Anorectal Malformations with Visible Fistulas: Theoretical Substantiation of a New Version of the Cutback Procedure

Author(s): Michael D. Levin, MD, PhD, DSc*

An analysis of the literature on the pathological physiology of anorectal malformations (ARM) with visible fistulas (perineal and vestibular) was performed. Histological, manometric, and radiological studies support the findings of Stephens and his followers that the bowel below the pubococcygeal line is a normally functioning anal canal, with an anterior displacement of the anus. The results of the cutback procedure, which completely preserves all elements of the anal canal, are distributed as follows (good - 85-90%; fair - 8-15%; poor ≈ 2%). After the introduction of posterior sagittal anorectoplasty (PSARP) without any scientific evidence, the ectopic anal canal was called a fistula, and pediatric surgeons began to destroy all elements of the anal canal. Applying the same method of evaluating long-term results after PSARP, we obtained the following results: - good -?; fair ≈ 40%; poor ≈ 60%). We have proposed a modification of the cutback procedure that differs in that, to simplify the management of postoperative patients and to avoid bougienage of the newly created anus, a tracheostomy tube with a diameter of 1.3–1.5 cm is inserted into the rectum. In the rectum, the balloon is inflated to fix the tube. Previously dissected skin, subcutaneous tissue, and the wall of the anal canal are sutured with single sutures from the ectopic anus to the tube. Conclusion: Analysis of studies on the pathophysiology of ARM with visible fistulas indicates the presence of a normally functioning anal canal. A great advantage of the cutback procedure compared to PSARP has been shown. We substantiated the modification of the cutback procedure, which facilitates the postoperative management of the patient, excludes bougienage of the newly created anus, and prevents the development of chronic constipation.