# Anorectal Malformations — GCMD Library living collection Updated: n/a · 21 episodes · 363 cited statements ## Episodes ### Tools ### High-Yield Summaries - [The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527) — podcast · 15:45 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527.md) - [Anorectal Malformations with Dr. Andrea Bischoff](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315) — podcast · 47:46 · [machine version](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315.md) ### In-depth Review - [Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299) — podcast · 43:47 · [machine version](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299.md) - [Colorectal Quiz Episode 33: Cloaca Extrophy](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-extrophy-5642) — podcast · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-extrophy-5642.md) - [Complications of Anorectal Malformations with Dr. Marc Levitt](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304) — podcast · 48:09 · [machine version](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304.md) - [Colorectal Quiz episode 12 Newborn ARM Part 1](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890) — video · 11:28 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890.md) - [Colorectal Quiz Episode 13 Newborn ARM Part 2](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891) — video · 15:48 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891.md) - [Colorectal Quiz Episode 14: ARM Newborn Part 3](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155) — podcast · 10:03 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155.md) - [Colorectal Quiz Episode 2: When to redo a PSARP](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580) — podcast · 18:15 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580.md) - [Colorectal Quiz Episode 17: Cloaca Part 1](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322) — podcast · 27:29 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322.md) - [Colorectal Quiz Episode 18: Cloaca Part 2](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336) — podcast · 23:10 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336.md) - [Colorectal Quiz Episode 24: Cloaca Part 3](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-4775) — podcast · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-4775.md) ### Work-up and Treatment - [Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115) — podcast · 19:59 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115.md) - [Colorectal Quiz Episode 29: Female ARM-Post Op Management](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181) — podcast · 25:09 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181.md) ### Articles and Infographics - [Comparing 30-day outcomes between early versus delayed repair of anorectal malformations with perineal or rectovestibular fistulas: An analysis of the ACS NSQIP-Pediatric database](https://library.globalcastmd.com/watch/comparing-30-day-outcomes-between-early-versus-delayed-repair-of-anorectal-malformations-with-perineal-or-rectovestibular-fistulas-an-analysis-of-the-acs-nsqip-pediatric-database-3107) — article · [machine version](https://library.globalcastmd.com/watch/comparing-30-day-outcomes-between-early-versus-delayed-repair-of-anorectal-malformations-with-perineal-or-rectovestibular-fistulas-an-analysis-of-the-acs-nsqip-pediatric-database-3107.md) - [Anatomy of the Rectourethral Fistula in ARM](https://library.globalcastmd.com/watch/anatomy-of-the-rectourethral-fistula-in-arm-1630) — article · [machine version](https://library.globalcastmd.com/watch/anatomy-of-the-rectourethral-fistula-in-arm-1630.md) ### Technique Videos - [Descending Colostomy for Anorectal Malformations Dr. Tamer Ashraf Wafa](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002) — video · 5:09 · [machine version](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002.md) - [Laparoscopic pull-through for Hirschsprung disease updated 2024](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895) — video · 7:49 · [machine version](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895.md) - [Technique: Female PSARP](https://library.globalcastmd.com/watch/technique-female-psarp-742) — video · [machine version](https://library.globalcastmd.com/watch/technique-female-psarp-742.md) - [Technique: PSARP in female with no fistula](https://library.globalcastmd.com/watch/technique-psarp-in-female-with-no-fistula-1009) — video · [machine version](https://library.globalcastmd.com/watch/technique-psarp-in-female-with-no-fistula-1009.md) - [Technique: PSARP in Male with Rectobulbar Fistula](https://library.globalcastmd.com/watch/technique-psarp-in-male-with-rectobulbar-fistula-1010) — video · [machine version](https://library.globalcastmd.com/watch/technique-psarp-in-male-with-rectobulbar-fistula-1010.md) ## Chapters - [0:00](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=0) Introduction and Prenatal Evaluation of Cloaca (Ep 3) - [2:38](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=158) Prenatal Counseling and Indications for Fetal Intervention (Ep 3) - [6:05](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=365) Newborn Physical Examination and Diagnosis (Ep 3) - [9:46](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=586) Initial Workup and Management of Hydrocolpos (Ep 3) - [13:26](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=806) Colostomy Creation and Vaginostomy Technique (Ep 3) - [18:17](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1097) Pathophysiology of Hydrocolpos and Urogenital Sinus (Ep 3) - [22:28](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1348) Timing and Imaging for Definitive Repair (Ep 3) - [28:41](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1721) Multidisciplinary Team and Surgical Planning (Ep 3) - [34:27](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2067) Urethral Length and Surgical Technique Selection (Ep 3) - [37:34](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2254) Management of Non-Reaching Vagina and Vaginal Replacement (Ep 3) - [40:21](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2421) Common Errors in Cloaca Repair and Contact Information (Ep 3) - [0:00](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=0) Introduction and Missed Diagnoses in the Newborn Period (Ep 5) - [2:57](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=177) Perineal Fistula in Males: Diagnosis and Management (Ep 5) - [7:33](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=453) Perineal Fistula in Females: Diagnostic Challenges (Ep 5) - [10:11](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=611) Examination Techniques and Missed Cloaca (Ep 5) - [15:13](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=913) Colostomy Technique and Common Errors (Ep 5) - [19:51](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1191) Anoplasty Placement and Stimulator Use (Ep 5) - [23:17](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1397) Distal Colostogram Interpretation (Ep 5) - [26:36](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1596) Avoiding Urinary Tract Injury During Dissection (Ep 5) - [29:41](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1781) Choosing Between Posterior Sagittal and Laparoscopic Approach (Ep 5) - [33:36](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2016) Preventing and Managing Perineal Body Dehiscence (Ep 5) - [38:25](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2305) Complications Specific to Laparoscopic and PSARP Approaches (Ep 5) - [40:51](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2451) Managing the Soiling 4-Year-Old and Indications for Redo (Ep 5) - [0:00](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=0) Introduction and Initial Perineal Examination (Ep 2) - [1:37](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=97) Perineal Examination Technique and Rectal Perineal Fistula Diagnosis (Ep 2) - [4:54](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=294) Workup for Associated Anomalies (Ep 2) - [7:30](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=450) Management of Hemisacrum and Presacral Mass (Ep 2) - [10:20](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=620) Timing of Repair: Primary versus Colostomy (Ep 2) - [12:46](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=766) Female Patients and Vestibular Fistula (Ep 2) - [14:30](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=870) Late Diagnosis and Elective Management (Ep 2) - [16:42](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1002) Ideal Colostomy Technique (Ep 2) - [19:13](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1153) High Pressure Distal Colostogram Technique (Ep 2) - [22:03](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1323) Surgical Approaches by Malformation Type (Ep 2) - [24:32](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1472) Cloaca Diagnosis and Management (Ep 2) - [27:22](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1642) Prognosis for Bowel Control by Defect Type (Ep 2) - [32:14](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1934) Bowel Management Program for Fecal Incontinence (Ep 2) - [38:23](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2303) Enema Components and Adjustment Protocol (Ep 2) - [41:53](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2513) Bowel Management for Constipation (Ep 2) - [0:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=0) Introduction to the Colorectal Quiz series and the two expert surgeons (Ep 1) - [1:52](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=112) Case presentation: full-term neonate with imperforate anus at 20 hours of life (Ep 1) ## Statements Every statement is attributed, typed, and timestamped; the link is the citation. - Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period. — Marc Levitt (clinical) [Ep 5 · 2:57](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=177) - Male babies with perineal fistula may pass meconium and no one notices anything wrong with their anorectal anatomy, typically presenting in the first year of life with severe constipation. — Marc Levitt (clinical) [Ep 5 · 3:06](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=186) - A newborn anus should accept a size 12 Hagar dilator and a 1-year-old should accept a size 15. — Marc Levitt (clinical) [Ep 5 · 6:13](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=373) - Relocating a perineal fistula into the sphincters improves anatomy but does not completely fix constipation; patients will inherently have some constipation requiring aggressive treatment. — Marc Levitt (clinical) [Ep 5 · 4:54](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=294) - If a perineal fistula is not centered in the sphincter, patients with loose stool will soil, and athletic activity will cause soiling because sphincter squeeze cannot completely close the hole. — Marc Levitt (clinical) [Ep 5 · 5:38](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=338) - In females, diagnostic criteria for perineal fistula are: hole too close to vagina (inadequate perineal body), inadequate hole size by Hagar dilators, and hole not centered in sphincter. — Marc Levitt (clinical) [Ep 5 · 8:02](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=482) - If a female's anal opening is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, no surgery is needed; the perineal body will lengthen with growth. — Marc Levitt (clinical) [Ep 5 · 8:47](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=527) - The standard practice of checking temperature on forehead or ear rather than rectally makes it easier to miss anorectal malformations in newborns. — Marc Levitt (opinion) [Ep 5 · 4:25](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=265) - An anesthesia nerve stimulator costing $150 with appropriate needle probes works as well as commercial $15,000 stimulators for identifying sphincter muscles. — Marc Levitt (clinical) [Ep 5 · 11:06](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=666) - 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. — Marc Levitt (clinical) [Ep 5 · 17:18](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1038) - Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections. — Marc Levitt (clinical) [Ep 5 · 17:45](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1065) - With transverse colostomy and large rectourethral fistula, the left colon absorbs urine which doesn't exit the mucous fistula, potentially causing acidosis from urine absorption. — Marc Levitt (clinical) [Ep 5 · 18:38](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1118) - Prolapse risk depends on colostomy location: mid-transverse allows bilateral prolapse, hepatic flexure allows only distal prolapse, proximal sigmoid allows only distal prolapse because left colon is fixed to retroperitoneum. — Marc Levitt (clinical) [Ep 5 · 19:58](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1198) - Marking the sphincter ellipse on skin surface