and fluid intake support is needed to maintain the physiology of the gastrointestinal system. Fibre promotes post-operative wound healing by eliciting immune responses and modulating inflammatory cytokines, neutrophils, lymphocytes, and mast cells (Poerwosusanta et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Fibre can protect the surgical site from inflammation. High-quality dietary fibre can effectively modulate the immune system by balancing pro- and anti-inflammatory cytokines (Barrea et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAdequate fibre and fluid intake reduces the risk of constipation and faecal incontinence. Fibre has proven beneficial as a non-pharmacological management of constipation (Staller et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The potential of fibre as an essential nutrient has yet to be optimised as a critical component of post-operative care in anorectal malformations. In addition to its role as a prebiotic in improving the function of the gastrointestinal system, adequate-fibre intake can increase stool volume, promote smooth stool texture, and reduce transit time, ensuring proper intestinal motility (Weber et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Adequate fluid intake is needed for food absorption. Insufficient fluid intake can lead to constipation and worsen faecal incontinence symptoms. In dehydrated conditions, the colon's absorption of food and fluid increases. Dehydration can cause an increase in food and fluid absorption by the colon, making faeces' consistency challenging to pass (Segal et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe present study demonstrated that dietary fibre and adequate fluid intake significantly influence the functional outcomes of Posterior Sagittal Anorectoplasty (PSARP) in patients with anorectal malformations (ARMs). Patients with low or deficient fibre intake were substantially less likely to achieve satisfactory surgical outcomes, as reflected in poorer voluntary bowel control and higher constipation scores. These findings underscore the critical role of nutritional factors particularly dietary fibre in maintaining bowel function and ensuring favourable post-operative recovery in children with ARMs. Our results are consistent with previous research indicating that dietary fibre enhances intestinal motility and stool consistency, thereby reducing the incidence of constipation and faecal incontinence. A study found that children who maintained a fibre-rich diet after ARM repair demonstrated better continence scores and fewer gastrointestinal complaints compared to those with inadequate fibre intake (Rajindrajith et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Similarly, other studies reported that sufficient fibre consumption promoted bowel regularity and enhanced stool passage among paediatric patients with chronic constipation (Salvatore et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThese studies support our findings that optimal dietary fibre intake is essential for achieving long-term bowel functionality following reconstructive surgery. From a physiological standpoint, fibre acts as a prebiotic that modulates the gut microbiota, promotes the growth of beneficial bacteria, and regulates short-chain fatty acid production. These processes enhance intestinal peristalsis and enhance stool quality. Adequate fluid intake complements these effects by maintaining stool hydration and facilitating smooth defecation. Dehydration increases colonic fluid reabsorption, leading to hard stool and exacerbating constipation. This mechanism aligns with the observations of (Evans et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), who highlighted that sufficient hydration mitigates constipation by optimizing the water balance in the gastrointestinal tract. Therefore, combining high-fibre foods with proper hydration may represent an effective non-pharmacological approach to enhance post-surgical bowel regulation. Beyond its physiological impact, dietary management plays an important psychosocial role in post-PSARP care. Many children with ARMs experience dietary restrictions due to fear of constipation or incontinence, often leading to poor fibre and fluid intake.