**Background:** Anorectal malformations (ARM) affect 1 in 3000–5000 children. Despite surgical repair, a significant proportion experience persistent bowel dysfunction, including constipation and fecal incontinence. While anorectal defects are well-recognized contributors, the role of colonic motility in this cohort is poorly understood. Manometry offers a direct method to assess colonic motor function.
**Methods:** This systematic review was conducted per PRISMA guidelines with a prospectively registered protocol (PROSPERO CRD42020177344). Four databases (Embase, MEDLINE, PubMed, Cochrane Library) were searched from January 1, 1985 to July 22, 2021. Inclusion criteria: post-operative colonic manometry in children (0–18 years) after ARM repair; English language; observational studies or clinical trials. Two authors independently screened and extracted data. Quality was assessed using the Newcastle-Ottawa Scale (NOS).
**Key Results:** Of 256 unique records, 4 studies met inclusion criteria (Burjonrappa 2010; Demirogullari 2010; Heikenen 1999; van den Berg 2006). The combined total cohort comprised 151 children, of whom 35 (21 male, age range <2–18 years) with ARM underwent post-operative colonic manometry. Median manometry cohort size was 10 (range 2–13). ARM type was reported for 25 children: high (n=9), low (n=4), cloacal (n=1), and by fistula location (anovestibular n=1, perineal n=4, rectourethral n=2, rectovaginal n=1, rectovesical n=1, vestibular n=2). Associated anomalies were reported in only 2 studies (5 children with sacro/spinal anomalies). Operative repair type was described by only 1 study. Quality appraisal using NOS identified poor quality across all eligible studies.
Three studies used water-perfused catheters with 4–8 sensors at 10–15 cm intervals; one did not report equipment. No study used high-resolution manometry. Bowel preparation varied (sodium phosphate, polyethylene glycol, or overnight fast alone). Sedation or general anesthesia was used in 3 studies. Catheter placement was via colonoscopy with guidewire (2 studies) or colonoscopy with fluoroscopy (1 study); no study described intraluminal catheter securement.
HAPCs were the most commonly assessed parameter, but no two studies used the same definition. Heikenen et al. defined HAPCs as contractions ≥80 mmHg amplitude, ≥10 s duration, propagating ≥30 cm; Demirogullari et al. used ≥60 mmHg amplitude; van den Berg et al. used ≥60 mmHg, ≥10 s, ≥30 cm. Heikenen et al. found HAPCs in all 10 children with ARM, with 81% propagating to the neorectum (vs. a proposed norm of 14%). Demirogullari et al. identified HAPCs in 60% (6/10) of children with ARM, and propagated contractions reached the rectosigmoid in only 40% (4/10). Following Bisacodyl, 70% of ARM children showed HAPCs vs. 40% of children with severe colonic dysmotility (p=0.019). Van den Berg et al. identified post-Bisacodyl HAPCs in 60% (6/10) of ARM children; normal colonic motility was found in 4/9 with proximal data. Total absence of HAPCs was associated with poor cecostomy response. Burjonrappa et al. reported undefined "hyperperistalsis" in both patients studied.
Bowel function assessment was inconsistent: only Burjonrappa et al. used a validated instrument (Modified Wingfield Score); van den Berg et al. used a study-specific questionnaire; two studies did not report their assessment approach. Among van den Berg et al.'s ARM subgroup, 90% had more-than-occasional fecal incontinence and 60% had bowel movement frequency <5/week.
**Clinical Implications:** This review reveals a striking paucity of evidence on colonic motility in children after ARM repair. The four available studies are limited by heterogeneous protocols, low-resolution manometry, poor reporting of surgical and clinical characteristics, and lack of standardized outcome measures. No commonly reported conclusions could be drawn. The suggestion that altered colonic motility—particularly excessive HAPC propagation to the neorectum—may contribute to fecal incontinence requires confirmation with high-resolution techniques. Future research must emphasize standardized manometry protocols (including ≤2 cm sensor spacing), robust reporting of ARM type, associated anomalies, operative repair, and validated bowel function assessments. High-resolution colonic manometry may identify clinically relevant motor patterns (e.g., cyclic retrograde motor activity at the rectosigmoid junction) that could inform management of post-operative bowel dysfunction.