The hidden mortality of imperforate anus.

BACKGROUND: Anorectal malformations (ARMs) affect 1 in 4000-5000 births and are a big challenge in western countries. However, little is known about ARMs in Africa. The aim of this study is to evaluate the incidence, treatment and outcome of ARMs in Malawi.
MATERIALS AND METHODS: Over a 4-year period (2006-2009), data was extracted from patients up to and including the age of 5 years or less who underwent a colostomy, posterior sagittal anorectoplasty or colostomy closure.
RESULTS: Of the data that could be retrieved 46 patients met the criteria of congenital ARMs; 65.2% were female (N = 30) and 34.8% were male (N = 16). The median distance from patient to the hospital was 79 km and the median age at presentation was 24 days. In female patients: The most common ARM was the vestibular fistula (N = 21; 70%), a recto-vaginal fistula was found four times, a cloaca was found three times and a perineal fistula or no fistula were both found once each. The most common ARM among boys was the recto-urethral fistula (N = 10). Two boys had no fistula. A perineal fistula and a recto-vesical fistula were both found once each. Nearly, half of the patients (N = 22) had complications. Complications occurred less often in the group, which lived closest to the Surgical Unit (25%). Associated anomalies were found in one patient.
CONCLUSION: This study shows a skewed distribution of age at presentation and type of ARM. The most likely explanations are (1) the distance to the hospital: Because none of the male patients presented after 4 weeks and many may have passed away before arriving at the tertiary care centre; (2) lack of knowledge among primary caregivers since very few patients with rectoperineal fistulas were seen. The rate of complications was high, probably also related to advance age at presentation. Therefore, Malawi needs more awareness for earlier detection and quicker intervention.