Despite significant developments in the understanding of the pathological anatomy and physiology, and innovation of novel surgical techniques, the results of surgical therapy of ARM remain far from perfect. Completely normal bowel function, comparable to that of healthy individuals, is not possible in many patients with high and intermediate malformations. At present it is evident that PSARP and its modifications can improve the dismal outcome found in adult patients who have undergone conventional repairs. It remains to be seen whether novel mini-invasive lapa-roscopic techniques further improve the promising results that have been achieved with PSARP. Clearly the most important role of a pediatric surgeon in the management of patients with ARM is to perform as optimal repair as possible, taking into account the unique anatomy of each patient. An optimal operation restores normal anatomy and preserves all potential sphincter structures. Secondary surgery for failed or inadequate primary reconstruction is unlikely to provide results that are comparable to those achieved following a successful primary operation. In contrast to more or less commonly accepted earlier assumptions, many patients with low malformations also have functional problems that continue beyond childhood. Therefore, not only the patients with high anomalies, but all patients with ARM need careful follow-up, preferably in a specialized unit, throughout their childhood. Functional complications, especially treatable ones, such as constipation, should be detected and treated early to achieve an optimal outcome. The treatment of defective continence should be commenced well before the child reaches school age to overcome the devastating social consequences of fecal soiling and to integrate the child to the social context of his peers. Because the management of ARM requires years of commitment and special knowledge concerning the anatomical and physiological characteristics of this complex group of congenital malformations, these children should be treated by specialized medical personnel in specialized referral centers.
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