\u003c/p\u003e\u003cp\u003eEducating caregivers about the importance of balanced nutrition can significantly enhance compliance and post-operative outcomes. Our findings resonate with those of (Fitzpatrick et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), who emphasized that structured dietary guidance should be integrated into follow-up visits to reduce long-term bowel dysfunction in ARM patients. Furthermore, considering the high prevalence of low-vegetable consumption among Indonesian children, the present study also highlights the cultural aspect of dietary habits as a potential barrier to recovery. The present findings also add to the growing body of evidence supporting comprehensive, multidisciplinary post-operative management in paediatric surgery. While surgical precision remains fundamental, non-surgical interventions such as diet optimization, bowel training, and lifestyle education should not be overlooked. Incorporating dietary assessment tools, such as the Semi-Quantitative Food Frequency Questionnaire (SQ-FFQ) used in this study, allows clinicians to monitor nutritional adequacy and tailor interventions accordingly.\u003c/p\u003e\u003cp\u003eThis approach aligns with the holistic model proposed by (Pasar\u0026oacute;n et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), which advocates for individualized bowel management programs combining medical, surgical, and behavioural components. Nevertheless, this study has several limitations. The retrospective design may introduce recall bias, particularly regarding dietary assessment, as respondents\u0026rsquo; memory may influence the accuracy of reported intake. Additionally, all participants in this study had uniformly good fluid intake, limiting our ability to analyse variations in hydration status statistically. Future studies should adopt a prospective or cohort design with larger sample sizes and include biochemical markers of hydration to strengthen causal inference. It would also be beneficial to explore the long-term impact of consistent dietary interventions on bowel continence, quality of life, and nutritional status. In summary, the current study provides strong evidence that sufficient fibre and fluid intake are critical determinants of successful surgical outcomes in ARM patients following PSARP. These findings not only reinforce the physiological basis of gastrointestinal recovery but also emphasize the practical importance of dietary counselling in post-operative care. By integrating nutritional management into routine follow-up protocols, clinicians can enhance bowel function, prevent complications, and ultimately enhance the quality of life of children undergoing anorectal reconstruction.\u003c/p\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003ePotential impact\u003c/h2\u003e\u003cp\u003eThis study scientifically proves that insufficient fibre intake in post-operative anorectal malformation patients may lead to suboptimal surgical outcomes in the field of pediatric surgery. Conversely, sufficient fibre and fluid intake is significantly associated with good voluntary bowel movement, faecal continence, and no constipation. Educating patients and their families about the importance of consuming sufficient fibre and fluids is crucial. This study could enhance guidelines and treatments in the future.\u003c/p\u003e\u003cp\u003eStrengths and limitations\u003c/p\u003e\u003cp\u003eThis study is believed to be the first to analyse the impact of a high-fibre diet and adequate fluid intake on definitive anorectal malformation surgery outcomes. However, it is essential to acknowledge some limitations, including the small sample size and the hybrid data collection method used. The hybrid data collection method may lead to differences in respondents' perceptions of the questionnaire during online data collection. Although the SQ-FFQ is an ideal tool for collecting dietary pattern data over time compared to other questionnaires, respondents' memory may still significantly impact the results due to information recall bias. Future cohort studies with a larger sample size and inclusion of risk factor variables that influence the lifestyles of Kalimantan people, who may not like vegetables, are needed.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study found that the crucial role of consuming enough fibre and fluids enhances the outcomes of PSARP surgery. Inadequate intake of fibre and fluids is significantly associated with suboptimal surgical outcomes, while adequate intake is linked to better bowel movements and faecal continence. It is firmly established that a high-fibre diet and adequate fluid intake positively affect surgical outcomes.This study highlights the crucial role of dietary fibre and adequate fluid intake in improving the functional outcomes of Posterior Sagittal Anorectoplasty (PSARP) among patients with anorectal malformations. Children who maintained sufficient fibre intake exhibited significantly better voluntary bowel movement, lower constipation rates, and enhanced faecal continence compared to those with poor fibre intake.