before making any incision prevents confusion from muscle stimulation after dissection is open, avoiding misplaced anoplasty. — Marc Levitt (clinical) [Ep 5 · 21:30](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1290) - A distal colostogram showing flattening of the rectum corresponding to the pubococcygeal line indicates insufficient contrast or pressure; more pressure is needed to overcome the sphincters and reveal the true rectal position and fistula. — Marc Levitt (clinical) [Ep 5 · 24:26](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1466) - Fistula level is determined by viewing the urethra as a reverse C or elbow: fistula at or below the elbow is bulbar, above the elbow is prostatic, at bladder neck is bladder neck fistula. — Marc Levitt (clinical) [Ep 5 · 25:23](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1523) - Bulbous rectum on colostogram may be reachable posterior sagittally and difficult laparoscopically; tapered rectum is better approached laparoscopically. — Marc Levitt (clinical) [Ep 5 · 25:55](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1555) - Opening posterior sagittally without knowing exact rectal location risks finding and potentially mobilizing bladder neck instead of rectum. — Marc Levitt (clinical) [Ep 5 · 27:00](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1620) - Bulbar and low prostatic fistulas with bulbous rectum are best approached posterior sagittally; high prostatic with tapered rectum and bladder neck fistulas are best approached laparoscopically. — Marc Levitt (clinical) [Ep 5 · 30:09](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1809) - Attempting laparoscopy for bulging rectum below peritoneal reflection at low prostatic or bulbar level risks leaving behind a remnant of the original fistula (roof) if the surgeon is timid. — Marc Levitt (clinical) [Ep 5 · 30:43](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1843) - Laparoscopy replaces laparotomy, not PSARP; a mini-PSARP during laparoscopy allows safe entry through peritoneal reflection and tacking rectum to posterior muscle complex to prevent prolapse. — Marc Levitt (opinion) [Ep 5 · 31:48](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1908) - Rectal prolapse occurs in about 3% of cases, particularly in patients without great muscles. — Marc Levitt (epidemiological) [Ep 5 · 33:35](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2015) - Rectal prolapse more than 3 millimeters should be treated because it causes bleeding, mucus, and can inhibit bowel control in patients with good muscle potential. — Marc Levitt (clinical) [Ep 5 · 34:14](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2054) - Circumferential prolapse can be trimmed in two separate ambulatory sessions (half circumference each), avoiding hospitalization and eliminating need for dilation since half the circumference remains untouched. — Marc Levitt (clinical) [Ep 5 · 34:48](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2088) - Perineal body dehiscence is the most common cause of reoperation in female ARM repairs. — Marc Levitt (clinical) [Ep 5 · 36:03](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2163) - Complete anterior rectal wall mobilization to the areolar plane between rectum and vagina is essential to avoid tension on the anoplasty that can lead to perineal body dehiscence. — Marc Levitt (clinical) [Ep 5 · 35:41](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2141) - Clear liquids only for one week postoperatively prevents hard stool formation while allowing more stool volume, showing good perineal body healing results without traditional 7-day NPO period. — Marc Levitt (clinical) [Ep 5 · 36:45](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2205) - If perineal body dehiscence is recognized on days 5-8, taking the patient back to OR to re-suture can salvage the repair; by 3-4 weeks the entire perineal body is dehisced and unsalvageable. — Marc Levitt (clinical) [Ep 5 · 37:48](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2268) - During laparoscopic approach for high rectums, the IMA must be preserved because prior colostomy may have disrupted collaterals down the left colic, making the rectum completely dependent on IMA blood supply. — Marc Levitt (clinical) [Ep 5 · 39:33](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2373) - Continence potential in ARM patients is predicted by three factors: original malformation type, sacral ratio, and spine quality (ARM continence index). Three A's predicts continence, three C's predicts incontinence. — Marc Levitt (clinical) [Ep 5 · 42:14](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2534) - A bulbar fistula with sacral ratio of 1 and normal spine should 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. — Marc Levitt (clinical) [Ep 5 · 43:19](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2599) - Initial management of soiling 4-year-old with continence potential is bowel management with enemas to achieve cleanliness, then trial of laxatives when older and more mature to attempt voluntary bowel movements. — Marc Levitt (clinical) [Ep 5 · 43:52](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2632) - Indications for redo pull-through include any patient with continence potential who has improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum). — Marc Levitt (clinical) [Ep 5 · 44:39](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2679) - The major problem with anorectal malformations is that surgical errors may not become apparent for years; an improperly placed anus appears successful initially but presents with soiling at age 4. — Marc Levitt (opinion) [Ep 5 · 46:25](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2785) - Patients with anorectal malformation with good prognosis for bowel control will have well-formed buttocks with a good midline groove and a good anal dimple, while patients with bad prognosis will have a flat bottom and no clear delineation of the anal dimple. — Andrea Bischoff (clinical) [Ep 2 · 1:52](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=112) - In a newborn baby, a normal caliber anus should accommodate a number 12 Hegar dilator. — Andrea Bischoff (clinical) [Ep 2 · 2:31](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=151) - In a rectal perineal fistula, the sphincter mechanism is in a horseshoe shape with posterior and lateral portions having sphincter but the anterior portion lacking sphincter. — Andrea Bischoff (clinical) [Ep 2 · 3:42](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=222) - 8% of patients with anorectal malformation will have esophageal atresia. — Andrea Bischoff (epidemiological) [Ep 2 · 5:01](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=301) - 30% of patients with anorectal malformation will have cardiac anomalies, but in only 10% of them are these anomalies hemodynamically significant. — Andrea Bischoff (epidemiological) [Ep 2 · 5:27](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=327) - 50% of patients with anorectal malformation have associated urological defects. — Andrea Bischoff (epidemiological) [Ep 2 · 5:54](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=354) - 25% of patients with anorectal malformation have tethered cord. — Andrea Bischoff (epidemiological) [Ep 2 · 6:02](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=362) - If no fistula is identified on initial examination, the patient should be re-examined after 24 hours because it takes time for air to travel distally and for meconium to pass through a tiny fistula. — Andrea Bischoff (clinical) [Ep 2 · 6:31](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=391) - Cross-table lateral film with pelvis elevated should never be done before 24 hours of life because it will give the false impression of a high malformation due to muscle tone. — Andrea Bischoff (clinical) [Ep 2 · 7:04](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=424) - Spinal ultrasound is adequate to detect tethered cord in babies less than 3 months of age; after 3 months, MRI is needed due to ossification. — Andrea Bischoff (clinical) [Ep 2 · 8:22](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=502) - Tethered cord has more influence on the urinary tract rather than the gastrointestinal tract in terms of prognosis. — Andrea Bischoff (clinical) [Ep 2 · 8:47](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=527) - Presacral masses are most commonly found in malformations with good prognosis such as rectal perineal fistula, rectal vestibular fistula, and rectal atresia, but when present, the prognosis changes. — Andrea Bischoff (clinical) [Ep 2 · 9:53](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=593) - The advantage of primary newborn repair is that bowel preparation is not required since meconium is considered sterile. — Andrea Bischoff (clinical) [Ep 2 · 11:55](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=715) - It is better to open a colostomy and have a perfect operation than to do a primary repair and have a complication such as dehiscence retraction that requires re-operation. — Andrea Bischoff (opinion) [Ep 2 · 12:20](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=740) - Patients with anorectal malformation have one chance to have the right operation; secondary operations or re-operations usually change the prognosis for bowel control. — Andrea Bischoff (clinical) [Ep 2 · 12:33](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=753) - Vestibular fistula is the most common type of anorectal anomaly in females. — Andrea Bischoff (epidemiological) [Ep 2 · 13:36](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=816) - An 8 French feeding tube should be used to catheterize a suspected vestibular fistula if it cannot be visualized. — Andrea Bischoff (clinical) [Ep 2 · 13:30](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=810) - Cloaca patients have never been seen with disorder of sexual differentiation; they are all females with normal ovaries. — Andrea Bischoff (clinical) [Ep 2 · 25:23](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1523) - The ideal colostomy should be totally diverting, located in the descending colon to leave enough distal bowel for pull-through and avoid prolapse. — Andrea Bischoff (clinical) [Ep 2 · 17:58](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1078) - The proximal stoma should be located in the center of a triangle formed by the left rib, umbilicus, and iliac crest to ensure it is surrounded by normal skin for stoma bag application. — Andrea Bischoff (clinical) [Ep 2 · 18:23](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1103) - During colostomy creation, all distal bowel should be irrigated with plenty of normal saline to remove all meconium. — Andrea Bischoff (clinical) [Ep 2 · 18:59](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1139) - For high pressure distal colostogram, a number 8 French Foley catheter is normally used in the mucous fistula. — Andrea Bischoff (clinical) [Ep 2 · 19:55](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1195) - During distal colostogram, the patient should be turned to perfect lateral position with knees at 90 degrees and one femur exactly in front of the other, and the radiologist must show all reference points including mucous fistula, sacrum, and anal marker. — Andrea Bischoff (clinical) [Ep 2 · 20:50](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1250) - In rectal urethral bulbar fistula, the most important portion of the operation is separation between the rectum and the long common wall with the urethra, with minimal rectal mobilization needed. — Andrea Bischoff (clinical) [Ep 2 · 22:45](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1365) - In rectal urethral prostatic fistula, the common wall with urethra is shorter than bulbar fistula but more rectal dissection is needed to gain length. — Andrea Bischoff (clinical) [Ep 2 · 23:11](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1391) - In rectal bladder neck fistula, the rectum joins the urinary tract in a T fashion and the challenge is gaining enough length to reach the perineum while preserving good blood supply through selective ligation of mesenteric vessels. — Andrea Bischoff (clinical) [Ep 2 · 23:45](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1425) - Cloaca with common channel less than 3 centimeters can be repaired posterior sagittally with total urogenital mobilization. — Andrea Bischoff (clinical) [Ep 2 · 26:56](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1616) - Rectal perineal fistula patients with normal sacrum and no tethered cord have 100% chance of bowel control. — Andrea Bischoff (clinical) [Ep 2 · 28:08](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1688) - Malformations with better prognosis for bowel control will suffer from more constipation. — Andrea Bischoff (clinical) [Ep 2 · 28:18](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1698) - Rectal vestibular fistula patients with normal sacrum and no tethered cord have 95% chance of bowel control. — Andrea Bischoff (clinical) [Ep 