Validation of the SAIS and AFQoL Scoring Systems for Predicting Fecal Continence and Quality of Life in Patients with Anorectal Malformations: A Cohort Study

Introduction: Current ARM classification systems focus primarily on anatomical variations and surgical techniques but do not comprehensively address long-term functional outcomes and QoL impact. To address these limitations, we introduce two novel scoring systems in this study: 1- Sacral Anomaly and Incontinence Severity (SAIS) Score, a novel metric integrating sacral morphology (hypoplasia or agenesis) with incontinence severity to enhance the predictive accuracy of continence outcomes. 2- Anorectal Function and Quality of Life (AFQoL) Score, a focused scoring system designed to quantify the psychosocial and functional burden of incontinence in ARM patients, capturing the impact on daily activities, social integration, and mental well-being.

Methods: This study was a retrospective cohort analysis conducted at a single pediatric surgery unit, focusing on 157 patients with anorectal malformations (ARMs) operated on by (posterior sagittal anorectoplasy PSARP). Sacral Development Assessment (SAIS Score), sacral function was quantified using the Sacral Anomaly Index Score (SAIS): Hypoplasia (≤4 sacral vertebrae) and agenesis (≤2 sacral vertebrae) were determined via pelvic X-ray and MRI. Psychosocial impact and health-related QoL were evaluated using the Anorectal Malformation Quality of Life (AFQoL) score, assessing: Social limitations due to fecal incontinence, impact on daily activities, psychological distress, and self-perceived severity of symptoms. Descriptive Statistics, mean values ± standard deviations were used for Kelly, SAIS, and AFQoL scores. All analyses were performed using SPSS (v26.0) with statistical significance set at P = 0.05.

Results: SAIS ≥9 predicted severe incontinence with 91% sensitivity and 88% specificity. Optimal SAIS cutoff for predicting severe incontinence: ≥9 (92% positive predictive value). Optimal SAIS cutoff for predicting favorable continence: ≤3 (96% negative predictive value). A strong negative correlation exists between AFQoL (quality of life) and Kelly (bowel function) scores across all ARM groups. A significant correlation (r = 0.84, P < 0.01) between AFQoL and incontinence rates, validating AFQoL’s sensitivity in capturing real-life disease burden.

Conclusion: This study provides strong clinical validation for the SAIS and AFQoL scores in predicting fecal continence and quality of life in ARM patients. SAIS is a reliable predictor of incontinence severity, with higher scores (≥8) strongly correlating with poor bowel function. AFQoL effectively quantifies QoL impairment, demonstrating excellent predictive accuracy for severe psychosocial distress. These novel scores provide clinicians with objective, standardized, and actionable tools for risk stratification, patient counseling, and personalized treatment planning.