\u003c/p\u003e\u003cp\u003eThese findings affirm that nutritional factors are essential components of post-operative recovery and should be considered alongside surgical precision and bowel management protocols. Despite these encouraging results, several limitations should be acknowledged. First, the retrospective design of this study relied on self-reported dietary data, which may introduce recall bias and inaccuracies in estimating nutrient intake. Second, the relatively small sample size and single-region population limit the generalizability of the findings to broader demographic or cultural contexts. Third, the uniformity of good fluid intake among participants precluded statistical comparison of different hydration levels, which could have provided a more comprehensive understanding of the fluid fibre interaction. Lastly, other potential confounders such as physical activity, psychological stress, or socioeconomic status were not evaluated, though they may influence bowel function outcomes. Future research should employ a prospective cohort or interventional design to confirm these findings and establish causal relationships between nutrition and post-surgical bowel function. Expanding the study across multiple centres with larger, more diverse populations would strengthen external validity. Moreover, integrating objective biomarkers such as hydration status, stool transit time, and gut microbiota analysis could provide deeper insight into the underlying physiological mechanisms. Longitudinal studies assessing dietary adherence and long-term quality of life after PSARP are also warranted. In conclusion, a high-fibre diet and sufficient fluid intake represent simple yet powerful non-pharmacological strategies to enhance bowel function and reduce complications after PSARP surgery. Incorporating structured dietary education into post-operative care plans could serve as an effective adjunct to surgical and rehabilitative interventions, ultimately improving patient outcomes and quality of life. These findings may serve as a foundation for developing standardized dietary guidelines for children recovering from anorectal malformation surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthical Approval:\u003c/h2\u003e\u003cp\u003e This study was approved by the Ethics Committee of Ulin and Siaga Hospitals, Banjarmasin, Indonesia. Written informed consent was obtained from all participants or their guardians.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding Statement\u003c/h2\u003e\u003cp\u003eThis research was self-funded by the authors. No external financial support, grant, or sponsorship was received from any individual, institution, or organization during the planning, execution, or publication of this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eH.P. and M.B. conceptualized and designed the study. A.A.W. and J. were responsible for data collection and patient recruitment. M.I.K. and C.K.N. performed data analysis and statistical interpretation. R.P. contributed to the manuscript drafting, critical revision, and interpretation of the results. Z.N. supervised the study and provided final approval of the version to be published. All authors reviewed and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to express their sincere gratitude to the medical staff of the Pediatric Surgery Department at RSUD Ulin Banjarmasin, whose support and collaboration made this study possible. We also thank the Dietitian and Nutrition Unit for their valuable assistance in dietary monitoring and patient education during the study. Finally, the authors acknowledge the contribution of Universitas Lambung Mangkurat for providing research facilities and ethical oversight.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAgrawal V, Gupta S, Li\u0026ecirc;m NT, Acharya H, Sharma D (2022) Laparoscopic-Assisted Modified Posterior Sagittal Anorectoplasty for Rectobulbar Urethral Fistula of Anorectal Malformation: A Prospective Study. J Indian Association Pediatr Surg 27(2):216\u0026ndash;222\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAli Q, Ma S, La S, Guo Z, Liu B, Gao Z, Farooq U, Wang Z, Zhu X, Cui Y (2022) Microbial short-chain fatty acids: a bridge between dietary fibers and poultry gut health\u0026mdash;a review. Anim Bioscience 35(10):1461\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnita Abdul Aziz D, Velayutham R, Osman M, Latiff ZA, Lim FSK, Nor MM (2017) Anorectal anomaly with rectovestibular fistula: a historical comparison of neonatal anterior sagittal anorectoplasty without covering colostomy and postoperative anal dilatation to the classical three-stage posterior sagittal anorectoplasty. Open Access Surg, 33\u0026ndash;44\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArini HRB, Hadju V, Thomas P, Ferguson M (2022) Nutrient and food intake of Indonesian children under 5 years of age: a systematic review. Asia