
==== Front
Medicine (Baltimore)
Medicine (Baltimore)
MD
Medicine
0025-7974
1536-5964
Lippincott Williams & Wilkins Hagerstown, MD

39312317
MD-D-23-10510
00018
10.1097/MD.0000000000039811
3
6200
Research Article
Observational Study
Incidence of associated anomalies in children with anorectal malformation: A 1-year prospective observational study in a low-income setting
https://orcid.org/0000-0002-7460-3205
Wondemagegnehu Belachew Dejene MD a*
Asfaw Solomon Wubetu MD mamatsoll@gmail.com
b
Mamo Tihtina Nigussie MD tihutin@yahoo.com
a
Aklilu Woubedel Kiflu MD woubedel@yahoo.com
a
Robelie Amezene Tadess MD amezene.tadesse@aau.edu.et
a
Gebru Fisseha Temesgen MD fisseha.temesgen@aau.edu.et
a
Gebreselassie Hanna Getachew MD a
a Department of Surgery, Division of Pediatric Surgery, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
b Department of Surgery, Unit of Pediatric Surgery, College of Health Sciences, Jig Jiga University, Jig Jiga, Ethiopia.
* Correspondence: Belachew Dejene Wondemagegnehu, Department of Surgery, Division of Pediatric Surgery, Addis Ababa University College of Health Sciences, Lideta Sub, Zambia St, Addis Ababa 26038 1000, Ethiopia (e-mail: belachew99@yahoo.com).
20 9 2024
20 9 2024
103 38 e3981123 11 2023
23 8 2024
01 9 2024
Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.

Anorectal malformations (ARMs) consist of a range of anomalies that are often associated with other anomalies The purpose of the study is to assess the incidence of associated congenital anomalies that are seen in patients with ARMs. An observational prospective study was conducted on 162 cases with ARM from February 2019 to January 2020, and data were collected on patient demographics, type of ARM, and associated anomalies using a prestructured questionnaire and analysis done using SPSS (IBM), version 23, software. Relevant statistical analysis was done, and the results are presented in tables and charts. Of 162 cases studied, 70 of them were males and 92 were females with a male-to-female ratio of 0.76:1. The majority of male patients (45%) had rectourethral fistulas, whereas 63% of the females had rectovestibular fistula. While 76 (47%) patients presented with isolated ARM, 86 (53%) had ≥1 associated congenital malformations. Forty-eight (30%) patients presented with a single associated anomaly, whereas 20 (12%) patients had≥3 associated anomalies. The commonest associated anomalies were urologic 26.5% followed by genital (22.8%), cardiac 20.4%, and musculoskeletal 16.6%, and 12.3% of them had vertebral; anorectal; cardiac; tracheoesophageal fistula; renal; limb association. More than half of the children have other associated abnormalities. We found urogenital anomalies to be the most common associated congenital defects. A lower incidence of cardiac and spinal cord anomalies was noted suggesting a need for active workup to be in line with the latest standards of care.

anorectal malformation
associated anomalies
congenital defects
screening
OPEN-ACCESSTRUE
SDCT
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pmc1. Introduction

Anorectal malformations (ARMs) consist of a range of anomalies that occur in approximately 1 in 5000 live births. Defects are often associated with other anomalies.[1] The rate of these anomalies differs by the type of ARM, ranging from 20% to 80% in different literatures, and involves genitourinary, cardiac, musculoskeletal (vertebral, spinal, and limb), and other gastrointestinal systems.[2] Five percent to 31% of patients with ARM tend to have vertebral; anorectal; cardiac; tracheoesophageal fistula; renal; limb (VACTERL) associations (≥3 anomalies).[3]

Associated congenital anomalies can lead to overall mortality and contribute to serious morbidity.[4] Children with VACTERL association had poorer quality of life compared to children without associated anomalies that influence the prognosis for sexual function and fertility.[5,6]

