1. About achalasia

2. Open letter to Mr. Peña

3. Motility of the stomach in health and disease

4. Duodenal Motility

6. Anorectal reflexes

5. Enema & Cenna

7. Hirschsprung's Disease

8. GERD -Pathophysiology



Figure 2. Figures from the peer-reviewed article.

  1. The marker is located near the anal dimple. B. The marker is located in the significant distance from the anal dimple. My asterisk is located near the anal dimple.  P-C: pubococcygeal line. C. The marker is located outside the body of patient.

Because of these errors, a false idea is created about the great remoteness of the distal contour of the open anal canal from the anal dimple. In fact, the distance between the open anal canal and the skin is from 2 mm to 5 mm, depending on the age and represents the thickness of the skin and subcutaneous tissue [8].

An accurate determination of the level of ARM is easier and safer to determine 24 hours after birth, when the rectum is filled with a large volume of gas and meconium. The abdominal compression causes: an increase of the rectal pressure to the threshold level, the opening of the anal canal and the penetration of the gas into the distal gut, what outlines the distal contour of the anal canal. This reflex acting lasts a few seconds. For its registration it is necessary the fluoroscopic observation (Figure 3).

Figure 3. Lateral radiographs of a newborn boy with ARM, made in a horizontal position (my observation). A. At rest. B.

After accidentally introducing a contrast agent into the soft tissues of the perineum instead to the rectum.  As a result of the reflex opening of the anal canal, the distal anal wall approached the anal dimple.

  6. At the augmented-pressure distal colostomy, the administration of the contrast agent is performed under uncontrolled pressure, which is significantly higher than the rectal pressure required for the reflex opening of the anal canal [9]. As a result, there is a mechanical opening of the anal canal, which continues all the time while this pressure is maintained. Such pressure can lead to rupture of the intestinal wall.  


I believe that readers of the journal who are involved in the diagnosis of ARM and perform the surgical operations deserve to know the normal anatomy and physiology of anorectal area, as well as the pathological anatomy and physiology of the ARM. The best way to achieve this is open discussion on the pages of the journal pediatric surgery.

   Surgery of the anorectal area in children is part of the general gastroenterology. It is important that data and results are communicated and compared accurately. For that to happen, the terminology used must be precise and uniform [10].   


  1. Kraus SJLevitt MAPeña A. Augmented-pressure distal colostogram: the most important diagnostic tool for planning definitive         surgical repair of anorectal malformations in boys.  Pediatr Radiol. 2018 Feb;48(2):258-269.

  2. Peña A, Devries PA. Posterior sagittal anorectoplasty: important technical considerations and new applications. J Pediatr Surg. 1982 Dec;17(6):796-811.

  3. Bharucha AE. Pelvic floor: anatomy and function. Neurogastroenterol Motil. 2006 Jul;18(7):507-19. Review.

  4. Mittal RK, Bhargava V, Sheean G, et al. Purse-string morphology of external anal sphincter revealed by novel imaging techniques. J Physiol Gastrointest Liver Physiol. 2014 Mar;306(6):G505-14

  5. Raizada V1, Mittal RK. Pelvic floor anatomy and applied physiology. Gastroenterol Clin North Am. 2008 Sep;37(3):493-509, vii. doi: 10.1016/j.gtc.2008.06.003.

  6. Kim AY. How to interpret a functional or motility test - defecography.J Neurogastroenterol Motil. 2011 Oct;17(4):416-20. doi: 10.5056/jnm.2011.17.4.416.

  7. Levitt MA1, Peña A. Anorectal malformations. Orphanet J Rare Dis. 2007 Jul 26;2:33.

  8. Levin MD. https://www.anorectalmalformations.com.

  9. Levin MD. The role of the external anal sphincter in the physiology of the pelvic floor. Pelviperineology. 2017 Dec;36(4):108-12.

  10. Bordeianou LG1, Carmichael JCPaquette IM,  Consensus Statement of Definitions for Anorectal Physiology Testing and Pelvic Floor Terminology (Revised). Dis Colon Rectum. 2018 Apr;61(4):421-427.  

9. Why do children suffer after an enema?

© 2015 Created by Dr. Levin Michael