Two Trends in Modern Treatment of Anorectal Malformations

Author(s): Michael D. Levin

For 40 years, citing the decisions of the Krickenbeck classification, Peña and his followers blocked the publication of articles that contradicted Peña's experience, even though all of Peña's innovations had no scientific basis. Peña’s false claims about the absence of an anal canal in anorectal malformations (ARMs), the insignificant role of the puborectalis muscle, and the significant role of the subcutaneous portion of the external anal sphincter served as a justification for posterior sagittal anorectoplasty (PSARP). Since 1982, most pediatric surgeons have used PSARP, which destroys the anal canal. The poor treatment outcomes were explained by the congenital absence of the anal canal and spinal pathology. Alberto Peña managed to convince practicing physicians that his experience, not the results of scientific research, solves all the problems of pediatric colorectal surgery. Massive propaganda has created a generation of pediatric surgeons ignorant of the anatomy and physiology of the anorectal area, both in normal and ARMs. Because of their belief in Peña's infallibility, pediatric surgeons ignore articles that irrefutably prove the presence of an anal canal, the preservation of which ensures normal continence and defecation. A review of the literature revealed two trends. (1) Some pediatric surgeons who recently promoted PSARP, understand its destructive nature and are moving to less traumatic procedures (2). Another, more widespread category of pediatric surgeons employs methods far from scientific to assert status quo that prevents scientific research to improve treatment for patients with ARMs.