As reported by Kruger et al,[7] clinically significant anomalies may have been missed in a third of these patients, and 93% of fully screened cases showed ≥1 associated anomalies. Overall, there is a low rate of VACTERL screening practices, which underscores the importance of systematic screening for associated anomalies in children with ARMs.[8]

During the first 24 hours of life, the newborns should be evaluated for associated defects, which include esophageal atresia, cardiac, and renal anomalies. Timely assessment is necessary to identify anomalies requiring intervention and to prevent undue stress and delayed treatment.[9] The lumbar spine and the sacrum should be reviewed radiologically to look for spinal and sacral abnormalities.[10] Shaul and Harrison[11] recommended spinal ultrasonography or magnetic resonance imaging (MRI) in all neonates with ARM, even in patients who have normal plain films and low defects to rule out occult spinal pathologies such as tethered cord or lipoma of the cord.

ARM is the most common cause of early neonatal obstruction in Tikur Anbesa Specialized Hospital, Ethiopia.[12] Literature on the rates of screening and identification of associated anomalies in patients with ARMs is limited. The study was aimed at assessing the rate of occurrence of associated congenital anomalies that are seen in patients with ARMs based on clinical, operative, and imaging findings.

2. Methods

2.1. Study area and period

The study was conducted between February 1, 2019, to January 31, 2020, in Tikur Anbessa Tertiary Teaching Hospital, Addis Ababa, Ethiopia, where a significant number of pediatric colorectal cases are managed by residents, fellows, and consultants.

2.2. Source population

The source population includes all children who were admitted for the management of ARM in the study period.

2.3. Study population and sampling technique

A total of 162 children were admitted for the management of ARM in the study period. Regardless of their antenatal or postnatal conditions, all of these patients were included in the study and screened for the presence of associated anomalies.

2.4. Study design

The study was an institution-based prospective observational study.

2.5. Study variables

Study variables include age, sex, type of ARM, type of associated anomalies, and screening methods applied.

2.6. Data quality control measures

The investigators thoroughly examined patient charts and reviewed clinical findings to get as much information as possible. The questionnaires were filled out by the principal investigator during ward rounds.

2.7. Data collection tool

A structured set of questionnaires was designed according to the preset objectives. Data regarding the patient demographics, type of ARM, and associated anomalies were collected via clinical examination, imaging, and reviewing operation findings (Supplemental Material-1, Supplemental Digital Content, http://links.lww.com/MD/N629). For this study and to facilitate comparison between studies in the literature, abnormalities were categorized as genitourinary, cardiovascular, gastrointestinal, and musculoskeletal (including spinal cord). Chromosomal abnormalities were also recorded. An ultrasound (US) was performed to rule out urogenital anomalies. Micturating cystourethrogram was done for patients with identified genitourinary abnormalities during the US investigation. An echocardiogram was requested for those with cardiac auscultatory findings. Pelvic and lumbosacral radiographs were performed to look for musculoskeletal and spinal anomalies. The spinal US was done for those who were <3 months of age for spinal anomalies.

2.8. Data processing, analysis, and interpretation

For this study and to facilitate comparison between studies in the literature, abnormalities were categorized as genitourinary, cardiovascular, gastrointestinal, and musculoskeletal (including vertebra). Chromosomal abnormalities based on phenotypic features were also recorded. Data were analyzed using SPSS (IBM) for Windows, version 23, statistical software. Relevant statistical analysis was done, and the results were presented in tables and charts. P < .05 was considered statistically significant where applicable.

3. Results

3.1. Sociodemographic characteristics

A total of 162 patients between 1 day to 11 years of age with a mean age of 20 months were studied for associated anomalies. Seventy (43.2%) of the patients were males with a male-to-female ratio of 0.76:1. The Majority of them 113/162 (69.8%) presented at the neonatal age, of which 77/162 (47.5%) presented before the age of 4 days and 36/162 (22%) presented between 4 days and 1 month; 153/162 (94.4%) of them were term infants with 91% of them having a record of normal birth weight.

