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Author(s): Priyanka Bamoria [1]; Simmi K. Ratan (corresponding author) [1]; Shasanka Shekhar Panda [2]; Sujoy Neogi [1]; Shramana Mandal [3]; Chiranjiv Kumar [1]; Gaurav Saxena [1] INTRODUCTION Constipation is one [...], Introduction: This study was undertaken to assess the distribution of ganglion cells (GCs) and interstitial cells of Cajal (ICCs) across different points of distal rectal pouch in anorectal malformation (ARM) patients over the three stages of repair. We hypothesize that along with the surgical factors, there could be intrinsic factors as well which can be the cause of dysmotility in these patients after surgical repair. Methodology: Full-thickness colonic biopsy specimens were taken from the proximal stoma, distal stoma, and distal rectal pouch of 21 boys aged 0-8 months undergoing 3 staged repair of ARM at our tertiary care center between August 2022 and December 2023. There was an interstage interval of approximately 12-14 weeks. All underwent high-divided sigmoid colostomy in stage 1. Biopsy specimens for GC and ICC number were routinely processed, and immunohistochemistry was done for CD117. The data was assessed and compared with respect to location and stage of surgery. Results: Both GC and ICC showed a gradual decrease in mean number over three stages for both proximal and distal ends of colostomy. For proximal stoma, the distribution of either cell type did not differ across the stages, but for distal stoma, the number of cells was significantly lower in the second stage (following colostomy, before posterior sagittal anorectoplasty). However, no difference was noted between the second and third stages. This indicates that factors during/just after colostomy itself must be responsible for decrease in ICC/GC. Conclusion: Lesser number of GC and/or ICC in the distal pouch from stage 2 onward may point toward its association with projected hypomotility in ARM patients. Apart from innate distribution, we also infer that this could be consequent to vascular insult which may occur at the time of divided colostomy. Loop stoma may be a better alternative as vascularity is uninterrupted in loop colostomy. Keywords: Anorectal malformations, distal stoma, ganglion cells, interstitial cells of Cajal immunohistochemistry, posterior sagittal anorectoplasty