Anorectal Malformations Complications
With Dr. Mark Levitt · hosted by Dr. Todd Ponsky · Marc Levitt
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Podcast
Anorectal Malformations Complications
Marc Levitt · 48 min · Published Feb 2016
Podcast
Anorectal Malformations Complications
Marc Levitt · 48 min · Published Feb 2016
Podcast
Complications of Anorectal Malformations with Dr. Marc Levitt
48 min · Published Jan 2017
Podcast
Complications of Anorectal Malformations with Dr. Marc Levitt
48 min · Published Jan 2017
Video
Pediatric Colorectal Contraversies Part I: Pediatric Colorectal Contraversies...
Dr. Todd Ponsky · 25 min · Published Aug 2017
Podcast
Colorectal Quiz: Episode 2
Marc Levitt · 18 min · Published Jan 2021
Podcast
(500) Days of Summer (classic Movie Review: Zooey Deschanel, Joseph Gordon-Levitt, Marc Webb) by The Cory Baker Show
Marc Levitt · Published Aug 2026
Video
Dr. Marc Levitt on the CTO Mission in Pediatric Colorectal Surgery
Marc Levitt · Published Jul 2026
Video
Introducing Dr. Marc Levitt: Pediatric Colorectal Surgeon Profile
Marc Levitt · Published Jul 2026
Video
Integrated Care Concept in Pediatric Colorectal Surgery by Marc Levitt
Marc Levitt · Published Jul 2026
Video
Patient Outreach and Communication in Pediatric Colorectal Surgery
Marc Levitt · Published Jul 2026
Video
Keynote Address on Pediatric Colorectal Surgery by Dr. Marc Levitt
Marc Levitt · Published Jul 2026
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Andrea Kesar Discusses Marc Levitt's Contributions to Pediatric Colorectal Surgery
Marc Levitt · Published Jul 2026
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Hirschsprung's Disease with Dr. Marc Levitt
Marc Levitt · 22 min · Published Jul 2026
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Introduction to Dr. Marc Levitt's Pediatric Colorectal Surgery Practice
Marc Levitt · Published Jul 2026
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Meeting with Marc Levitt: Clinical Discussion with Ivon Martinez
Marc Levitt · Published Jul 2026
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The History of International Colorectal Surgery Team Development
Marc Levitt · Published Jul 2026
What the experts said
Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period.
Males with missed perineal fistula typically present in the first year of life with severe constipation after passing meconium through a very tiny fistulous orifice.
By the time of presentation, the rectum and sigmoid have dilated because stool has been passing through a very tiny fistulous orifice which is not normal anal or rectal mucosa.
The current standard is to check temperature on the forehead or in the ear rather than rectally, which means clinicians may not look at the anus and might not detect malformations.
Relocating a perineal fistula into the sphincters does not completely fix constipation, though it improves anatomy by making the hole adequately sized and lined by mucosa.
Patients with uncorrected perineal fistula can have some semblance of continence with formed stool, but will soil with loose stool or athletic activity because they cannot completely close the hole when squeezing sphincters.
A newborn anus should accept a size 12 Hagar dilator, and a one-year-old should accept a size 15.
A bucket handle (lifted skin tag that a probe can pass underneath) is consistent with a perineal fistula even when the fistula itself is not visible.
Little beads of meconium (black) or mucus (white) along the scrotal raphae are consistent with a perineal fistula.
Diagnostic criteria for perineal fistula in females: hole too close to vagina (inadequate perineal body), inadequate hole size, or hole not centered in sphincter.
If the hole is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, the patient does not need surgery—the perineal body will lengthen with growth.
Examination under anesthesia with stimulation can confirm whether a questionable hole is properly centered within the sphincter.
An anesthesia nerve stimulator ($150) with appropriate needle probes works as well as commercial Peña stimulators ($15,000).
The vast majority of male ARM patients have a rectourethral fistula at bladder neck, prostatic, or bulbar level.
Rectourethral fistula patients should not be approached primarily because the surgeon does not know where the rectum is; colostomy with distal colostogram is safer.
With posterior sagittal incision for unknown rectal location, the surgeon will find something midline, white, and shiny that might be urinary tract rather than rectum.
With laparoscopy, all rectourethral fistulas go slightly below the peritoneal reflection, making it impossible to distinguish bladder neck, prostatic, or bulbar level.
Cloaca patients have no anus and a urogenital sinus but have two completely normal ovaries with no endocrine problem.
Urogenital sinus with normal anus is a unique entity often dealt with by urologists, distinct from cloaca.
The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through by the location of the colostomy or mucous fistula.
Incompletely dividing loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections.
Transverse colostomies can prolapse and, with large rectourethral fistula, cause the left colon to absorb urine (which doesn't exit the mucous fistula), leading to acidosis.
Distal colostogram through transverse colostomy is difficult because it requires high pressure and the entire distal segment is filled with meconium that's hard to clean out.