3.2. Clinical findings

Regarding their presentation, 80/162 (49.4%) of the patients presented with a passage of meconium or fecal matter through abnormal routes without significant signs of intestinal obstruction. During screening by physical examination, the commonest findings noticed were features of Down syndrome, signs of esophageal atresia, cardiac anomalies, and also gross abnormalities in male or female external genitalia, spine, and limbs (Table 1).

Table 1 Findings during screening for associate anomalies by physical examination.

Physical findings	n (%)	
Signs of Down syndrome	9 (5.6)	
Excessive oral secretion with failure to pass a nasogastric tube	3 (1.9)	
Respiratory distress	13 (8)	
Diaphoresis during feeds and cyanosis	6 (3.7)	
Murmur during cardiac auscultation	12 (7.4)	
Abdominal wall defect	2 (1.2)	
Abdominal mass	4 (2.5)	
Hypospadias	9 (13)*	
Undescended testis	10 (14.3)*	
Bifid scrotum	2 (2.9)*	
Scrotal transposition	4 (5.7)*	
Vaginal septum	7 (7.6)†	
Hydrocolpos	2 (2.2)†	
Abnormal spinal curvature	4 (2.5)	
Midline sacral dimple	10 (6.2)	
Polydactyly	4 (2.5)	
Syndactyly	1 (0.6)	
Club foot	7 (4.3)	
Physical examination findings of associate congenital anomalies during screening in 162 children admitted for anorectal malformation from February 1, 2019, to January 31, 2020, at Tikur Anbessa Tertiary Hospital, Addis Ababa, Ethiopia.

* Frequency of findings from 70 males.

† Frequency of findings from 92 females.

3.3. Screening by investigation

3.3.1. Echocardiography

It was done only for 35/162 (21.6%) selected patients, and 19/162 (11.7%) of them had cardiac anomalies. Of them, atrial septal defect was found on 7/19 (37%), ventricular septal defect in 5/19 (26%), patent ductus arteriosus in 2/19 (10%), tetralogy of Fallot in 2/19 (10%), and patent foramen ovale in 1 patient. Seven patients had 2 combinations of these defects, while 2 had complex cardiac disease with a combination of >2 anomalies.

Chest X-rays were done in 27/162 (16.7%) patients, and 11 (6.8%) had anomalies detected including tracheoesophageal fistula and congenital diaphragmatic hernia.

3.3.2. Renal and pelvic US

Almost all patients were scanned for renal anomalies and showed anomalies in 35/162 (21.6%) patients. Renal agenesis was found in 10/162 (6.2%) of them and hydronephrosis in 16/162 (10%) cases in combination with other anomalies such as vesicoureteral reflux in 5 patients, renal fusion anomalies in 4, and ectopic kidney in 2 cases. Voiding cystourethrography was done for 9 patients, of whom 6 had a further workup for hydronephrosis (one with unremarkable result and 5 with vesicoureteral reflux), 1 ureterocele, 1 recurrent rectourethral fistula, and 1 coiled posterior urethral course, which was requested for post anorectoplasty urinary incontinence. Intravenous pyelography(IVP) was done for 5 patients of whom 2 had megaureter, 2 nonexcreting kidneys, and another 1 showed a duplex system with ureterocele.

3.3.3. Lumbosacral and pelvic X-ray

It was done for 130/162 (80.3%) patients and showed an anomaly in 12/130 (9.2%) of them, of whom hemi sacrum and sacral agenesis were found in 5 patients each. Butterfly vertebrae in 1 patient and spinal process defect of lower vertebra in another patient. The sacral ratio (SR) was calculated in 115/162 (70%) patients to look for the sacral vertebral anomaly, the overall mean anteroposterior SR was 0.7, 8 patients exhibited an SR of ≤0.4, and these 5 patients were from rectoprostatic category and 3 from pouch colon (Fig. 1).