2 · 28:40](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1720) - Rectal urethral bulbar fistula has 85% chance of bowel control. — Andrea Bischoff (clinical) [Ep 2 · 28:57](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1737) - Anorectal malformation without fistula has 80% chance of bowel control. — Andrea Bischoff (clinical) [Ep 2 · 29:02](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1742) - Rectal urethral prostatic fistula has 60% chance of bowel control. — Andrea Bischoff (clinical) [Ep 2 · 29:08](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1748) - Rectal bladder neck fistula has 20% chance of bowel control. — Andrea Bischoff (clinical) [Ep 2 · 29:14](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1754) - Cloaca with common channel less than 3 centimeters and normal sacrum has generally about 70% chance of bowel control. — Andrea Bischoff (clinical) [Ep 2 · 29:24](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1764) - The only indication to keep a colostomy is incapacity to form solid stool; most patients with anorectal malformation have normal colon and can form solid stool. — Andrea Bischoff (opinion) [Ep 2 · 29:57](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1797) - Patients prefer the quality of life of a pull-through with bowel management rather than with a colostomy. — Andrea Bischoff (opinion) [Ep 2 · 30:20](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1820) - All children with anorectal malformations should be out of diapers at the same age that other children are normally out of diapers, which in the United States is usually at 3 years of age. — Andrea Bischoff (guideline) [Ep 2 · 30:43](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1843) - After 3 years of age, if the child has not potty trained, formal bowel management should start: enemas for children with bad prognosis, enemas on temporary basis for borderline bowel control, and laxatives for children with bowel control and constipation. — Andrea Bischoff (guideline) [Ep 2 · 31:13](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1873) - Bowel management for fecal incontinence consists of finding the enema that completely cleans the colon and allows the child to be clean in underwear for 24 hours. — Andrea Bischoff (clinical) [Ep 2 · 31:41](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1901) - Determining which enema works for each child is a trial and error process that usually takes about one week. — Andrea Bischoff (clinical) [Ep 2 · 32:55](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1975) - Contrast enema without bowel preparation can divide fecally incontinent patients into two groups: those with dilated colon and tendency for constipation, and those with non-dilated colon and tendency for diarrhea. — Andrea Bischoff (clinical) [Ep 2 · 33:17](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1997) - For dilated hypomotile colon, a large and concentrated enema is needed to clean the colon, but after cleaning there is natural tendency not to produce bowel movements. — Andrea Bischoff (clinical) [Ep 2 · 33:32](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2012) - For non-dilated hypermotile colon, a small enema (sometimes just normal saline) is needed, but the challenge is keeping the colon from moving between enemas, usually requiring constipating diet and medication to slow the colon. — Andrea Bischoff (clinical) [Ep 2 · 33:54](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2034) - Enema base is normal saline 200 to 1000 mLs, with additives to increase concentration: liquid glycerin 10-40 mLs, Castile soap 9-27 mLs, or Fleet sodium phosphate (33 mLs for ages 2-4, 66 mLs for ages 7-10, 133 mLs for over 10 years). — Andrea Bischoff (clinical) [Ep 2 · 34:33](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2073) - The enema should be done at the same time every day and the entire process (administration, holding, evacuation) should last one hour. — Andrea Bischoff (clinical) [Ep 2 · 38:33](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2313) - Enema adjustments are made based on parent/patient report and abdominal radiograph; if real stool accidents occur and radiograph is not clean, concentration should be increased. — Andrea Bischoff (clinical) [Ep 2 · 39:12](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2352) - Enema frequency is always once daily; concentration is adjusted rather than volume or frequency. — Andrea Bischoff (clinical) [Ep 2 · 39:36](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2376) - The Malone procedure (appendicostomy) is not the treatment for fecal incontinence; the treatment is finding the enema that works. The appendicostomy provides independence. — Andrea Bischoff (clinical) [Ep 2 · 40:32](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2432) - Appendicostomy is offered when the child wants to do the enema independently or for patients with borderline bowel control who remain enema-dependent after yearly trials off enemas. — Andrea Bischoff (clinical) [Ep 2 · 40:50](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2450) - For constipation management, disimpaction is required before determining laxative dosage to avoid severe cramping. — Andrea Bischoff (clinical) [Ep 2 · 42:19](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2539) - Disimpaction protocol consists of 3 enemas per day for 3 days; most children are disimpacted after day 3. — Andrea Bischoff (clinical) [Ep 2 · 42:35](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2555) - If still impacted after 3 days of enemas, admit for nasogastric tube with GoLYTELY for 2 days plus enemas; disimpaction under anesthesia is extremely rare (approximately 4 cases in 8 years). — Andrea Bischoff (clinical) [Ep 2 · 42:52](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2572) - Senna-based laxative is preferred, given at 6 PM to produce bowel movement the next day, with dosage range from 8.8 mg to 175 mg. — Andrea Bischoff (clinical) [Ep 2 · 43:30](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2610) - Laxative dosage is adjusted daily based on bowel movement frequency, consistency, and abdominal radiograph showing stool burden; if no bowel movements in 24 hours, give enema and increase laxative dose. — Andrea Bischoff (clinical) [Ep 2 · 43:37](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2617) - The most common prenatal ultrasound finding in cloaca is a pelvic mass, often representing a dilated vagina (hydrocolpos). — Marc Levitt (clinical) [Ep 3 · 2:38](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=158) - Fetal intervention for cloaca is unlikely to be necessary; babies should typically go to term. — Marc Levitt (clinical) [Ep 3 · 3:56](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=236) - Fetal hydrocolpos drainage has been performed at least once (case report from Japan) for massive hydronephrosis with impending renal loss, similar to bladder drainage for urethral valves. — Marc Levitt (clinical) [Ep 3 · 5:14](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=314) - In cloaca, there is one perineal hole below the clitoris and no anus; this is not ambiguous genitalia, there is no adrenal problem, and the baby is a normal female with two normal ovaries. — Marc Levitt (clinical) [Ep 3 · 6:37](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=397) - A urogenital sinus (single hole with normal anus present) may be associated with virilization and requires evaluation for adrenal hyperplasia and electrolyte abnormalities. — Marc Levitt (clinical) [Ep 3 · 6:57](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=417) - To examine a newborn for cloaca, grab the labia and lift them up and out with very good lighting to see if there is a single hole or distinct urethral, vaginal, and rectal orifices. — Marc Levitt (clinical) [Ep 3 · 8:36](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=516) - Many patients considered cloacas actually have vestibular fistulas; with better examination you can see three holes (urethra, vagina, and rectal opening in vestibule). — Marc Levitt (clinical) [Ep 3 · 9:03](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=543) - Initial workup for cloaca includes ultrasound for hydronephrosis and kidney number, spinal ultrasound for tethered cord, cardiac auscultation, and plain X-ray of spine to assess sacrum. — Marc Levitt (clinical) [Ep 3 · 9:59](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=599) - Intermittent catheterization of the common channel may decompress hydrocolpos, but is not reliable because the catheter may enter the urethra, right or left vagina, or rectum; success should be confirmed by ultrasound. — Marc Levitt (clinical) [Ep 3 · 11:14](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=674) - If hydrocolpos is bilateral, open into both vaginas at the dome, remove some of the common wall (septum), and one tube will drain both sides. — Marc Levitt (clinical) [Ep 3 · 13:14](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=794) - For vaginostomy, use an 8 or 10 French pigtail catheter (not a straight catheter) because as hydrocolpos recedes, straight catheters fall out but curled catheters do not. — Marc Levitt (clinical) [Ep 3 · 14:15](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=855) - Vesicostomy is rarely needed in cloaca; the problem is usually hydrocolpos compressing the trigone and distal ureters, not bladder drainage. Draining the hydrocolpos relieves the ureteral obstruction. — Marc Levitt (clinical) [Ep 3 · 15:05](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=905) - Vesicostomy is indicated only when the bladder does not drain after successful hydrocolpos decompression, which occurs in very rare circumstances with very long narrow common channels or absent urethra. — Marc Levitt (clinical) [Ep 3 · 16:28](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=988) - Vesicostomy is also indicated in the rare circumstance of massive bilateral ureteral reflux, where decompressing the system protects the ureters until later repair. — Marc Levitt (clinical) [Ep 3 · 17:54](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1074) - Hydronephrosis in cloaca is caused by hydrocolpos pressing forward on the trigone and compressing the distal ureters where they enter the bladder. — Marc Levitt (clinical) [Ep 3 · 20:11](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1211) - Hydrocolpos develops because urine preferentially fills the vagina through the vaginal fistula rather than exiting the common channel, likely due to mechanical factors (steep urethral angle). — Marc Levitt (clinical) [Ep 3 · 18:21](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1101) - Hydrocolpos fluid is typically a turbid combination of mucus and urine; maternal estrogen effect can increase mucus production and rarely cause blood in the hydrocolpos. — Marc Levitt (clinical) [Ep 3 · 18:48](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1128) - Cystoscopy in the newborn period is not advantageous; the required scope is tiny, visualization is poor, the perineum is swollen, and it is better to minimize OR time in newborns. — Marc Levitt (opinion) [Ep 3 · 20:29](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1229) - Laparoscopic approach to colostomy and hydrocolpos drainage (described by Michigan group) provides excellent visualization and is a valuable technique. — Marc Levitt (clinical) [Ep 3 · 20:49](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1249) - For massive hydrocolpos extending above the umbilicus, use a lower midline incision to access the dome, and consider a tubeless vaginostomy sutured to the abdominal wall like a G-tube. — Marc Levitt (clinical) [Ep 3 · 21:17](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1277) - Urogenital sinus (single perineal opening with normal anus) requires workup for adrenal problems causing virilization, though it can occur without virilization. — Marc Levitt (clinical) [Ep 3 · 22:28](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1348) - Most urogenital sinuses can be managed with perineal urogenital mobilization without touching the rectum; high UG sinus cases may require a transrectal (Astra) approach. — Marc Levitt (clinical) [Ep 3 · 23:17](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1397) - Definitive cloaca repair timing: perform endoscopy and cloacography at 2–3 months of age, then repair anytime thereafter within one year, ideally before 6 months if managing from birth. — Marc Levitt (clinical) [Ep 3 · 23:57](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1437) - The two critical endoscopic measurements are common channel length (from perineum to urethral takeoff) and urethral length (from urethral takeoff to bladder neck); urethral length determines the surgical approach. — Marc Levitt (clinical) [Ep 3 · 25:25](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1525) - Traditional classification uses 3 cm common channel length (≤3 cm straightforward, >3 cm complicated), but urethral length is equally important and not mentioned in published