Levitt's preference is proximal sigmoid colostomy with separated stomas, leaving the entire sigmoid loop for pull-through, with tiny flat mucous fistula.
Prolapse location depends on colostomy site: mid-transverse (both sides), hepatic flexure (distal only), proximal sigmoid (distal only because left colon is fixed to retroperitoneum).
Ileostomies prolapse frequently because they are free-floating unless tacked to the anterior abdominal wall.
Levitt marks the anoplasty location by drawing a circle around the pinkish sphincter ellipse on the skin surface before making any incision to avoid getting lost when muscles are jumping from stimulation.
Really good surgeons have put anuses in incorrect locations because they don't have a sense of center once everything is disrupted and open.
The distal colostogram is an absolutely vital study; mistakes are made from poorly done studies and misinterpretation.
The basic colostogram questions are: where is the rectum, how low is it, is it reachable posterior sagittally or better approached laparoscopically, and what is its relationship to the urinary tract.
Common colostogram error: insufficient contrast and pressure give false impression that rectum is high or that there's no fistula.
If the distal colostogram shows a straight line at the bottom of the rectum corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure to overcome sphincter compression.
With adequate pressure, the colostogram shows a bulging rectum at the bottom and evidence of a fistula, revealing exactly where the rectum is.
Fistula classification: if at the urethral 'elbow' or below, it's bulbar; above the elbow is prostatic; at bladder neck is bladder neck fistula.
If opening posterior sagittal without knowing rectal location, the surgeon will find a whitish shiny structure that might be bladder neck rather than rectum.
When opening posterior sagittal for rectourethral fistula, if the rectum is right under the coccyx it's usually prostatic; distal to coccyx is usually bulbar.
Bladder neck fistulas are not reachable posterior sagittally and are better approached laparoscopically, as are very high prostatic fistulas with tapered rectums.
Bulbar and bulbous prostatic fistulas can be found right under the coccyx and are preferably done posterior sagittally rather than laparoscopically.
Some surgeons use a catheter with balloon in the mucous fistula or a gastroscope to look for light intraoperatively to locate the rectum, though Levitt doesn't use these techniques.
Surgeons should never go to the operating room without knowing exactly what anatomy to expect; the key question is where is the rectum and is it the most posterior structure.
Bulbar or low prostatic fistulas with bulging rectum are more easily approached posterior sagittally; high prostatic with tapered narrow rectum is best served by laparoscopy.
Attempting laparoscopy for bulging rectum below peritoneal reflection (low prostatic/bulbar) requires unnecessary extra work and risks leaving behind a remnant of the original fistula (ROOF).
Attempting posterior sagittal approach for high rectum is very difficult to mobilize and risks urinary tract injury; these cases are best served laparoscopically.
Levitt performs a mini-PSARP when doing laparoscopy to safely enter the pelvis through the peritoneal reflection and to tack the rectum to the posterior edge of the muscle complex to avoid prolapse.
Prolapse is very common after laparoscopic pull-through if the rectum is not hitched to the pelvis or tacked to the muscle complex.
Prolapse prevention measures include: putting rectum in right location, properly closing levators, closing posterior wall to posterior edge of muscle complex for 3-4 stitches, and not over-dissecting the rectum.
Prolapse occurs in about 3% of cases, particularly in those without great muscles.
Rectal prolapse causes bleeding, mucus, and can inhibit bowel control in patients with good potential because they cannot close the opening with prolapsed tissue through it.
Levitt treats prolapse of more than 3mm, trimming it ideally while the colostomy is still in place.
For circumferential prolapse, Levitt performs half the circumference in two different ambulatory settings, which families prefer to hospitalization and eliminates need for dilation since half the circumference is untouched.
Perineal body dehiscence is the most common cause of reoperation in female ARM repairs.
The key to preventing perineal body dehiscence is complete mobilization of the anterior rectal wall from the posterior vaginal wall to reach the areolar plane and avoid tension on the anoplasty.
Levitt uses 3-0 suture for perineal body closure in babies and 4-0 Vicryl on perineal skin.
Levitt traditionally used 7-day NPO on 10% dextrose but is now trialing clear liquids only for a week, recognizing the major problem is hard stool rather than stool volume.
The major risk of regular diet and early discharge is hard stool passing through the repair, splitting it open and causing dehiscence.
If perineal body dehiscence is detected on days 5-8, Levitt takes the patient back to OR to re-suture, which can salvage the situation; by 3-4 weeks the whole thing is dehisced and nothing can be done.
Laparoscopy causes trouble if attempting to dissect a rectum that's too low, risking getting too close to urinary tract or being too timid and leaving behind remnant of original fistula.
Passage of trocar through small perineal incision is risky; Levitt makes a 3-4cm posterior sagittal incision and hugs the hollow of the sacrum for safer passage into the pelvis.
For high rectums (especially bladder neck fistulas), dissection of distal rectum is challenging to achieve adequate reach with good blood supply.
The IMA must be preserved because prior colostomy disrupted collaterals down the left colic, making the rectum completely dependent on the IMA.