# Anal Strictures — GCMD Library living collection

Everything in the library about anal stricture — built automatically from dossiers that name it.

Updated: n/a · 3 episodes · 48 cited statements

## Episodes
### Surgical Management
- [Anal Dilatations After PSARP: Current Practice, Evidence & Future Directions in Pediatric Colorectal Surgery](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907) — video · 51:52 · [machine version](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907.md)

### Evidence & Research
- [Post Operative Anal Dilatations for the Prevention of Anal Strictures in Children With Anorectal Malformation: A Systematic Review](https://library.globalcastmd.com/watch/post-operative-anal-dilatations-for-the-prevention-of-anal-strictures-in-childre-11031) — video · 0:48 · [machine version](https://library.globalcastmd.com/watch/post-operative-anal-dilatations-for-the-prevention-of-anal-strictures-in-childre-11031.md)

### In-Depth Reviews
- [Top Themes From The Stay Current App](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999) — video · [machine version](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=0) Introduction to Stay Current App Review (Ep 1)
- [1:08](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=68) Number 9: Anorectal Malformation (Ep 1)
- [2:30](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=150) Number 8: Congenital Diaphragmatic Hernia (Ep 1)
- [4:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=240) Number 7: Esophageal Atresia (Ep 1)
- [5:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=300) Number 6: GERD (Ep 1)
- [6:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=360) Number 5: Pyloric Stenosis (Ep 1)
- [7:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=420) Number 4: Perioperative Management (Ep 1)
- [8:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=480) Number 3: Hirschsprung's Disease (Ep 1)
- [10:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=600) Number 2: Intussusception (Ep 1)
- [12:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=720) Number 1: Blunt Trauma (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/post-operative-anal-dilatations-for-the-prevention-of-anal-strictures-in-childre-11031?t=0) Questioning Routine Anal Dilatations After ARM Surgery (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=0) Introduction and Current Dilation Practice at Cincinnati Children's (Ep 3)
- [7:06](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=426) Teaching Families to Dilate (Ep 3)
- [11:28](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=688) Evidence Base and the Nationwide Trial (Ep 3)
- [20:10](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=1210) Stricture Management: Strictureplasty vs Redo PSARP (Ep 3)
- [26:08](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=1568) Psychological Burden on Families (Ep 3)
- [35:26](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=2126) Patient Selection and Alternative Approaches (Ep 3)
- [40:40](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=2440) Future Research Directions (Ep 3)
- [45:10](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=2710) Take-Home Messages for Surgeons and Families (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- The Stay Current app is viewed by 6,000 pediatric surgeons (epidemiological) [Ep 1 · 0:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=0)
- Stay Current Pediatric Surgery was released in February of 2019 (clinical) [Ep 1 · 0:43](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=43)
- Users have shared over 450 pieces of content approximately 1400 times (epidemiological) [Ep 1 · 1:08](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=68)
- Digital anal dilation is safe if the digits are appropriately sized and if the families follow a strict protocol of dilations (clinical) [Ep 1 · 1:27](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=87)
- Techniques for laparoscopic CDH treatment include utilizing a needle to decompress bowel laparoscopically (clinical) [Ep 1 · 2:30](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=150)
- Creating a pneumothorax allows easier retraction of the hernia sac in laparoscopic CDH repair (clinical) [Ep 1 · 2:30](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=150)
- A laparoscopic detectable magnet can be utilized for greater maneuverability of the hernia sac (clinical) [Ep 1 · 2:30](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=150)
- The evidence supporting best practices for long gap esophageal atresia is currently low quality (clinical) [Ep 1 · 4:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=240)
- Patients with long gap esophageal atresia should receive appropriate long-term follow-up (guideline) [Ep 1 · 4:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=240)
- Workup, diagnosis, and treatment of GERD patients is complex (opinion) [Ep 1 · 5:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=300)
- The latest recommendation for Nissen fundoplication involves minimal dissection at the GE junction (guideline) [Ep 1 · 5:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=300)
- The Nissen wrap should be performed above the left gastric artery (guideline) [Ep 1 · 5:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=300)
- Multiple randomized control trials have shown that ad lib feeds are superior or equivalent to protocolized feeds for pyloric stenosis (clinical) [Ep 1 · 6:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=360)
- All infants less than 50 weeks post-conceptual age at the time of surgery need some level of observation for apnea monitoring (guideline) [Ep 1 · 7:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=420)
- NPO guidelines include clears up to two hours preop and breast milk up to four hours preop (guideline) [Ep 1 · 7:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=420)
- Clinicians tend to be too restrictive with NPO guidelines (opinion) [Ep 1 · 7:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=420)