Figure 1. The mean sacral ratio in 115 children admitted for anorectal malformation (ARM) and screened for associated congenital vertebral anomalies by spinal and pelvic X-rays from February 1, 2019, to January 31, 2020, at Tikur Anbessa Tertiary Hospital, Addis Ababa, Ethiopia.

3.3.4. Spinal US and other imaging

The spinal US was done in 61/162 (37%) patients, and a tethered cord was found in 4 (6%) of them. MRI done for 2 patients showed lumbar epidural lipoma and sacral agenesis with caudal regression syndrome. Pelvic US shows cystic pelvic mass and omphalocele in 1 patient. A plain abdominal X-ray was done in 9 cases and was unremarkable (Table 2).

Table 2 Type of screening investigations done for associated anomalies in children with anorectal malformation.

System screened	Patients	
n	Percent of the total	
Echocardiography	35	21.6	
Renal ultrasound	160	98.7	
Voiding cystourethrography	8	4.9	
Spine/pelvic X-ray	130	80.2	
Spinal ultrasound	61	37.6	
MRI of spine	2	1.2	
Limb X-ray	0	0	
Chest X-ray	27	16.7	
Plain abdominal X-ray	9	5.5	
Type of investigations done in the screening of associated congenital anomalies in 162 children admitted for anorectal malformation from February 1, 2019, to January 31, 2020, at Tikur Anbessa Tertiary Hospital, Addis Ababa, Ethiopia.

MRI = magnetic resonance imaging.

3.4. Type of ARM

The 2 most common types of ARMs diagnosed among male and female patients were rectourethral fistula (45%) and vestibular fistula (63%), respectively. The variant of the urethral fistula could not be specified for those male children labeled unspecified because patients did not undergo definitive repair till the study time (Table 3).

Table 3 Types of ARMs according to Krickenbeck classification.

Male	Female	
Type of ARM	n (%)	Type of ARM	n (%)	
Perineal	22 (31.4)	Perineal	6 (6.5)	
Rectourethral bulbar	15 (21.4)	Vestibular	58 (63.0)	
Rectourethral prostatic	5 (7.1)	Cloaca	16 (17.4)	
Rectourethral unspecified	12 (17.1)			
Rectobladderneck	3 (4.2)	Vaginal	3 (4.3)	
No fistula	11 (15.7)	No fistula	5 (5.4)	
Rectal atresia	1 (1.4)	Rectal atresia	1 (1.0)	
Rare variant*	1 (1.4)	Rare variant†	3 (3.2)	
Total	70 (100)	Total	92 (100)	
Types of ARMs according to Krickenbeck classification in 162 children admitted for ARM and screened for associated congenital anomalies from February 1, 2019, to January 31, 2020, at Tikur Anbessa Tertiary Hospital, Addis Ababa, Ethiopia.

ARM = anorectal malformation.

* 1 pouch colon.

† Rare type: 2 pouch colon, 1 cloacal exstrophy.

3.5. Associated anomalies

While 76 patients (47%) presented with isolated ARM, 86/162 (53%) had ≥1 associated congenital malformations; 48/162 (30%) patients presented with a single associated anomaly, 18/162 (11%) had 2 anomalies, and 20/162 (12%) patients had ≥3 associated anomalies. The most commonly occurring associated anomalies were genitourinary (49.3%), of whom 26.5% of them were urologic and 22.8% of them were genital anomalies. Cardiac anomalies were seen in 20.4% of the patients as a single association or with other anomalies (Fig. 2).

Figure 2. Frequencies of associated congenital anomalies found on clinical and radiologic screening in 162 children admitted for anorectal malformation from February 1, 2019, to January 31, 2020, at Tikur Anbessa Tertiary Hospital, Addis Ababa, Ethiopia. VACTERL = vertebral; anorectal; cardiac; tracheoesophageal fistula; renal; limb.