Pac J Public Health 34(1):25\u0026ndash;35\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarber TM, Kabisch S, Pfeiffer AFH, Weickert MO (2020) The health benefits of dietary fibre. Nutrients 12(10):3209\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarrea L, Muscogiuri G, Frias-Toral E, Laudisio D, Pugliese G, Castellucci B, Garcia-Velasquez E, Savastano S, Colao A (2021) Nutrition and immune system: from the Mediterranean diet to dietary supplementary through the microbiota. Crit Rev Food Sci Nutr 61(18):3066\u0026ndash;3090\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBedford MR, Svihus B, Cowieson AJ (2024) Dietary fibre effects and the interplay with exogenous carbohydrases in poultry nutrition. Anim Nutr 16:231\u0026ndash;240\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBellini M, Tonarelli S, Barracca F, Rettura F, Pancetti A, Ceccarelli L, Ricchiuti A, Costa F, de Bortoli N, Marchi S (2021) Chronic constipation: is a nutritional approach reasonable? Nutrients 13(10):3386\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBianchi A (2023) The Surgical Management of Children with Intestinal Failure. Frailty in Children: From the Perioperative Management to the Multidisciplinary Approach. Springer, pp 89\u0026ndash;107\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrownlee I (2014) The impact of dietary fibre intake on the physiology and health of the stomach and upper gastrointestinal tract. Bioactive Carbohydr Diet Fibre 4(2):155\u0026ndash;169\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCanzan F, Longhini J, Caliaro A, Cavada ML, Mezzalira E, Paiella S, Ambrosi E (2024) The effect of early oral postoperative feeding on the recovery of intestinal motility after gastrointestinal surgery: a systematic review and meta-analysis of randomized clinical trials. Front Nutr 11:1369141\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eColavita K, Andy UU (2016) Role of diet in fecal incontinence: a systematic review of the literature. Int Urogynecol J 27(12):1805\u0026ndash;1810\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCui J, Lian Y, Zhao C, Du H, Han Y, Gao W, Xiao H, Zheng J (2019) Dietary fibers from fruits and vegetables and their health benefits via modulation of gut microbiota. Compr Rev Food Sci Food Saf 18(5):1514\u0026ndash;1532\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDanielson J, Karlbom U, Graf W, Wester T (2017) Outcome in adults with anorectal malformations in relation to modern classification\u0026mdash;which patients do we need to follow beyond childhood? J Pediatr Surg 52(3):463\u0026ndash;468\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDepkes RI (2017) Profil kesehatan republik indonesia. \u003cem\u003eJakarta: Badan Penelitian Dan Pengembangan Kesehatan Kemenkes RI\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEl-Sharkawy AM, Sahota O, Maughan RJ, Lobo DN (2014) The pathophysiology of fluid and electrolyte balance in the older adult surgical patient. Clin Nutr 33(1):6\u0026ndash;13\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEvans GH, James LJ, Maughan RJ, Shirreffs SM (2024) Effects of an active lifestyle on water balance and water requirements. Lifestyle Medicine, Fourth Edition. CRC, pp 123\u0026ndash;132\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFitzpatrick JA, Melton SL, Yao CK, Gibson PR, Halmos EP (2022) Dietary management of adults with IBD\u0026mdash;the emerging role of dietary therapy. Nat Reviews Gastroenterol Hepatol 19(10):652\u0026ndash;669\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGreenwood-Van Meerveld B, Johnson AC, Grundy D (2017) Gastrointestinal physiology and function. Gastrointest Pharmacol, 1\u0026ndash;16\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHabibaturochmah H, Fitranti DY (2014) Hubungan Konsumsi Air, Asupan Zat Gizi, Dan Aktivitas Fisik Dengan Persen Lemak Tubuh Pada Remaja Putri. J Nutr Coll 3(4):595\u0026ndash;603\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHakalmaz AE, Tekant GT (2023) Anorectal malformations and late-term problems. Turkish Archives Pediatr 58(6):572\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHartriyanti Y, Melindha ND, Wardani RK, Ermamilia A, Lestari SK (2023) The Valid and Reliable Semi-Quantitative Food Frequency Questionnaire among the Sleman Under Five Children. INQUIRY: J Health Care Organ Provis Financing 60:00469580231152323\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJaacks LM, Crandell J, Liese AD, Lamichhane AP, Bell RA, Dabelea D, D\u0026rsquo;Agostino RB Jr, Dolan LM, Marcovina S, Reynolds K (2014) No association of dietary fiber intake with inflammation or arterial stiffness in youth with type 1 diabetes. J Diabetes Complicat 