Abstract

Introduction: Previous generations of pediatric surgeons demonstrated the presence of an anal canal in low anorectal malformations (ARMs). A cutback procedure, which preserved the anal canal, yielded good results in 90% of patients. For high types, pull-through surgery with passage of the rectum through the puborectalis muscle (PRM) loop was recommended. In 1982, Peña described a pull-through surgery using a posterior sagittal approach, which involved cutting the PRM loop and claimed good functional results, although he never compared them with the results of other surgeries. He also supported the idea that the type of ARMs called ectopia anus in vagina, which had a narrow vagina, is “persistent cloaca”, which should be treated as if they were children with a true cloaca. The aim of the research is to analyze the pathological anatomy and physiology of the ARMs, including persistent cloaca.
Results: All of Peña’s claims about the pathological anatomy and physiology of the ARM, justifying posterior sagittal anorectoplasty (PSARP), lacked scientific substantiation. Claiming PSARP to be the ideal procedure, he proposed using it in patients with low-type ARMs. Comparison of results using the same assessment method shows poor results after PSARP. All patients suffer from varying combinations of fecal incontinence and chronic constipation. By this time, information had emerged that the anal canal is also present in high-type ARMs. Peña et al. describe the typical function of the anal canal in urethral fistulas but refer to it as the rectum, which supposedly justifies the use of PSARP, which destroys the anal canal. Secondly, by calling patients with ectopic anus in a narrow vagina “persistent cloaca,” he claimed that their bladder and urethral function were damaged without scientific evidence. The surgeries he proposed led to severe consequences. At the same time, evidence was described in the literature that these girls have normal urinary function.
Conclusion: Based on this analysis, the manuscript argues that preservation of the native anal canal and urinary structures may be possible in a substantial proportion of patients, resulting in normal fecal continence and defecation. Proposes alternative pathogenetic interpretations of several ARMs. The purpose of this work is not merely to challenge established views, but to encourage critical scientific discussion regarding the relationship between clinical experience and evidence-based medicine in pediatric colorectal surgery. A review of the literature suggests that a reconsideration of attitudes toward PSARPs has already begun. Recently, articles have been published on new surgical approaches proposed since PSARP damage muscle structures.

Keywords

anorectal malformations; posterior sagittal anorectoplasty; cutback procedure; pediatric colorectal surgery; persistent cloaca; Peña’s experience; evidence-based medicine