3.6. Management of patients

Colostomy was done for 82/92 (89%) of female and 58/70 (82%) of male patients either for the relief of obstruction or as the prerequisite for the definitive procedure. Colostomy with definitive surgery was done in 26/92 (28%) of females and 2/70 (2.8%) of male patients. In male patients with perineal fistula, cutback anoplasty was done for 15/70 (21.4%) and minimal anorectoplasty for 2 of them. Posterior sagittal anorectoplasty was performed in 43/162 (35 males and 8 females), while anterior sagittal anorectoplasty was performed in 52/92 (56.6%) female patients of whom 46.7% were vestibular fistula and 3 males with perineal fistula. Definitive management was not performed during the study period in 43/162 (26.5%) patients due to their age or long elective list.

On postoperative follow-up, 9 patients had perineal wound dehiscence and failed anoplasty, and stenosis in 8 requiring redo anoplasty and dilatations. Four patients had fecal incontinence, and of them, one had sacral agenesis and the other one had an SR of 0.3. Five patients died, and 4 of them were due to sepsis (1 late presentation, 1 aspiration pneumonia from tracheoesophageal fistula, and 2 from undiagnosed cause of respiratory distress with early onset neonatal sepsis) and one due to cardiac anomalies with heart failure. However, further follow-up will be required for better analysis and correlations of complications with the type of ARM and spinal and vertebral anomalies for those who are on colostomy and have undergone definitive treatment during the study period.

4. Discussion

In this study, the majority of ARMs found were rectourethral for male and rectovestibular for female patients. There was also a relatively higher number of rare anomalies and male patients without fistula. About half of the patients exhibited ≥1 associated anomaly, which was relatively lower than the Western report. The commonest associations seen in this study were urologic anomalies followed by genital and cardiac anomalies. All deaths in our patients were directly related to associated anomalies.

4.1. Sociodemographic patterns and presentations

In this study, female patients outnumber their male counterparts slightly, with a male-to-female ratio of 0.76:1. This finding is in line with similar studies by Mfinanga et al,[13] Kayima et al,[14] Gama and Tadess,[15] and Banu et al[16] but was contradictory to the reports by Lane et al,[8] Vd Merwe et al,[17] Hasan et al,[18] Ford et al,[19] and Oh et al,[20] where males predominate. We could not find in the literature the reasons for these gender differences, and this warrants further investigation.

The age at initial presentation was statistically associated with gender (P=.001) and place of delivery (P=.005) as 70% of males presented within 3 days of life contrary to 70% of females who came after 4 days. This can be explained by the type of ARM; males present earlier with intestinal obstruction signs. Those who were born in the hospital also come earlier because of early diagnosis and referral.

4.2. Type of ARM

The majority of ARMs were rectourethral in males and rectovestibular fistulas in females followed by perineal fistulas and cloaca, which is similar to one of the largest studies published by Levitt and Peña.[1] However, the incidence of ARM without fistula was higher (15%) in male patients compared to this report, and also, there was a relatively high percentage of rare variants of ARMs, particularly in females, such as rectovaginal fistulas and pouch colon (3% each).

4.3. Associated anomalies

The frequencies of associated anomalies (53%) were low compared to studies of high-income countries, such as 71% in the United States, 77% in Singapore, 56.1% in the United Kingdom, 65% in Korea,72% in Europe, 69% in South Africa, and 58% in India,[2,17,19–22] but were higher compared to other studies in low-income countries 16.5% in Tanzania, 20% in Uganda, and 48.5% in Bangladesh.[13,14,16] This is explained by a cost-effective approach, limited access to trained pediatric surgeons, and the lack of facilities for prompt diagnosis of associated congenital anomalies in low-income countries.