- Pre-op antibiotic prophylaxis must be administered within 60 minutes before incision (guideline) [Ep 1 · 7:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=420)
- Redosing of antibiotics is needed for the duration of the operation (guideline) [Ep 1 · 7:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=420)
- Generally, antibiotics are not needed after surgery unless the case determines otherwise (guideline) [Ep 1 · 7:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=420)
- Hirschsprung's disease is the number one search topic on the app overall (epidemiological) [Ep 1 · 8:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=480)
- The transition zone can vary widely depending on the extent of disease with numbers as high as 22 centimeters for total colonic Hirschsprung's disease (clinical) [Ep 1 · 8:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=480)
- Coyle et al recommend resecting greater than 5 cm proximally to the normal biopsy to avoid transition zone pull through (guideline) [Ep 1 · 8:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=480)
- Management of suspected Hirschsprung's associated enterocolitis includes prompt evaluation of the patient, rectal irrigations with normal saline, NPO, IV fluids, antibiotics and continuous monitoring (guideline) [Ep 1 · 8:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=480)
- Patients with intussusception should go to the operating room if they have peritoneal signs or if they fail reduction after three attempts (guideline) [Ep 1 · 10:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=600)
- Patients can be safely discharged home after four hours of observation after a successful intussusception reduction (clinical) [Ep 1 · 10:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=600)
- Patients with intussusception can have the air enema repeated every hour up to three times as long as there are no signs of peritonitis before operative exploration (guideline) [Ep 1 · 10:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=600)
- Patients who are asymptomatic for four hours after a successful intussusception reduction can be discharged from the emergency department (guideline) [Ep 1 · 10:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=600)
- Non-operative management should be primarily considered in hemodynamically stable patients with blunt solid organ injuries (guideline) [Ep 1 · 12:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=720)
- Angioembolization should be considered for ongoing or delayed bleeding, high grade injuries and early hemodynamic compromise before proceeding to the operating room (guideline) [Ep 1 · 12:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=720)
- Alberto Pena espouses routine dilation starting at 2 weeks for every child with an anorectal malformation repair, regardless of age, and considered it so integral to success that he would not offer revision surgery to older children unwilling to dilate. — Nelson Rosen (clinical) [Ep 3 · 0:04](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=4)
- The Cincinnati protocol targets 12mm Hegar diameter for newborns in the first 4 months, 13mm for the second 4 months, 14mm up to one year, with increases thereafter based on Pena's published table. — Nelson Rosen (clinical) [Ep 3 · 5:05](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=305)
- The Cincinnati dilation technique involves inserting the dilator for 30 seconds, removing it, reinserting for 30 seconds (one complete dilation), performed twice daily, advancing 1mm in size every 7 days until goal size is reached. — Nelson Rosen (clinical) [Ep 3 · 6:02](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=362)
- Once goal size is reached, dilations are tapered in frequency over approximately 9 months: once daily for 1 month, every other day for 1 month, with the last 3 months being once monthly. — Nelson Rosen (clinical) [Ep 3 · 6:23](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=383)
- Dr. Rosen's current practice cutoff for routine dilations is 1.5 to 2 years of age, as older children remember the procedure and fighting with the child escalates emotional trauma for both child and parent. — Nelson Rosen (opinion) [Ep 3 · 7:59](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=479)
- When two patients allocated to the dilation arm who did not perform consistent dilations are moved to the non-dilation arm, the stricture rate becomes approximately 37% without dilation vs 14% with dilation. — Nelson Rosen (epidemiological) [Ep 3 · 17:06](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=1026)
- Heineke-Mikulicz strictureplasty is a very good operation for surface strictures at the anal canal, but once a stricture sets in, you never truly get a soft, stretchable, compliant anal canal. — Nelson Rosen (clinical) [Ep 3 · 18:59](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=1139)
- Long strictures represent failure of pull-through blood supply rather than failure of dilation, and opening just the surface will not adequately treat a long strictured segment. — Nelson Rosen (clinical) [Ep 3 · 23:05](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=1385)
- Studies supporting strictureplasty have not followed patients for 10, 20, or 30 years to assess long-term functional impact and ability to avoid permanent ostomy. — Nelson Rosen (opinion) [Ep 3 · 19:18](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=1158)
- Starting dilations under anesthesia may send the wrong message to parents that the procedure is traumatic enough to require anesthesia, whereas performing it awake in clinic demonstrates to parents that the child can tolerate it. — Nelson Rosen (opinion) [Ep 3 · 26:25](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=1585)
- Some children tolerate dilations without crying or resistance, while others clearly find the process unpleasant, but many therapies deemed important are challenging to get through. — Nelson Rosen (opinion) [Ep 3 · 27:10](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=1630)