papers. — Marc Levitt (clinical) [Ep 3 · 25:27](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1527) - Endoscopy can falsely suggest the rectum is reachable when it is actually a long narrow fistula with healthy rectum high in the abdomen; contrast study (cloacogram) is needed to assess this. — Marc Levitt (clinical) [Ep 3 · 26:21](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1581) - 3D cloacogram reconstruction is superior to 2D fluoroscopy; experienced surgeons answer anatomy questions more correctly with 3D imaging, and printed 3D models may be even better. — Marc Levitt (clinical) [Ep 3 · 28:34](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1714) - Cloaca patients benefit from collaborative multidisciplinary approach; the days of a single surgeon handling these cases alone are over. — Marc Levitt (opinion) [Ep 3 · 30:29](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1829) - Urogenital mobilization, first described by Alberto Pena in 1996, mobilizes urethra and vagina as a unit without operating on the wall between them, eliminating the 10% urethral-vaginal fistula rate of prior techniques. — Marc Levitt (clinical) [Ep 3 · 32:15](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1935) - Urogenital mobilization is appropriate when common channel is ≤3 cm AND urethral length above the takeoff is at least 1.5–2 cm; this leaves adequate urethral length after splitting the common channel. — Marc Levitt (clinical) [Ep 3 · 33:39](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2019) - With inadequate urethral length, do not perform total urogenital mobilization; instead leave the common channel to become the urethra and separate the vagina from it—a technically demanding operation. — Marc Levitt (clinical) [Ep 3 · 34:26](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2066) - After separating vagina from common channel, repair the common channel and cover with anorectal fat pad and possibly SIS to ensure well-healed urethra and avoid urethral-vaginal fistula. — Marc Levitt (clinical) [Ep 3 · 34:50](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2090) - If urogenital mobilization is attempted but the complex does not reach, the only option is abdominal delivery of the urogenital complex; if this fails, separating the vagina from a circumferentially dissected common channel risks devascularizing and losing the urethra. — Marc Levitt (clinical) [Ep 3 · 35:09](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2109) - Urogenital mobilization with inadequate urethral length leaves the patient with urinary leakage that cannot be controlled without tightening or closing the bladder neck. — Marc Levitt (clinical) [Ep 3 · 35:52](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2152) - Separating the vagina from the common channel and leaving the common channel as the entire urethra gives the patient about a 4 cm urethra, allowing intermittent catheterization and continence. — Marc Levitt (clinical) [Ep 3 · 36:05](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2165) - Type 1 cloaca (common channel ~1 cm with adequate urethral length): mobilize the vagina and leave the urethra slightly hypospadiac; patient will void if no neurogenic bladder component. — Marc Levitt (clinical) [Ep 3 · 36:40](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2200) - Patients with tethered cord or neurogenic bladder need a visible urethral orifice that is easily catheterized; slightly hypospadiac urethra is acceptable only if certain the patient will void and not need intermittent catheterization. — Marc Levitt (clinical) [Ep 3 · 37:11](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2231) - When native vagina does not reach after full mobilization, options include vaginal switch (disconnect one side preserving ovarian blood supply, switch dome down, remove septum) or vaginal replacement. — Marc Levitt (clinical) [Ep 3 · 38:00](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2280) - For vaginal replacement, left colon is the preferred option; sigmoid may be used depending on the vascular arcade. — Marc Levitt (opinion) [Ep 3 · 38:46](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2326) - Tissue engineering of vaginas using patient stem cells is on the horizon (work at Wake Forest and Mexico); this would revolutionize cloaca care by eliminating the need for vaginal replacement. — Marc Levitt (clinical) [Ep 3 · 39:10](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2350) - Complex cloacas requiring specialized expertise include those with common channel >3 cm or urethral length (takeoff to bladder neck) <1.5 cm. — Marc Levitt (clinical) [Ep 3 · 39:48](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2388) - The most common problem in redo cloacas is the surgeon never realized it was a cloaca and only fixed the rectum, leaving the urogenital sinus untouched. — Marc Levitt (clinical) [Ep 3 · 40:27](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2427) - The second most common redo problem is inadequate mobilization of structures, leaving the patient with a stenosed or lost vagina. — Marc Levitt (clinical) [Ep 3 · 40:58](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2458) - For anorectoplasty, if you don't get it perfect, you might not have the best outcomes, which separates it from other surgical procedures. — Jason Frischer (opinion) [Ep 9 · 0:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=0) - The original malformation in Case 1 was a prostatic fistula. — Marc Levitt (clinical) [Ep 9 · 4:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=270) - The patient in Case 1 has a tethered cord and a sacral ratio of 0.66. — Marc Levitt (clinical) [Ep 9 · 4:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=280) - The family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work and is the child going to be clean and in normal underwear. — Jason Frischer (opinion) [Ep 9 · 5:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=350) - The higher the malformation, the worse the prognosis. — Jason Frischer (clinical) [Ep 9 · 6:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=385) - A sacrum ratio of 0.7 or greater usually means normal or close to normal sphincters and good muscle tone, indicating that spine innervation of that area is probably good. — Jason Frischer (clinical) [Ep 9 · 6:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=395) - Patients can come with associated spinal anomaly, most commonly tethered cord, but the worst is a myelomeningocele, and those patients have much more trouble with continence. — Jason Frischer (clinical) [Ep 9 · 6:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=400) - Visual cues for identifying correct sphincter location include the anal dimple, a midline raised area where the sphincters are, the ellipse, color change, indentation or raised area, and appropriate perineal body length. — Marc Levitt (clinical) [Ep 9 · 7:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=449) - It's amazingly common to have a mislocated anus, either because the surgeon misses where the center is during laparoscopic pull-through or opens the PSARP incision first. — Jason Frischer (clinical) [Ep 9 · 7:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=464) - A key pitfall is opening the PSARP incision first; instead, mark the sphincters first, then open the PSARP so you don't get confused when placing the anoplasty in the correct location. — Jason Frischer (clinical) [Ep 9 · 8:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=485) - Case 2 patient was born with a vestibular fistula, has a normal spine and an excellent sacrum, indicating a much better prognosis for bowel control. — Marc Levitt (clinical) [Ep 9 · 8:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=520) - The electrical stimulator used is the same one that anesthesia uses for their train of four, with an inexpensive connection with little pins. — Marc Levitt (clinical) [Ep 9 · 9:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=590) - You have to tell your anesthesiologist not to give skeletal muscle relaxant because the stimulator is a little bit weaker than the traditional stimulator. — Marc Levitt (clinical) [Ep 9 · 10:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=610) - In higher malformations such as a bladder neck fistula in a boy, the sphincter complex isn't always where you think it's going to be and is sometimes more anterior than anticipated. — Jason Frischer (clinical) [Ep 9 · 10:19](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=619) - If you know the anatomy is off, you should do the redo, and there's an advantage to getting the anatomy right the younger the child is. — Marc Levitt (opinion) [Ep 9 · 13:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=808) - For a two-year-old with a mislocated anus or bad prolapse, offer a redo and let them live in diapers for a year or two with better anatomy, then see if they can successfully potty train. — Marc Levitt (opinion) [Ep 9 · 13:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=830) - Many patients present after the age of potty training because they're incontinent, and evaluation reveals the reason is they don't have the best operation—their anus isn't in the right place. — Marc Levitt (clinical) [Ep 9 · 14:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=860) - For patients presenting with incontinence after potty training age, do the redo and usually add a Malone at the same time so they can learn how to get control with their new anatomy before attempting voluntary bowel movements. — Marc Levitt (opinion) [Ep 9 · 14:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=870) - The process of learning control with new anatomy after redo and Malone may take 6 to 12 months. — Marc Levitt (clinical) [Ep 9 · 14:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=875) - For a patient with a mislocated anus that's 50% within the sphincter complex, three and a half years old and fecally incontinent, one approach is to redo them, do a Malone, get them perfectly clean mechanically, then see if they can develop bowel control. — Marc Levitt (opinion) [Ep 9 · 15:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=903) - An alternative approach for borderline cases is to let the child take their car out for a ride first and see how it works—if it drives well, stay with that anatomy; if not, then consider the redo. — Jason Frischer (opinion) [Ep 9 · 15:19](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=919) - If patients haven't declared their continence yet because they're not old enough to do so from a behavioral point of view, give them a chance—they may succeed. — Marc Levitt (opinion) [Ep 9 · 15:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=945) - The target part of the colon to create the stoma is in the most proximal part of the sigmoid colon, as high as possible close to the descending colon, to avoid future stoma prolapse. (clinical) [Ep 17 · 0:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=0) - The site of the proximal stoma is in the center of a triangle between the anterior superior iliac spine, costal margin, and the umbilicus. (clinical) [Ep 17 · 0:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=0) - The distal colon is brought out at the medial end of the incision as a mucous fistula that is made as narrow as possible. (clinical) [Ep 17 · 0:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=0) - The incision is oblique and about 5 to 6 centimeters in length. (clinical) [Ep 17 · 0:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=0) - The layers are carefully opened to avoid bowel injury due to the colonic distension. (clinical) [Ep 17 · 1:30](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=90) - The distal and proximal limbs are carefully identified to avoid stoma reversal. (clinical) [Ep 17 · 1:30](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=90) - A purse-string suture is applied around the stoma site using a 4-0 suture. (clinical) [Ep 17 · 1:30](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=90) - A 12-French catheter is introduced through a small puncture for suction of meconium and emptying the distal colon. (clinical) [Ep 17 · 1:30](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=90) - Saline is used to help liquefy the thick meconium during washing and suction until the colon is completely cleaned out. (clinical) [Ep 17 · 1:30](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=90) - A window in the mesentery is created with preservation of the marginal vessels. (clinical) [Ep 17 · 3:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=180) - Bipolar diathermy is applied to the vessels distal to the marginal vessels, with coagulation kept close to the colonic wall, creating a 2 cm window. (clinical) [Ep 17 · 3:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=180) - Two fine bulldogs are applied to occlude the colonic lumen before the colon is divided. (clinical) [Ep 17 · 3:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=180) - Additional division of the mesenteric vessels