4.3.1. Genitourinary abnormalities and investigations

Urologic anomalies are reported as one of the most commonly associated abnormalities found in patients with ARM.[1,20] The baseline workup for genitourinary abnormalities was a renal and pelvic US, which was performed in 98% of patients with 49.3% incidence of urogenital anomalies of which 26.5% were urologic anomalies. This rate was higher than some reports[16,18] but much lower compared to other studies of 50% to 80%,[1] which may be attributed to a large group of patients who were not routinely screened for vesicoureteral reflux in our study. However, the rate was somewhat comparable to 43.1% and 52% reported by Vd Merwe et al[17] and Goossens et al.[23] Only 6 of the patients had voiding cystourethrography done during follow-up guided by clinical and US findings with a rate of vesicoureteral reflux being 3%, which is significantly lower than reported by others ranging from 13% to 38%.[24,25] The commonest urologic anomalies detected in this study on screening were hydronephrosis in 10% and renal agenesis in 6% of the total patients with ARM.

4.3.2. Spinal and musculoskeletal abnormalities and investigations

Workup for musculoskeletal abnormalities included X-rays, US of the spine, and MRI of the spinal cord. Thirty-two (20%) patients had an associated musculoskeletal defect, which is similar to studies in the United Kingdom but lower compared to reports of 42.5% by Vd Merwe et al,[17] 28% by Mittal et al,[22] 45.5% by Stoll et al,[19,27] and 36% by de Blaauw et al.[26] The detected anomalies were vertebral (9%), limb (7%), and spinal cord (3.7%).

Calculation of the SR was made in 115 (70%) patients, and most were done in anteroposterior view because of technical difficulties in neonates and infants. In this study, it was found that SR was significantly affected in patients with recto prostatic and pouch colon, which is in agreement with most reports in the literature, that is, the higher the type of ARM, the lower the SR.

Spinal US was done in 61 (37%) and detected tethered cord in 4 (6%) patients only, which is contradictorily low compared to other studies: 25% in the study by Levitt and Pena,[1] 20% in the study by Minneci et al,[2] 13.8% in the study by Vd Merwe et al,[17] and 18% in the study by De Blaauw et al.[26] Of 7 patients who have skin stigmata of the occult spinal cord, 43% (3/7) had anomalies. This lower detection rate can be due to the lower sensitivity of US.[17,22] Another remarkable observation was that tethered cord was common in the lower type of anomalies (in perineal and vestibular fistulas) similar to other studies suggesting a need for full VACTERL screening in all patients with ARM.[8,11,28,29]

4.3.3. Cardiac abnormalities and investigations

Echocardiography was done for only 21% of patients, and this rate of screening was significantly lower than that of 68.9% reported by Minneci et al,[2] 77% by Lane et al,[8] and 79% by Vd Merwe et al.[17] The lower screening rate resulted in a lower detection rate of cardiac anomaly (11.7%) compared to other studies 31% in Europe, 20% in South Africa, 23% in Korea, and 20% in Tanzania.[13,17,20,26] This low incidence was due to our cost-effective approach as only clinically selected patients were subjected to scanning. The ability to detect a murmur will depend on the physician’s experience. In our study, 44% of patients who had cardiac anomalies were missed by clinical examination; thus, routine screening by cardiologists of all patients with ARM may be useful. Atrial septal defects and ventricular septal defects were the most common defects in this study, which is similar to most studies.

4.3.4. Gastrointestinal abnormalities and investigations

Most of these anomalies rely on a clinical presentation for detection, and confirmatory study modalities include X-rays, US, and contrast studies. Our rate of overall gastrointestinal abnormality and esophageal atresia was low 6/162 (3.7%) and 3/162 (1.8%) compared to European studies of 15% and 9% but similar to South Africa’s 4.3 and 1.8%.[16,17] These anomalies manifest within the first few days of life and their presentation can often be impressive with the ARM occasionally being an incidental finding.

4.3.5. Syndromic ARMs

Nine patients had dysmorphic features of Down syndrome and 1 patient with features of Patau syndrome with a total of 6.2%, which was lower than similar studies[17]; 22% of our patients with Down syndrome presented with fistula, which was inconsistent with widely studied associations of <5%, and this may be due to a low number of patients in our series. Twenty patients (12%) have ≥3 associated anomalies commonly referred to as VACTERL, which is within the literature range of 5% to 31%.[3,29] However, less than studies that performed complete assessment.[30]

This study assessed only the rate of occurrence of associated anomalies based on the types of ARMs and further management, and their outcome results will be followed in the future. Limitations encountered were problems in some patients’ documentation of follow-up and retrieval of X-ray results from the database.