28(3):305\u0026ndash;310\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKurze I, Geng V, B\u0026ouml;thig R (2022) Guideline for the management of neurogenic bowel dysfunction in spinal cord injury/disease. Spinal Cord 60(5):435\u0026ndash;443\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKyrklund K, Neuvonen MI, Pakarinen MP, Rintala RJ (2018) Social morbidity in relation to bowel functional outcomes and quality of life in anorectal malformations and Hirschsprung\u0026rsquo;s disease. Eur J Pediatr Surg 28(06):522\u0026ndash;528\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMacVicar E, Cullen F, Kastora SL, Parnaby C, Mackay C, Ramsay G (2022) A systematic review of the impact of post-operative oral fluid intake on ileus following elective colorectal surgery. Int J Surg 103:106651\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeldrum OW, Yakubov GE (2025) Journey of dietary fiber along the gastrointestinal tract: role of physical interactions, mucus, and biochemical transformations. Crit Rev Food Sci Nutr 65(22):4264\u0026ndash;4292\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNasr IW, Etchill EW (2024) Congenital Anorectal Malformations and Hirschsprung Disease in the Neonate. Principles of Neonatology. Elsevier, pp 738\u0026ndash;744\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOwens E (2022) The qualitative and quantitative outcomes of children with Hirschsprung\u0026rsquo;s Disease and Anorectal Malformations. The University of Liverpool (United Kingdom)\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePasar\u0026oacute;n R, Calisto JL, Gurucharri BP, Levitt MA (2024) Health Literacy Implementation Principles: Pediatric Colorectal Program Development. J Pediatr Surg Nurs 13(1):36\u0026ndash;42\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePoerwosusanta H, Gunadi G, Gunawan P, Fauzi AR, Budi AS, Poerwosusanta AR, Esmeralda E, Aditia D, Oktavianti IK, Kania N (2022) Mast Cell Essential Roles: Will it be a Novel Tool for Differentiating the Severity of Pediatric Appendicitis? Open Access Macedonian J Med Sci 10(A):812\u0026ndash;816\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eProch\u0026aacute;zkov\u0026aacute; N, Falony G, Dragsted LO, Licht TR, Raes J, Roager HM (2023) Advancing human gut microbiota research by considering gut transit time. Gut 72(1):180\u0026ndash;191\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRahimi M, Shamsi A, Hasan AA (2022) Comparison of Various Analgesic Protocols for Control of Postoperative Pain Following Anorectal Surgery. \u003cem\u003eArchives of Anesthesia and Critical Care\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRajindrajith S, Gordon M, Dovey TM, Benninga MA, Sinopoulou V (2024) Dietary interventions for the management of chronic constipation in children. Cochrane Database Syst Rev 2024(2):CD014865\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRocourt DV, Kulaylat AS, Kulaylat AN, Leung S, Cilley RE (2019) Primary posterior sagittal anorectoplasty outcomes for rectovestibular and perineal fistulas using an accelerated pathway: a single institution study. J Pediatr Surg 54(9):1778\u0026ndash;1781\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRotaru V, Chitoran E, Gelal A, Gullo G, Stefan D-C, Simion L (2025) Living After Pelvic Exenteration: A Mixed-Methods Synthesis of Quality-of-Life Outcomes and Patient Perspectives. J Clin Med 14(18):6541\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalvatore S, Battigaglia MS, Murone E, Dozio E, Pensabene L, Agosti M (2023) Dietary fibers in healthy children and in pediatric gastrointestinal disorders: a practical guide. Nutrients 15(9):2208\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSegal S, Saks EK, Asfaw TS, Arya LA (2013) Increased fluid intake is associated with bothersome bowel symptoms among women with urinary incontinence. Urogynecology 19(3):152\u0026ndash;156\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShen L, Huang C, Lu X, Xu X, Jiang Z, Zhu C (2019) Lower dietary fibre intake, but not total water consumption, is associated with constipation: a population-based analysis. J Hum Nutr Dietetics 32(4):422\u0026ndash;431\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSochacka-Tatara E, Pac A (2014) Relative validity of a semi-quantitative FFQ in 3-year-old Polish children. Public Health Nutr 17(8):1738\u0026ndash;1744\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStaller K, Song M, Grodstein F, Whitehead WE, Matthews CA, Kuo B, Chan AT (2018) Increased long-term dietary fiber intake is associated with a decreased risk of fecal incontinence in older women. Gastroenterology 155(3):661\u0026ndash;667\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTUMIRAN MA (2024) How to deal with