is done to ensure adequate placement of the two stomas at the two ends of the wound. (clinical) [Ep 17 · 3:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=180) - The colon is fixed to the peritoneum using 4-0 absorbable sutures starting on both ends. (clinical) [Ep 17 · 4:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=240) - The peritoneum in between the stomas is approximated with interrupted sutures. (clinical) [Ep 17 · 4:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=240) - The distal stoma is made as narrow as possible. (clinical) [Ep 17 · 4:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=240) - The muscles are approximated using interrupted sutures, followed by closure of the skin with interrupted subcuticular sutures. (clinical) [Ep 17 · 4:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=240) - The stoma edges are fixed to the skin with 5-0 sutures. (clinical) [Ep 17 · 4:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=240) - The stoma bag shall be applied to the proximal stoma only. (clinical) [Ep 17 · 4:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=240) - A cross-table lateral film (also called crossfire film) is obtained by placing the baby prone in the NICU and shooting a crossfire X-ray; the old fashioned version was an invertogram. — Levitt (clinical) [Ep 8 · 1:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=76) - Cross-table lateral films can be obtained early and then around 24 hours later in cases where there is no evidence of fistula on exam. — Jason Frischer (clinical) [Ep 8 · 1:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=109) - If the air column stops at about the 4th sacral vertebral body with a large distance between the air column and the sphincter marker, the patient should be considered for diversion and distal colostogram to delineate anatomy. — Jason Frischer (clinical) [Ep 8 · 2:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=126) - When the air column is very close to where the anticipated anal opening should be located, primary anoplasty may be performed. — Jason Frischer (clinical) [Ep 8 · 2:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=169) - A cross-table lateral film showing air column stopping at approximately the 4th sacral vertebral body with large distance to sphincter is almost definitely a rectal urethral fistula worthy of colostomy. — Levitt (clinical) [Ep 8 · 3:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=210) - A cross-table lateral film showing air column very close to the anticipated anal opening is probably almost a perineal fistula or no fistula, and may be appropriate for primary repair, but one must be careful as it might be a low bulbar fistula. — Levitt (clinical) [Ep 8 · 3:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=219) - For every patient with anorectal malformation, one should know the type of malformation, the quality of the sacrum, and the quality of the spine. — Levitt (clinical) [Ep 8 · 4:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=286) - High malformation, poor sacrum, poor spine indicates not good continence potential; low malformation, normal sacrum, normal spine indicates good potential for bowel control, with many gradations in between. — Levitt (clinical) [Ep 8 · 4:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=286) - The PCPLC consortium is calculating data across 15 centers to develop predictions where malformation type, sacral ratio, and spine status can predict continence percentage. — Levitt (clinical) [Ep 8 · 5:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=312) - Whether to perform primary anoplasty in cases with close air column depends on individual surgeon comfort and the level of post-operative care available at the institution. — Jason Frischer (opinion) [Ep 8 · 6:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=373) - In a male patient where the fistula opening is in the sphincter but in the northernmost part of the sphincteric ellipse, posterior rectal wall only mobilization should be performed, avoiding any anterior wall mobilization to remove the risk of urethral injury. — Levitt (clinical) [Ep 8 · 6:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=400) - The common wall between the rectum and the urethra is closer and longer than some people anticipate. — Jason Frischer (clinical) [Ep 8 · 7:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=436) - When a fistula opening is in the sphincter but just the most anterior portion, one does not need to dissect or even touch the anterior rectal wall. — Levitt (clinical) [Ep 8 · 7:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=449) - A patient at 24 hours with no obvious fistula and cross-table lateral showing air column not very distal needs a colostomy. — Jason Frischer (clinical) [Ep 8 · 7:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=461) - A single perineal orifice in a newborn indicates cloaca: the vagina, urethra, and rectum are fused internally into a single common channel. — Richard Wood (clinical) [Ep 10 · 2:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=125) - Hydrocolpos is distension of the vagina caused by accumulation of fluid. — Richard Wood (clinical) [Ep 10 · 2:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=151) - Prenatal diagnostic yield for cloacal malformations is still much lower than desired. — Richard Wood (epidemiological) [Ep 10 · 3:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=224) - Hydrocolpos on prenatal ultrasound should alert to the possibility of cloaca. — Richard Wood (clinical) [Ep 10 · 4:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=240) - Subtle prenatal signs of cloaca include abnormal kidneys (e.g., single kidney) and two-vessel cord. — Richard Wood (clinical) [Ep 10 · 4:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=260) - In the majority of cloaca patients, diagnosis is made at birth rather than prenatally. — Marc Levitt (epidemiological) [Ep 10 · 5:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=341) - Physical exam of cloaca perineum with good lighting and labial distraction reveals a clitoral hood, underdeveloped labia minora, a single perineal orifice, and a perineal groove suggesting muscle complex. — Richard Wood (clinical) [Ep 10 · 6:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=388) - In a child with cloacal malformation who does not have an anus, there is no indication to investigate for ambiguous genitalia or disorders of sexual differentiation; these children are female and do not need karyotyping. — Richard Wood (guideline) [Ep 10 · 7:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=436) - Initial urgent management priorities in cloaca are: ensure kidney and urine decompression, diagnose hydrocolpos, and confirm patient is safe for anesthesia (cardiac assessment, TEF screen). — Richard Wood (guideline) [Ep 10 · 7:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=476) - Modern practice has moved away from routine vaginostomy toward clean intermittent catheterization (CIC) through the common channel to drain hydrocolpos. — Richard Wood (guideline) [Ep 10 · 9:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=562) - CIC technique: pass a tube through the common channel, drain fluid, confirm by ultrasound that the tube is in the hydrocolpos/vagina, decompress it, and repeat catheterization regularly. If effective, proceed with colostomy and continue CIC postoperatively. — Richard Wood (clinical) [Ep 10 · 9:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=564) - Seattle Children's (Paul McGarrian, Jeff Evansino, Caitlin Smith) demonstrated that many hydrocolpi can be drained perineally, changing prior dogma of routine vaginostomy. — Marc Levitt (clinical) [Ep 10 · 10:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=606) - When catheterizing the common channel, the anatomy of the urethral takeoff makes it more likely to enter the vagina than the bladder. — Marc Levitt (clinical) [Ep 10 · 10:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=640) - After passing a catheter for hydrocolpos drainage, obtain bedside ultrasound immediately to confirm catheter position in the hydrocolpos and successful decompression. — Richard Wood (guideline) [Ep 10 · 12:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=753) - Live ultrasound during catheter drainage shows that as the hydrocolpos drains, the bladder fills—demonstrating the pathophysiology of ureteral obstruction by the hydrocolpos. — Marc Levitt (clinical) [Ep 10 · 13:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=781) - In almost every cloaca, vesicostomy is unnecessary; the hydrocolpos must be drained, and perineal catheterization can relieve bladder outlet obstruction by decompressing the hydrocolpos and allowing ureters to drain. — Marc Levitt (guideline) [Ep 10 · 13:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=820) - CIC frequency: initially three times daily in the NICU, then twice daily when families take over. Follow with serial ultrasounds every 2–3 days initially, then weekly, then monthly at home to confirm kidney decompression. — Richard Wood (guideline) [Ep 10 · 15:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=901) - The goal of hydrocolpos drainage is kidney decompression. If kidneys are completely normal despite hydrocolpos, the hydrocolpos is not urgent; if kidneys are obstructed, drainage is critical. — Richard Wood (clinical) [Ep 10 · 15:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=901) - Even with a vaginostomy tube, serial ultrasound is required to confirm the tube is keeping kidneys decompressed; do not assume it is working without imaging confirmation. — Richard Wood (guideline) [Ep 10 · 16:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=980) - Newborn cloaca management summary: good exam with lighting to diagnose, no endocrine workup needed, renal/pelvic ultrasound and anesthesia safety tests, drain hydrocolpos (preferably by CIC), and colostomy within 24–48 hours. — Richard Wood (guideline) [Ep 10 · 17:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1022) - Colostomy should be performed as proximally as possible—at the descending-sigmoid junction—to preserve distal bowel length for future reconstruction. — Richard Wood (guideline) [Ep 10 · 17:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1075) - Laparoscopic colostomy in non-distended newborns offers excellent pelvic anatomic visualization, precise stoma site selection, and the ability to create a stoma without a skin bridge between proximal and distal limbs. — Richard Wood (clinical) [Ep 10 · 18:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1122) - Laparoscopic colostomy technique: mobilize lateral attachments of descending colon, bring bowel through mucus-fistula site, staple and washout distal limb until clean, then create separate incision for proximal stoma, leaving clean skin around working stoma and closing mucus-fistula site partially. — Richard Wood (clinical) [Ep 10 · 19:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1150) - If vaginostomy is required and the patient has a vaginal septum, open the anterior wall of the hydrocolpos and remove a small portion of the septum to drain both sides through one opening. — Richard Wood (clinical) [Ep 10 · 20:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1212) - Vaginostomy can be performed with or without a tube. Tubes can become encrusted and colonized, so tubeless (suturing vagina to abdominal wall) may be preferable if the vagina reaches the abdominal wall easily. — Richard Wood (clinical) [Ep 10 · 21:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1260) - For massive hydrocolpos requiring open vaginostomy, use a lower midline incision to get above the hydrocolpos, which is very adherent and inflamed against the anterior abdominal wall. A standard left lower quadrant incision will not provide adequate access. — Marc Levitt (clinical) [Ep 10 · 21:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1297) - For large hydrocolpos, a tubeless vaginostomy can be created by opening the dome, removing part of the septum, and suturing the vagina to the abdominal wall like a vesicostomy or gastrostomy, avoiding an indwelling tube as a nidus for infection. — Marc Levitt (clinical) [Ep 10 · 22:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1330) - Single perineal orifice with no anal opening is a cloaca and does NOT require endocrine workup. A perineal orifice with a normal anus is a urogenital sinus and DOES require endocrine workup (e.g., for congenital adrenal hyperplasia). — Marc Levitt (guideline) [Ep 10 · 23:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1388) - Urogenital sinus patients can also have hydrocolpos and hydronephrosis, requiring similar drainage management but no colostomy. — Marc Levitt (clinical) [Ep 10 · 23:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1420) - Post-discharge follow-up for cloaca: monitor kidney decompression with serial ultrasounds, follow kidney function tests, ensure stoma management and growth. Definitive imaging and reconstructive planning