Anorectal Malformations Complications
With Dr. Mark Leavitt · 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
ARMs in Neonates: Pediatric Colorectal Controversies 2014
105 min · Published Apr 2012
Video
Anorectal Malformation Management of Female Patients Part I: Pediatric...
26 min · Published Apr 2012
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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Video
Andrea Kesar Discusses Marc Levitt's Contributions to Pediatric Colorectal Surgery
Marc Levitt · Published Jul 2026
Video
Colorectal and Pelvic Reconstruction Techniques with Dr. Marc Levitt
Marc Levitt · Published Jul 2026
Podcast
Hirschsprung's Disease with Dr. Marc Levitt
Marc Levitt · 22 min · Published Jul 2026
Video
Introduction to Dr. Marc Levitt's Pediatric Colorectal Surgery Practice
Marc Levitt · Published Jul 2026
Video
Meeting with Marc Levitt: Clinical Discussion with Ivon Martinez
Marc Levitt · Published Jul 2026
Video
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 fistulas typically present in the first year of life with severe constipation
The standard now is to not check rectal temperature but to check temperature on the forehead or in the ear, which means you don't have to look at the anus
Relocating a perineal fistula into the sphincters does not completely fix constipation, though it improves the anatomy
A newborn anus should be Hagar dilator size 12, and a one-year-old should be size 15
A bucket handle skin tag is consistent with a perineal fistula, and you can pass a probe underneath it
Beads of meconium (black) or mucus (white) along the scrotal raphae are consistent with a perineal fistula
If the hole is of adequate size and centered in the sphincter, even if appearing slightly anterior with a short perineal body, the patient does not need surgery
You can do examination under anesthesia and stimulate to confirm whether the hole is properly centered within the sphincter
An anesthesia nerve stimulator costs $150 compared to $15,000 for a dedicated Pena stimulator and works just as well with different needles
The vast majority of male ARM patients will have a rectourethral fistula
All rectourethral fistulas go slightly below the peritoneal reflection, making it difficult to distinguish bladder neck, prostatic, or bulbar level by laparoscopy alone
Patients with rectourethral fistulas should be managed with colostomy and distal colostogram rather than primary repair
A cloaca patient can present at six months with constipation, having been successfully stooling out the cloaca
Ambiguous genitalia with clitoromegaly and a urogenital sinus has a completely normal anus, distinguishing it from cloaca which has no anus
The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through
Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections
Transverse colostomies with large rectourethral fistulas cause the left colon to absorb all the urine, potentially causing acidosis
Prolapse is related to where in the colon you choose to do the colostomy; mid-transverse can prolapse on both sides, hepatic flexure only distally, proximal sigmoid only distally
The anoplasty location should be marked on the skin surface before making any incision to avoid getting lost when looking at jumping muscles from the stimulator
If you see a straight line on the bottom of the rectum on distal colostogram corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure
If the fistula is at the urethral elbow or below, it's bulbar; above the elbow is prostatic; at the bladder neck is bladder neck fistula
When opening posterior sagittally without knowing rectal location, you will find a whitish shiny structure that may be bladder neck, not rectum
Prostatic fistulas are usually right under the coccyx; bulbar fistulas are distal to the coccyx, nearly at the perineal skin
Bulbar or low prostatic rectums with a bulge are more easily approached posterior sagittally; high prostatic tapered rectums are best served by laparoscopy
Laparoscopy for a bulging rectum below the peritoneal reflection risks leaving behind a remnant of the original fistula (roof)
Laparoscopy replaces laparotomy but should not give away the advantages of PSARP; a mini-PSARP allows safe entry and rectal fixation to prevent prolapse
Prolapse occurs in about 3% of cases, particularly in those without great muscles
Rectal prolapse more than about 3 millimeters should be trimmed, ideally when the patient still has their colostomy
Circumferential prolapse can be done in two stages (half the circumference each) in ambulatory settings, avoiding hospitalization and the need for dilation
The most common cause of reoperation is female repair in which the perineal body dehisces
Proper anterior rectal wall mobilization requires getting to the areolar plane between rectum and vagina to avoid tension on the anoplasty
Perineal body closure should use 3-0 suture in a baby and 4-0 Vicryl on the perineal skin
Traditional management is NPO for seven days on 10% dextrose; recently trialing clear liquids only for a week to prevent hard stool without complete NPO
If perineal body dehiscence is caught on day five to eight, taking the patient back to OR to re-suture can salvage the situation
The rectum after colostomy is completely dependent on the IMA because collaterals down the left colic may have been disrupted
Continence potential can be predicted by three factors: original malformation type, sacral ratio, and spine quality (the ARM continence index)
A bulbar fistula with sacral ratio of 1 and normal spine should absolutely have bowel control
A bladder neck fistula with sacral ratio of 0.4 and tethered cord or myelomeningocele has no chance of good bowel control
Initial management of soiling four-year-old is mechanical bowel management with enemas to achieve cleanliness, then trial laxatives for those with continence potential