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Dear colleagues!

I want to answer the question posed by yous in the title of the article "Females with Externally Visible but Stenosed Fecal Orifice - Low or High Anorectal Malformation" [1].


I. Anorectal malformations (ARM) with vestibular fistula are always low type. This means that patients  have an anal canal and these defects should be considered a vestibular ectopy of the anus. Understanding this is extremely important to preserve all elements of this anal canal.


II. X-ray studies were made unprofessionally. Radiographs should be done in the lateral projection to determine the length of the anal canal and the condition of the puborectalis muscle (see article " Radiological anatomy of the colon and anorectum" in my site:


III.  In each case, there was a megareсtum, which is caused by fecal impaction due to the stenotic and rigid outlet orifice.  The surgeon's task is to achieve a normal emptying of the rectum. Only in this case, in children of the first months of life can achieve a gradual normalization of the rectal size. As you saw, attempts at dilatation are futile.  In such cases, the only way is double cutting of the stenotic ring.


IV. In case 1, the enlarged rectum is filled with contrast medium, and the anal canal, as in the norm, is in a closed state. Your conclusion about "a narrow vestibular fistula" is erroneous. (see article “Pathophysiology of the anorectal malformations with fistula to the perineum and vestibule” in my site:



  1. In all patients, you have removed the internal anal sphincter.

  2. You cut off the superficial portion of the external anal sphincter from the coccyx.

  3. You detached the levator ani muscle from the anal canal.

  4. You did not save the puborectalis muscle.

  5. After your operations there were ruptures in the deep and subcutaneous parts of the external anal sphincter.

Counter question: Is it possible to expect a good functional result after the functioning anal canal with an anteriorly displaced orifice has been converted into a fistulous tract? 



Arunachalam P1, Sen S1, Sam CJ1, Meenalosani B1.

Females with Externally Visible but Stenosed Fecal Orifice - Low or High Anorectal Malformation. J Indian Assoc Pediatr Surg. 2017 Apr-Jun;22(2):124-125. doi: 10.4103/jiaps.JIAPS_217_16.


Yours faithfully

Michael Levin


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