are deferred until the patient is growing and thriving. — Richard Wood (guideline) [Ep 10 · 24:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1476) - Definitive diagnostic workup for cloaca is typically performed at 5 to 6 months of age. — Richard Wood (clinical) [Ep 11 · 1:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=113) - The workup includes multidisciplinary team evaluation (urology, gynecology, colorectal), cystovaginoscopy and examination under anesthesia, preoperative urodynamics catheter placement, and 3D cloacogram. — Richard Wood (clinical) [Ep 11 · 2:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=126) - During cystoscopy of the common channel, the easiest structure to enter is the vagina or vaginas; entering the urethra and bladder is challenging because the scope must point far upward to take the turn. — Richard Wood (clinical) [Ep 11 · 2:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=170) - The 3D cloacogram is acquired by injecting contrast into bladder, vagina(s), and rectal fistula, then using a vascular C-arm in radiology (or hybrid OR) with reconstruction software to create three-dimensional images. — Richard Wood (clinical) [Ep 11 · 3:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=224) - The major advantage of 3D reconstruction is spatial understanding of anatomy, because patients do not always present with textbook anatomy. — Richard Wood (opinion) [Ep 11 · 4:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=253) - During cystoscopy it is important to look for cervices to understand Müllerian development (one vagina vs. two, presence of uterus) and to identify ureteral orifices, which in complex malformations may attach anomalously low to the bladder or bladder neck. — Jason Frischer (clinical) [Ep 11 · 4:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=290) - The common channel takes a significant turn as it passes behind the pubis, especially in longer common channel cases. — Richard Wood (clinical) [Ep 11 · 6:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=375) - A multi-institutional study showed that cystoscopy significantly undermeasures common channel and urethral structures compared to 3D reconstruction, because a straight scope cannot measure the turn behind the pubis. — Richard Wood (clinical) [Ep 11 · 6:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=396) - Relying only on cystoscopy may result in significantly underreading the length of the common channel. — Richard Wood (clinical) [Ep 11 · 7:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=441) - Endoscopy performed by a general pediatric surgeon without extensive cloaca experience has value in distinguishing straightforward from complex cloacas and identifying cases that should be referred to specialized centers. — Marc Levitt (opinion) [Ep 11 · 7:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=461) - A major change in cloacal management occurred when surgeons began evaluating complexity before attempting repair and referring difficult cases to high-volume centers, reducing the need for reoperations that were common 10-15 years ago. — Marc Levitt (clinical) [Ep 11 · 7:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=479) - Lower confluence cloacas, if the surgeon knows the technique, are a beautiful and elegant operation; higher confluence cloacas requiring vaginal replacement and management of ectopic ureters should be done at specialized centers. — Marc Levitt (opinion) [Ep 11 · 8:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=524) - The algorithm published in 2017 ('Cloaca reconstruction: a new algorithm which considers the role of urethral length in determining surgical planning,' Journal of Pediatric Surgery) helps identify patients amenable to reproducible reconstruction vs. those needing complex reconstruction. — Richard Wood (clinical) [Ep 11 · 9:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=560) - Type 1 cloaca is defined as common channel length <1 cm; it is essentially a hypospadic urethra with a rectovaginal fistula. — Richard Wood (clinical) [Ep 11 · 10:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=628) - In type 1 cloaca, the hypospadic urethral orifice is not touched; the plan is vaginoplasty, anorectoplasty, and PSARP. — Richard Wood (clinical) [Ep 11 · 10:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=657) - Even in type 1 cloaca, the true rectum can still be high, so imaging is important to determine rectal position. — Richard Wood (clinical) [Ep 11 · 11:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=677) - For common channel length 1-3 cm, a normal urethra should be at least 1.5 cm long. — Richard Wood (clinical) [Ep 11 · 11:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=697) - If urethral length is >1.5 cm and common channel is 1-3 cm, the patient is amenable to total urogenital mobilization (TUM) and PSARP. — Richard Wood (clinical) [Ep 11 · 11:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=709) - If urethral length is <1.5 cm, urogenital separation (UGS) is advocated, because performing TUM on a 1 cm urethra would place the bladder neck near the perineum and could render the patient incontinent. — Richard Wood (clinical) [Ep 11 · 12:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=727) - The majority of 1-3 cm common channel cloacas have a normal length urethra and are amenable to TUM. — Richard Wood (clinical) [Ep 11 · 12:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=749) - For common channel >3 cm, patients often have urethral length <1.5 cm; in either case, UGS is advocated with repair of the common channel (left as the urethra), mobilization of the vagina to the perineum, and PSARP. — Richard Wood (clinical) [Ep 11 · 12:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=764) - If the vagina or vaginas cannot reach the perineum, the patient may need vaginal replacement to bridge the gap. — Richard Wood (clinical) [Ep 11 · 13:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=798) - If the rectum is high, consider an abdominal approach (open or laparoscopic-assisted PSARP) to mobilize rectal length. — Richard Wood (clinical) [Ep 11 · 13:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=814) - Hardy Hendren was the father of cloacal management in the late 1960s and 1970s, with specific focus on urology and urethral reconstruction. — Marc Levitt (clinical) [Ep 11 · 14:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=851) - Alberto Peña made a major advance in 1996 with the development of total urogenital mobilization (TUM), which kept the urethra and vagina together as a unit and mobilized them forward; prior to that, all patients had urogenital separation. — Marc Levitt (clinical) [Ep 11 · 14:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=876) - The next major change in the cloaca protocol occurred 21 years later, in 2017, when the algorithm incorporating urethral length measurement was presented at ABSA. — Marc Levitt (clinical) [Ep 11 · 15:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=910) - At the 2017 ABSA presentation, 91-year-old Hardy Hendren stated from the microphone that he agreed with everything presented and had no questions. — Marc Levitt (clinical) [Ep 11 · 16:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=974) - The 2017 algorithm is the first reproducible approach to cloacal management after 50 years of work on this challenging problem. — Marc Levitt (opinion) [Ep 11 · 17:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1023) - The algorithm has been validated in 116 consecutive patients without a single intraoperative plan change. — Richard Wood (clinical) [Ep 11 · 17:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1072) - Following the algorithm using the 3 cm and 1.5 cm thresholds allows surgeons to stay out of trouble; it provides a guide for which cases are reproducible and which require referral. — Richard Wood (opinion) [Ep 11 · 18:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1081) - The major change in the 2017 algorithm was the addition of urethral length measurement; previously the decision was based only on common channel length (less than or greater than 3 cm). — Marc Levitt (clinical) [Ep 11 · 18:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1104) - Measuring urethral length is critical because the patient needs an appropriately lengthed urethra at the end of the operation. — Marc Levitt (clinical) [Ep 11 · 18:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1119) - Urethral length is defined as the distance from where the common channel splits (urethra separates from vagina) to where the urethra enters the bladder, not from the single perineal orifice to the bladder neck. — Richard Wood (clinical) [Ep 11 · 19:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1149) - Measuring urethral length accurately with a cystoscope is difficult because the scope must navigate the curve behind the pubis, leading to significant under- or over-reading; this is especially important in longer common channel cases. — Richard Wood (clinical) [Ep 11 · 19:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1160) - The goal is to position the bladder neck above the urogenital diaphragm, where the external sphincter complex and urethra lie, so that intraabdominal pressure does not compromise continence. — Richard Wood (clinical) [Ep 11 · 19:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1180) - Urethral length can be measured using a ureteric catheter under fluoroscopy or with a scope, but the most accurate measurement comes from 3D imaging because it does not straighten structures and falsely measure them. — Richard Wood (clinical) [Ep 11 · 19:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1199) - Anorectal malformation patients require screening for VACTERL association: vertebral abnormalities (plain X-ray), cardiac defects (exam and echo), esophageal atresia (NG tube pass), renal abnormalities (kidney ultrasound), and limb abnormalities (physical exam). — Marc Levitt (guideline) [Ep 1 · 3:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=181) - Sacral ratio measurement should wait until the child is 3 months of age for true measurements, though early imaging gives a feel for pelvic development. — Marc Levitt (clinical) [Ep 1 · 3:55](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=235) - Spinal ultrasound in anorectal malformation patients should include evaluation of the presacral space to screen for presacral masses. — Marc Levitt (clinical) [Ep 1 · 4:22](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=262) - Presacral masses are rare in typical imperforate anus but occur in almost half of anal stenosis or rectal atresia cases, which require MRI evaluation. — Marc Levitt (epidemiological) [Ep 1 · 4:33](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=273) - Cross-table lateral X-ray should be obtained at approximately 24 hours of life to assess the air column position relative to the perineal skin, with the baby positioned prone to allow air to rise to the buttocks. — Jason Frischer (clinical) [Ep 1 · 5:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=308) - The cross-table lateral film should include a marker at the expected anal location to allow measurement of the distance between the air column and the perineal skin. — Jason Frischer (clinical) [Ep 1 · 6:28](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=388) - A sacral ratio greater than 0.7 connotes very good prognosis for bowel control and provides peace of mind for families regarding potty training and school readiness at 4 years of age. — Marc Levitt (clinical) [Ep 1 · 7:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=440) - Well-formed buttocks, visible sphincter mechanism location, and well-developed sacrum together predict good prognosis for continence. — Jason Frischer (clinical) [Ep 1 · 7:47](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=467) - The key to deciding whether to perform primary posterior sagittal anorectoplasty is knowing where the rectum is located; the danger is finding midline white structures like urethra, bladder neck, or bladder instead of rectum. — Marc Levitt (clinical) [Ep 1 · 9:06](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=546) - Colostomies and distal colostograms are performed to know exactly where the rectum is and whether to approach it perineally or laparoscopically. — Marc Levitt (clinical) [Ep 1 · 9:42](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=582) - The surgeon should never attempt posterior sagittal approach blind; imaging must confirm that the first structure encountered will be the air pocket of the distal rectum. — Jason Frischer (clinical) [Ep 1 · 9:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=598) - Colostomy is the safe choice for anorectal malformation repair, though it carries risks of complications from both the colostomy creation and the subsequent closure. — Marc Levitt (clinical) [Ep 1 · 10:24](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=624) - Surgeons have performed primary anorectoplasty on