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Dear colleagues!

I  have sent an analysis of the problem of anorectal malformations to 24 pediatric surgeons 13/08/16. Only Dr.  Einar Arnbjörnsson responded to my request to start a discussion. And it is very sad.

To demonstrate the need for such a discussion, I propose to analyze the case, described Yang G1 et al in "BMC Pediatr". 2016 May 13; 16: 65. (Imperforate anus with rectopenile fistula: a case report and systematic review of the literature.)

 At the diagram (C) of the X-ray study, presented by the authors, I have outlined the contours of a terminal intestine and I drew a pubococcigeal line. The rectum (R) is located cranial to this line, and the anal canal (Ac) is located caudal to it. On urethrography the opening of the bladder neck (internal urethral sphincter) in the form of a cone, the tip of which faces the urethra are  seen. Puborectalis muscle which separates the rectum from the anal canal, is located below the internal urethral sphincter.  The yellow continuous line represents the narrow rigid fistula extending into the subcutaneous tissue from the anal canal into the urethra. The length of the anal canal in full-term newborns is ~1.7 cm. The distance between the anal fossa (the end of long marker) and caudal contour of the anal canal is equal to the thickness of the skin and subcutaneous tissue, ie, 2-3 mm (Figure).

Pathophysiology.  Formation of the proximal part of the anal canal is derived from the endoderm. At the level of the subcutaneous tissue without encountering coming toward him the  channel from exoderm, the anal canal directed its proteolytic activity ahead upto the junction with the urethra. Narrow fistula is not able to drain the rectum.  On day 4 in the rectum has accumulated a large amount of meconium, which led to an increase in rectal pressure and the disclosure of the anal canal. Pressure is so strong that the anal canal is likely is constantly opened and filled meconium.  

Pathophysiological treatment:

Perforation of the perineum from anal fossa through the ring of the stretched subcutaneous portion of the external anal sphincter into the rectum. Introduction  into the rectum the tube of diameter 0.8 см. A week later, the tube can be removed and begin bougienage the anus. ("The pathophysiology of anorectal malformations. From a new concept to a new treatment". On my website: ).

It is not necessary to dissect the anal canal and sew of its edges to perineal skin. The anal canal retains an amazing ability to regenerate after the birth. After this procedure,  the fecal retention and defecation do not differ from the norm. If the fistula did not obliterating, the problem can be solved later. 

In the illustration "B"  is visible the part of the operation, which is made based on the idea that the anal channel in children with anorectal malformations absent. Why pediatric surgeons do not know and do not want to know: who, when and on what basis struck the anal canal from the representations about the anorectal malformations?

Michael Levin

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