4.4. Implication for practice and policy

Findings in this research bear multiple practical implications for the assessment of associated anomalies in children with ARM. First, this study identifies the commonest associated anomalies. It also reveals that the majority of ARM are term infants with normal birth weight. The research also highlights the significance of utilizing a screening protocol for screening associated anomalies. Moreover, the study serves as a baseline for subsequent research on this subject. These results collectively contribute to improving screening practice, management, and outcomes of children with ARM.

5. Conclusion

More than half of the children have other associated abnormalities. We found urogenital anomalies to be the most commonly associated congenital defects followed by musculoskeletal abnormalities. Lower incidence of cardiac and spinal cord anomalies was noted suggesting a need for active workup to be in line with the standards of care published by the latest literature.

Acknowledgments

The authors would like to thank pediatric surgery consultants, fellows, and residents of the College of Health Sciences, Addis Ababa University, for helping them during the data collection processes.

Author contributions

Conceptualization: Belachew Dejene Wondemagegnehu, Solomon Wubetu Asfaw, Fisseha Temesgen Gebru.

Data curation: Belachew Dejene Wondemagegnehu, Solomon Wubetu Asfaw.

Formal analysis: Belachew Dejene Wondemagegnehu, Solomon Wubetu Asfaw.

Methodology: Belachew Dejene Wondemagegnehu, Solomon Wubetu Asfaw, Fisseha Temesgen Gebru.

Resources: Belachew Dejene Wondemagegnehu, Solomon Wubetu Asfaw.

Software: Belachew Dejene Wondemagegnehu, Solomon Wubetu Asfaw.

Supervision: Belachew Dejene Wondemagegnehu, Solomon Wubetu Asfaw, Woubedel Kiflu Aklilu.

Validation: Belachew Dejene Wondemagegnehu, Tihtina Nigussie Mamo, Amezene Tadess Robelie, Woubedel Kiflu Aklilu, Fisseha Temesgen Gebru, Hanna Getachew Gebresilasie.

Visualization: Belachew Dejene Wondemagegnehu, Tihtina Nigussie Mamo, Amezene Tadess Robelie, Woubedel Kiflu Aklilu, Fisseha Temesgen Gebru, Hanna Getachew Gebresilasie.

Writing – original draft: Belachew Dejene Wondemagegnehu, Solomon Wubetu Asfaw.

Writing – review & editing: Belachew Dejene Wondemagegnehu, Solomon Wubetu Asfaw.

Supplementary Material

Abbreviations:

ARM anorectal malformation

MRI magnetic resonance imaging

SR sacral ratio

US ultrasound

VACTERL vertebral; anorectal; cardiac; tracheoesophageal fistula; renal; limb

As the study was conducted based on routine care of patients, the need for consent to participate was waived by the research ethics committee of the College of Health Sciences, Addis Ababa University. However, verbal informed consent was obtained from parents after the objective of the study was explained to them. Confidentiality was maintained throughout the research undertaking.

All methods were carried out per the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Ethical clearance was obtained from the research ethics committee of the Department of Surgery and the Institutional Review Board of the College of Health Sciences, Addis Ababa University, with Ref. No. 161/19/11.

The authors have no funding and conflicts of interest to disclose.

The datasets generated during and/or analyzed during the current study are not publicly available but are available from the corresponding author upon reasonable request.

Supplemental Digital Content is available for this article.

How to cite this article: Wondemagegnehu BD, Asfaw SW, Mamo TN, Aklilu WK, Robelie AT, Gebru FT, Gebreselassie HG. Incidence of associated anomalies in children with anorectal malformation: A 1-year prospective observational study in a low-income setting. Medicine 2024;103:38(e39811).
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