low anorectal malformations without knowing about a fistula, resulting in children later urinating out of the anus. — Marc Levitt (clinical) [Ep 1 · 11:10](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=670) - During primary posterior sagittal anorectoplasty, the surgeon should open the posterior wall of the rectum and inspect the anterior wall to rule out a fistula. — Marc Levitt (clinical) [Ep 1 · 12:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=729) - A bulbar fistula is located at the elbow of the urethra, using anatomic nomenclature based on the urethral location. — Jason Frischer (clinical) [Ep 1 · 12:55](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=775) - 95% of Down syndrome patients with imperforate anus have no fistula, but 5% do have a fistula, so distal colostogram is still indicated. — Marc Levitt (epidemiological) [Ep 1 · 13:44](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=824) - If the hole is in the center of the sphincter with adequate lumen and a perineal body is present, the patient does not need surgery. — Marc Levitt (clinical) [Ep 13 · 3:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=192) - If the hole is too small or outside of the sphincter, surgery is required. — Marc Levitt (clinical) [Ep 13 · 3:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=204) - Conversations about female perineal fistula management are more time-consuming than those about cloaca, and patients seek multiple opinions for this relatively benign malformation. — Marc Levitt (opinion) [Ep 13 · 2:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=145) - There are five valid management options for perineal fistula: colostomy then repair, primary repair, dilation then repair, simultaneous colostomy and repair, and dilation alone. — Marc Levitt (clinical) [Ep 13 · 4:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=260) - Diverting with a colostomy does not necessarily prevent perineal body dehiscence, and colostomy carries significant morbidity including closure complications. — Marc Levitt (clinical) [Ep 13 · 5:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=323) - Dilation alone is potentially acceptable but could be problematic if the fistulous distal end will not grow, leading to proximal distension. — Marc Levitt (clinical) [Ep 13 · 6:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=367) - A vestibular fistula is not a vaginal fistula because the posterior vaginal wall is intact with no fistula to it. — Marc Levitt (clinical) [Ep 13 · 9:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=554) - True vaginal fistulas are exceedingly rare in anorectal malformations. — Marc Levitt (epidemiological) [Ep 13 · 9:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=574) - Some perineal fistulas (position 4 on the classification) can be managed with posterior wall mobilization without touching the anterior wall. — Marc Levitt (clinical) [Ep 13 · 10:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=650) - Anal stenosis (position 5 on the classification) requires screening for Currarino syndrome. — Marc Levitt (clinical) [Ep 13 · 7:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=458) - Many children with anorectal malformations have associated genitourinary anomalies, which is well documented in the literature. — Kathleen Van Leeuwen (epidemiological) [Ep 13 · 12:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=732) - During vaginoscopy, seeing a single cervix does not definitively mean only one cervix is present; a second may be found later if there is a narrow side. — Kathleen Van Leeuwen (clinical) [Ep 13 · 12:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=768) - Surgeons performing vaginoscopy should look for single versus duplicated cervix, distal vaginal atresia, and vaginal septum. — Marc Levitt (clinical) [Ep 13 · 14:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=849) - The incidence of distal vaginal atresia is quite rare in anorectal malformations. — Marc Levitt (epidemiological) [Ep 13 · 14:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=861) - Vaginal septums occur in approximately 3 to 5% of vestibular fistulas. — Marc Levitt (epidemiological) [Ep 13 · 14:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=868) - Perineal fistulas can be associated with distal vaginal atresia, though less commonly than vestibular fistulas. — Marc Levitt (clinical) [Ep 13 · 14:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=876) - When neurologic anomalies are found in anorectal malformation patients, gynecological anomalies are more likely, especially on the same side. — Jason Frischer (clinical) [Ep 13 · 15:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=922) - For patients with anorectal malformations and ureteral abnormalities, differential renal function assessment (such as DMSA scan) is important to determine whether to reimplant the ureter or remove a non-functional kidney. — Marc Levitt (clinical) [Ep 13 · 16:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=996) - Absent kidneys in anorectal malformation patients are usually not truly absent but rather non-functional, often multicystic and dysplastic. — Marc Levitt (clinical) [Ep 13 · 17:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=1040) - Every surgeon caring for anorectal malformations should know the malformation type, spinal status (tethered cord, myelomeningocele, or normal), and sacral anatomy including sacral ratio. — Marc Levitt (guideline) [Ep 13 · 17:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=1064) - Sacral ratio calculation is valuable for informing family conversations about potential for bowel control in anorectal malformation patients. — Marc Levitt (clinical) [Ep 13 · 18:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=1095) - A patient with a low-type anorectal malformation (such as perineal fistula) but with associated spinal pathology has a different prognosis for bowel control than the same malformation with a normal spine. — Marc Levitt (clinical) [Ep 13 · 18:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=1095) - At Children's National, many surgeons start breast milk on post-op day 0 or 1 after primary perineal fistula repair, advance diet as tolerated, and discharge on post-op day 2-3. — Christine (clinical) [Ep 14 · 0:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=48) - Alberto Pena's original protocol mandated 7 days NPO with central line and hyperalimentation after ARM repair, feeding only on day 7 if healed. — Marc Levitt (clinical) [Ep 14 · 1:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=97) - A study by Carlos Reck (now in Vienna, Austria) compared NPO for 7 days versus clear liquids for 7 days and found the same amount of stool output in both groups. — Marc Levitt (clinical) [Ep 14 · 3:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=184) - The problem is not stool passage itself but hard stool passage that can disrupt the perineal body anastomosis. — Marc Levitt (clinical) [Ep 14 · 3:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=210) - Dr. Levitt's current protocol is regular IV (no PICC line), clear liquids or breast milk for 5 days, with very low dehiscence rate. Day 5 provides better healing than day 1-2. — Marc Levitt (clinical) [Ep 14 · 3:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=217) - There is no published article showing post-op day 1 regular diet (not breast milk, but actual food or formula) with a very low dehiscence rate. — Marc Levitt (opinion) [Ep 14 · 3:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=238) - Phoenix group (14 surgeons) performs most ARM repairs before children are on anything except breast milk or formula, does early repairs with early discharge home on ad lib PO intake, and reports very low dehiscence rate with close post-op follow-up. — Kathy (clinical) [Ep 14 · 4:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=272) - Perineal body dehiscence usually leads to no perineal body over several months, requiring redo surgery because the anterior anoplasty has no sphincter around it (it's split). — Marc Levitt (clinical) [Ep 14 · 5:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=345) - Nearly every redo case Dr. Levitt sees for perineal body dehiscence involved patients who were fed right away and discharged home. — Marc Levitt (clinical) [Ep 14 · 5:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=359) - Dr. Fisher's protocol for perineal body primary repair (no stoma) is 5-7 days NPO on D10 via midline catheter (not PICC line) until the repair is confirmed healed. — Jason Frischer (clinical) [Ep 14 · 7:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=437) - A randomized controlled trial by Richard Wood and Dr. Levitt compared dilation versus non-dilation for primary PSARP (cloacas excluded). Families were randomized and knew the backup plan for stricture was dilation ± Heineke-Mikulicz anoplasty. — Marc Levitt (clinical) [Ep 14 · 9:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=546) - In the dilation trial, both groups (dilation and non-dilation) had stricture rates somewhere between 10 and 20%. — Marc Levitt (clinical) [Ep 14 · 9:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=573) - Many patients' anoplasties look absolutely fine 8 weeks later at colostomy closure if they were never touched with a dilator, provided the anoplasty was healthy with no tension and good blood supply. — Marc Levitt (clinical) [Ep 14 · 10:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=625) - The dilation study was prompted by asking families their biggest concern about ARM care, and by far number one was dilations. This was family-driven research, not doctor-driven problem-solving. — Marc Levitt (clinical) [Ep 14 · 10:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=645) - The non-dilation protocol offers families a choice: dilate twice daily for 4 months, or accept a 10-15% risk of stricture requiring Heineke-Mikulicz anoplasty, with the child already going under anesthesia in 8 weeks for colostomy closure. — Marc Levitt (clinical) [Ep 14 · 11:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=685) - Dilations can drive couples apart. Often one family member does the dilations and over time doesn't want to come to clinic anymore. Parents feel guilty and find it traumatic to hold their child down for dilations. — Kathy (opinion) [Ep 14 · 12:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=736) - Jack Langer's protocol is to see patients weekly in clinic and pass a dilator himself rather than having families do it at home. — Marc Levitt (clinical) [Ep 14 · 13:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=825) - Full continence can be restored with a redo operation for stricture, and data is available showing this. One indication for redo is stricture. — Marc Levitt (clinical) [Ep 14 · 16:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=998) - The vast majority of patients needing intervention for stricture in the non-dilation protocol are already undergoing surgery for colostomy closure, making the intervention relatively minor. — Marc Levitt (clinical) [Ep 14 · 17:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1032) - Dr. Levitt has yet to meet a family that has chosen dilation when presented with the non-dilation option and its risks/benefits. — Marc Levitt (clinical) [Ep 14 · 17:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1041) - Some families at Phoenix have chosen dilation after being presented with the study data and options, preferring the known approach since long-term continence outcomes of non-dilation are not yet established. — Kathy (clinical) [Ep 14 · 18:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1088) - In Ghana, a colleague makes anoplasties slightly bigger knowing patients won't return for follow-up, anticipating some contraction will occur. — Marc Levitt (clinical) [Ep 14 · 19:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1177) - For redo ARM cases, Dr. Levitt makes the anoplasty a little bigger knowing there will be contraction. Redos are not dilated at all, but are examined under anesthesia at one month to check for early stricture. — Marc Levitt (clinical) [Ep 14 · 20:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1218) - For primary repairs, Dr. Levitt makes the lumen match what the maximal rectal lumen can be. With good mobilization (not overdoing it, throwing away as little rectum as possible), the anoplasty is usually a good size, about Hegar 13 or 14 at the end. — Marc Levitt (clinical) [Ep 14 · 20:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1233) - More than 90% of ARM patients' actual anatomy can be ascertained on physical exam alone — Marc Levitt (clinical) [Ep 6 · 2:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=153) - 95% of boys with ARM have a fistula somewhere — Marc Levitt (epidemiological) [Ep 6 · 4:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=276) - The term imperforate anus is actually a bad term because they're all perforate, they just don't perforate into where they ought to be perforating — Marc