History of Anorectal Malformations Treatments
Imperforate anus, a condition treated by the Colorectal Center at Cincinnati Children's Hospital Medical Center, has been a well-known and well-recognized condition since antiquity.
For many centuries, physicians, as well as individuals who practiced medicine, created an orifice in the perineum of children with imperforate anus. Some of these children survived. Most likely, they suffered from a type of defect that would now be recognized as "low".
Those with a "high" defect did not survive that kind of treatment. Amussat, in 1835, was the first individual who sutured the rectal wall to the skin edges, which could be considered the first actual anoplasty.
During the first 60 years of the 20th century, surgeons performed a perineal operation without a colostomy for the so-called low malformations.
High imperforate anus was usually treated with a colostomy performed in the newborn period, followed by an abdomino-perineal pull-through some time later in life, but surgeons lacked rational objective anatomic guidelines. Unfortunately this left many patients incontinent and was not an appropriate solution to the spectrum of malformations.
Considered the founders of pediatric surgery in North America, doctors William Ladd and Robert Gross, then at Boston Children's Hospital had a concept about the anatomy of anorectal malformations and published this in a textbook written by Dr. Robert Gross in 1953.
However, their anatomy was speculative, and too simplistic, they conceived that the connection between the rectum and the urinary tract was a long narrow "H" type fistula.
Dr. Douglas Stephens, from Melbourne Australia, made a significant contribution to the field by dissecting infants that had died from anorectal malformations. His view, however, was skewed because only those babies with the most severe malformations did not survive.
In 1953, Stephens proposed an initial sacral approach followed by an abdominoperineal operation, when necessary. The purpose of the sacral stage of the procedure was to preserve the puborectalis sling, considered a key factor in maintaining fecal continence.
Dr. Alberto Peña, while training at Boston Children's Hospital in 1969, met Dr. Justin Kelly, a trainee of Dr. Douglas Stephens.
Dr. Kelly taught surgeons at Boston Children's Hospital the Stephens technique, which involved a small sacral incision and a blind dissection near the urethra with the goal of pulling the rectum through the puborectalis sling.
In 1972, Dr. Peña returned to Mexico City as Chief of Pediatric Surgery where he asked his attending surgeons to select an area of expertise to work on. No one chose anorectal malformations so he took it on as his area of interest.
Dr. Peña began to operate on patients with the Stephens approach he learned in Boston but became extremely frustrated that the exposure was not adequate. Over an eight-year period, through 56 patients, Dr. Peña made his surgical incisions longer and longer to better see the anatomy.
Dr. Peña presented his experience to the Pacific Association of Pediatric Surgeons in Colorado Springs. His specific message was to make a longer incision and divide what he thought was the puborectalis muscle to facilitate the repair.
Dr. Peña's procedure was met with great skepticism. Dr. Stephens' associate Dr. Durham Smith said Dr. Peña's work must be wrong because neither he nor his colleagues had ever seen the puborectalis muscle. Dr. Peña returned to Mexico and decided to expose the entire anatomic area using a larger posterior sagittal incision to try to clarify the controversy.
On August 12, 1980, for the first time, Dr. Peña operated on a child with an anorectal malformation entirely posterior-sagittally and exposed, definitively, the precise anatomy.
He realized there was no discrete puborectalis muscle, but rather that the muscles formed a funnel-shaped sphincter complex. Dr. Peña used electric stimulation to place the rectum within the limits of the sphincter mechanism.
In 1982, Dr. Peña's posterior sagittal approach for the treatment of anorectal malformation was published.
Many doctors traveled to Mexico to watch Dr. Peña. Over the last 25 years, Dr. Peña's posterior sagittal approach has become the internationally accepted approach.
Exploring in this way allowed Dr. Peña to learn about the real anatomy of these malformations and to essentially re-write the old anatomic concepts. Dr. Peña dramatically changed the potential therapeutic and functional consequences of this congenital abnormality.
Dr. Peña has performed over 1,700 operations in many different countries across the world and has taught more than 50 courses to pediatric surgeons around the world. Dr. Peña maintains that anorectal malformations are a broad spectrum of complexity.
For more information or to request an appointment, please contact the Colorectal Center at Cincinnati Children's.