- Going too fast with dilations—advancing to larger sizes before the tissue is ready—can cause macro-tearing and create painful anal fissures that bleed, adding pain and bleeding to what should be a gentle process. — Nelson Rosen (clinical) [Ep 3 · 32:52](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=1972)
- If there is any pink on the lubricating jelly when removing a dilator, the starting size should be reduced by one millimeter to ensure a gentler introduction for the family. — Nelson Rosen (clinical) [Ep 3 · 33:49](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=2029)
- For children over 18 months where routine dilation is not planned, Dr. Rosen creates a slightly larger neo-anus at surgery (extending beyond the traditional center point of the muscle complex) to allow for some settling. — Nelson Rosen (clinical) [Ep 3 · 38:39](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=2319)
- Recent articles from Nationwide describe successful use of Kenalog injection to treat early strictures, which Dr. Rosen now uses at 6-week evaluation in older children instead of prolonged dilation protocols. — Nelson Rosen (clinical) [Ep 3 · 38:10](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=2290)
- Long-term functional outcomes in anorectal malformation patients must account for multiple factors: voluntary bowel movements, soiling rates, dependence on enema regimens, rates of returning to ostomy, and need for antegrade enema surgery. — Nelson Rosen (clinical) [Ep 3 · 21:23](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=1283)
- Properly designed trials must stratify by malformation type (perineal, bulbar, prostatic, vestibular fistulas) and control for confounding factors like tethered spinal cord or associated spinal malformations. — Nelson Rosen (opinion) [Ep 3 · 43:14](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=2594)
- Pure perineal fistulas have the best outcomes and typically do not have continence issues in the absence of surgical complications, making them less ideal for studying the impact of dilations on function. — Nelson Rosen (clinical) [Ep 3 · 43:37](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=2617)
- Vestibular fistulas are currently too heterogeneous for study because some surgeons still use traditional PSARP while others have adopted Belinda Dickey's perineal body-sparing approach. — Nelson Rosen (opinion) [Ep 3 · 44:09](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=2649)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Routine anal dilatations after surgery for anorectal malformations have been standard since the 1980s — Lizzy Lee summarizing a resource [Ep 2 · 0:11](https://library.globalcastmd.com/watch/post-operative-anal-dilatations-for-the-prevention-of-anal-strictures-in-childre-11031?t=11)
- Stricture rates after anorectal malformation surgery range from 0 to almost 40%, even with the classic Pena protocol — Lizzy Lee summarizing a resource [Ep 2 · 0:18](https://library.globalcastmd.com/watch/post-operative-anal-dilatations-for-the-prevention-of-anal-strictures-in-childre-11031?t=18)
- Alternative methods like weekly dilatations or skipping dilatations altogether showed similar outcomes to standard protocols — Lizzy Lee summarizing a resource [Ep 2 · 0:25](https://library.globalcastmd.com/watch/post-operative-anal-dilatations-for-the-prevention-of-anal-strictures-in-childre-11031?t=25)
- There is insufficient high quality evidence proving that dilatations after anorectal malformation surgery are actually necessary — Lizzy Lee summarizing a resource [Ep 2 · 0:32](https://library.globalcastmd.com/watch/post-operative-anal-dilatations-for-the-prevention-of-anal-strictures-in-childre-11031?t=32)
- More randomized trials are needed to determine whether post-operative anal dilatations are necessary — Lizzy Lee summarizing a resource [Ep 2 · 0:37](https://library.globalcastmd.com/watch/post-operative-anal-dilatations-for-the-prevention-of-anal-strictures-in-childre-11031?t=37)
- In a 2026 survey of 114 centers in 48 countries, 92% of centers performed dilations after PSARP, but one-third did not have a formal protocol. — Jose summarizes what Dr. Nelson Rosen said [Ep 3 · 10:35](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=635)
- The only randomized trial (49 children at Nationwide Children's) showed strictures in 21% with dilation vs 32% without dilation, a difference that was not statistically significant. — Jose summarizes what Dr. Nelson Rosen said [Ep 3 · 14:44](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=884)
- All patients in the Nationwide trial who required re-operations were in the non-dilated group, including the two patients allocated to dilation who did not perform consistent dilations. — Jose summarizes what Dr. Nelson Rosen said [Ep 3 · 24:16](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=1456)
- In an Oslo study, parents surveyed at a median of 10 years after dilations showed that 4 in 10 had moderate to severe post-traumatic stress symptoms, despite the center performing first dilation under anesthesia and offering psychological support. — Jose summarizes what Dr. Nelson Rosen said [Ep 3 · 25:55](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=1555)
- A 2022 Pediatric Surgery International article by Worley et al. (including de la Torre, Pena, and Bischoff) reported a retrospective review of 84 patients, all dilated, with no strictures. — Nelson Rosen summarizing a resource [Ep 3 · 40:58](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=2458)
- In an international survey, 73% of centers said they would participate in a proposed 184-patient non-inferiority trial using reduced surgery as the outcome measure. — Jose summarizes what Dr. Nelson Rosen said [Ep 3 · 39:52](https://library.globalcastmd.com/watch/anal-dilatations-after-psarp-current-practice-evidence-future-directions-in-pedi-16907?t=2392)

## Changelog
- Nov 13: Published again automatically — condition is back above threshold
- Nov 13: 3 items added automatically
- Nov 13: 5 items no longer name anal strictures
- Sep 7: Unpublished automatically — folded or below threshold
- Sep 7: 5 items added automatically

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