insufficient sample size due to non-response in surveys? Quantum J Social Sci Humanit 5(2):70\u0026ndash;86\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUpadhyaya VD, Bharti LK, Mishra A, Yousuf M, Mishra P, Kumar B (2021) Constipation after surgery for anorectal malformations: Unrecognised problem until it is a problem. Afr J Pediatr Surg 18(1):67\u0026ndash;71\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUtrilla Fornals A, Costas-Batlle C, Medlin S, Menj\u0026oacute;n-Lajusticia E, Cisneros-Gonz\u0026aacute;lez J, Saura-Carmona P, Montoro-Huguet MA (2024) Metabolic and nutritional issues after lower digestive tract surgery: The important role of the dietitian in a multidisciplinary setting. Nutrients 16(2):246\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWali MH, Bekova K, Abdulla N, Gurugubelli S, Lin YM, Banoth D, Butt SR (2024) Adherence to nutritional supplementation, follow-up care, and lost to follow-up in post bariatric surgery patients. J Ayub Med Coll Abbottabad 36(2):417\u0026ndash;426\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang G, Pan S (2025) Optimizing postoperative recovery in colorectal cancer patients through integrated psychological and nutritional interventions. J Cancer Surviv, 1\u0026ndash;10\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWeber TK, Toporovski MS, Tahan S, Neufeld CB, de Morais MB (2014) Dietary fiber mixture in pediatric patients with controlled chronic constipation. J Pediatr Gastroenterol Nutr 58(3):297\u0026ndash;302\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Figures","content":"\u003cp\u003eFigures 1-4 and Appendix Figures 1-4 are not available with this version.\u003c/p\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":"Anorectal Malformations, Krickenbeck, SO-FFQ, morbidity, surgical outcome","lastPublishedDoi":"10.21203/rs.3.rs-7836026/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7836026/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003ePosterior Sagittal Anorectoplasty (PSARP) is recognised as the primary surgical intervention for Anorectal Malformations (ARM). However, challenges persist in addressing post-operative incontinence and constipation. Sufficient fibre and fluid intake can mitigate surgical complications, which need to optimise the roles of these factors. This study aims to ascertain the influence of a high-fibre diet and adequate fluid intake on surgical outcomes after PSARP, focusing on voluntary bowel movement, incontinence, and constipation levels.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis retrospective observational analytical study encompassed 118 patients who underwent surgery at Ulin or Siaga Banjarmasin Hospital from 2018 to 2023. Data was collected using the Krickenbeck questionnaire to determine the surgical outcome, while the Semi-Quantitative-Food Frequency Questionnaire (SQ-FFQ) guided interviews were used to determine fibre and fluid intake. A logistic regression test determined odds Ratios (ORs) and 95% Confidence Intervals (95% CI).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eMost patients had satisfactory surgical outcomes, with 65 patients (55.08%) achieving this, followed by 41 patients (34.75%) with the best outcomes, and 12 patients (10.17%) with the poorest outcomes. Patients with deficit-fibre intake were 95.4% (Adj. OR\u0026thinsp;=\u0026thinsp;0.046, 95%CI: 0.005\u0026ndash;0.447, p\u0026thinsp;=\u0026thinsp;0.008) significantly less likely to have an adequate surgical outcome compared to moderate-fibre intake, and the low-fibre intake group was 98.7% (Adj. OR\u0026thinsp;=\u0026thinsp;0.013, 95%CI: 0.001\u0026ndash;0.214, p\u0026thinsp;=\u0026thinsp;0.002) less likely to have a satisfactory surgical outcome compared to those with moderate-fiber intake. The best surgical outcome occurred in 34.7% of the group with good fluid intake.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eA high-fibre diet and adequate fluid intake positively affect surgical outcomes after Posterior Sagittal Anorectoplasty.\u003c/p\u003e","manuscriptTitle":"The Positive Impact of a High-Fibre Diet and Adequate Fluid Intake on Surgical Outcomes After Posterior Sagittal Anorectoplasty","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-18 03:37:26","doi":"10.21203/rs.3.rs-7836026/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":"260e14e6-4f5d-4804-a231-d7fc2b0e758e","owner":[],"postedDate":"November 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-19T17:23:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-18 03:37:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7836026","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7836026","identity":"rs-7836026","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}