Levitt (opinion) [Ep 6 · 4:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=283) - The vast majority of male ARM enter into the urinary tract — Marc Levitt (epidemiological) [Ep 6 · 4:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=292) - It's useful to put a little gauze to check the urine for particulate matter when evaluating for rectourethral fistula — Marc Levitt (clinical) [Ep 6 · 5:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=322) - Patients with rectourethral fistulas need colostomies, then ultimately distal colostograms, and then definitive surgery — Marc Levitt (clinical) [Ep 6 · 5:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=344) - With a bucket handle malformation, you can be very confident that you have a perineal fistula — Marc Levitt (clinical) [Ep 6 · 7:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=429) - You can gently dilate the perineal fistula under the bucket handle to get meconium out and spare the baby a trip to the OR if they are too ill for surgery — Marc Levitt (clinical) [Ep 6 · 7:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=440) - The perineal fistula in bucket handle malformation is obviously anterior to the sphincter's center — Marc Levitt (clinical) [Ep 6 · 7:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=463) - In black ribbon malformation with meconium in scrotal raphae, the fistula parallels the urethra for a long distance, creating potential for urethral injury during surgery — Marc Levitt (clinical) [Ep 6 · 8:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=518) - For black ribbon malformation, you don't have to go crazy finding that fistula; you just basically need to unroof that meconium and then find a healthy rectum and make an anoplasty — Marc Levitt (clinical) [Ep 6 · 9:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=542) - The no-fistula defect is quite rare, only about 5% of cases — Marc Levitt (epidemiological) [Ep 6 · 10:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=622) - The no-fistula defect is not surprising if you had a trisomy 21 patient — Marc Levitt (clinical) [Ep 6 · 10:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=622) - The no-fistula defect is almost uniformly at the same level as a bulbar urethra — Marc Levitt (clinical) [Ep 6 · 10:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=622) - In a perineal fistula, the hole is too small, not in the center of the sphincter, and there is an inadequate perineal body. — Marc Levitt (clinical) [Ep 7 · 2:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=154) - Surgical indications for perineal fistula are: achieving a hole in the center of the sphincter with an adequate perineal body. — Marc Levitt (clinical) [Ep 7 · 2:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=168) - A perineal fistula just outside the sphincter ellipse needs to be moved back, which can be accomplished with posterior rectal wall mobilization if the perineal body is adequate and the hole is centered by the sphincter. — Marc Levitt (clinical) [Ep 7 · 3:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=198) - Perineal groove with mucosal lining usually does not require surgical intervention and will keratinize to look like a normal perineal body over time. — Jason Frischer (clinical) [Ep 7 · 4:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=285) - Indications to operate on a perineal groove include secreting mucus causing irritation or developing ulcers, where the mucosal lining can be excised, but this is extremely rare. — Jason Frischer (clinical) [Ep 7 · 4:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=297) - MRI can be used to determine if the rectum is correctly exiting the sphincter when physical exam is inconclusive. — Jason Frischer (clinical) [Ep 7 · 7:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=427) - A perineal fistula with adequate hole size, surrounded by sphincter, and with a perineal body (albeit short) does not require surgery. — Marc Levitt (clinical) [Ep 7 · 7:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=435) - A short perineal body will grow over time and cannot be surgically improved when other anatomic features are correct. — Marc Levitt (clinical) [Ep 7 · 7:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=469) - If a fistula does not have sphincter on the anterior aspect of the anoplasty, the patient will leak stool because they cannot close the hole, which warrants surgery to relocate the hole. — Marc Levitt (clinical) [Ep 7 · 8:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=524) - Vestibular fistula is very common in females and needs formal repair with the hole transposed to the center of the sphincter. — Marc Levitt (clinical) [Ep 7 · 9:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=598) - For vestibular fistula diagnosed in the newborn period in a well baby, primary repair can be done in the newborn period, or the baby can stool through the fistula for a couple of months followed by elective repair without a stoma after bowel prep. — Marc Levitt (clinical) [Ep 7 · 10:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=627) - Vestibular fistula patients diagnosed later (6, 8, 12 months) who have dilated their rectosigmoid need diversion as the first step, then repair. — Marc Levitt (clinical) [Ep 7 · 10:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=644) - The purpose of diversion in ARM repair is to avoid perineal body dehiscence. — Marc Levitt (clinical) [Ep 7 · 11:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=661) - Cloaca with a single perineal orifice and hypertrophied clitoral hood is not ambiguous genitalia. — Marc Levitt (clinical) [Ep 7 · 11:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=687) - Cloaca patients have no endocrine problem, do not need steroids, and do not need an endocrinologic workup. — Marc Levitt (clinical) [Ep 7 · 11:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=710) - Cloaca patients have no question of gender assignment—they are female. — Marc Levitt (clinical) [Ep 7 · 11:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=718) - Cloaca patients are still being misdiagnosed as ambiguous genitalia, with some babies not receiving proper gender assignment for one to two weeks. — Marc Levitt (clinical) [Ep 7 · 11:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=718) - For perineal exam in newborn females, good lighting and good visualization are essential, including using loupes or magnification and bringing external light sources. — Jason Frischer (clinical) [Ep 7 · 12:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=763) - The key to perineal exam is to push down and flatten the perineal body to assess if it is normal and to check anal size. — Marc Levitt (clinical) [Ep 7 · 13:26](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=806) - To evaluate for vestibular fistula, use both hands on the right and left labia, pull the labia toward you and open them to visualize the vaginal opening and urethra. — Jason Frischer (clinical) [Ep 7 · 14:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=851) - A biopsy taken from the mid to upper sigmoid confirms ganglion cells (clinical) [Ep 18 · 2:39](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=159) - Dissection begins on the upper rectum, carefully removing fat and dissecting at the peritoneal reflection (clinical) [Ep 18 · 2:45](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=165) - The lower sigmoid segment appears leathery while the more proximal sigmoid appears healthy (clinical) [Ep 18 · 2:53](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=173) - Care must be taken to check for the left ureter during dissection (clinical) [Ep 18 · 3:27](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=207) - The arcade to the biopsy site is preserved and the mesentery is taken adjacent to the bowel distal from this location (clinical) [Ep 18 · 3:30](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=210) - A good marginal branch from the IMA must be ensured, with everything distal to this branch dissected with ligature (clinical) [Ep 18 · 3:48](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=228) - The intended section of bowel must easily reach the perineum for the pull through to the coloanal anastomosis (clinical) [Ep 18 · 4:42](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=282) - With legs in lithotomy position, Lone Star pins are placed to expose and protect the anal canal (clinical) [Ep 18 · 4:57](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=297) - The purple line of Lee is marked 0.5 centimeters proximal to the dentate line, which is hidden by the pins (clinical) [Ep 18 · 5:04](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=304) - Dissection is performed in a full thickness, Swenson-like plane (clinical) [Ep 18 · 5:28](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=328) - The transanal dissection quickly breaks through to the location of the previous laparoscopic dissection (clinical) [Ep 18 · 5:33](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=333) - The bowel is pulled through maintaining its orientation and marked to avoid twisting (clinical) [Ep 18 · 6:07](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=367) - The anastomosis is performed with seromuscular bites to the sphincter, then a second layer mucosa to mucosa (clinical) [Ep 18 · 6:49](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=409) - Pulling apart opposing mosquito clamps and suturing between them takes away any size discrepancy during anastomosis (clinical) [Ep 18 · 7:34](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=454) ## Host summaries Recaps by a host of what the experts said — not the host's own clinical position. - A lot of surgeons agree that oftentimes your first shot might be your only shot to give this patient a good outcome and the right anatomy. — Jason Frischer summarizes what Dr. Marc Levitt said [Ep 9 · 0:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=40) - The vast majority of patients who get redos had mislocation, followed by stricture, then less common reasons including remnant of the original fistula (roof), rectal prolapse, and others. — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 9 · 12:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=720) - Quality of life improved with a redo operation. — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 9 · 12:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=750) - Patients had an improved ability to achieve continence after redo operations. — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 9 · 12:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=760) - In the JPS study, 20% of patients with a poor sacrum or poor spine actually developed bowel control after their redo. — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 9 · 12:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=775) - Patients with good potential (good sacrum and good spine) did extremely well after redo operations. — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 9 · 13:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=790) - Patients who did not develop voluntary bowel movements after redo were still able to be clean with a bowel management program using enemas or antegrade via a Malone. — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 9 · 12:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=770) - The average age of patients in the JPS study is about three and a half years, give or take. — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 9 · 13:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=790) - VACTERL represents: V for vertebral, A for anorectal, C for cardiac, T and E for tracheoesophageal fistula, R for renal, and L for limb. — Amanda Jensen summarizing the discussion [Ep 8 · 4:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=260) - Posterior rectal wall only mobilization technique is only appropriate in situations where the dot of the fistula is in the sphincteric ellipse. — Rod Gerardo summarizing the discussion [Ep 8 · 7:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=429) - Cloaca or anorectal malformation is associated with VACTERL and requires workup as such. — Amanda Jensen summarizing the discussion [Ep 10 · 2:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=178) - VACTERL association comprises: Vertebral anomalies, imperforate Anus, Cardiovascular anomalies, Tracheoesophageal fistula, Esophageal atresia, Renal/radial anomalies, and Limb defects. Three or more anomalies define the association. — Amanda Jensen summarizing the discussion [Ep 10 · 3:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=190) - Initial workup should include NG tube and chest X-ray, cardiac echo, and pelvic and renal ultrasound to assess for TEF, cardiac anomalies, hydrocolpos, and hydronephrosis. — Amanda Jensen summarizing the discussion [Ep 10 · 8:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=525) - Bilateral hydronephrosis with hydrocolpos requires management of the hydrocolpos as part of initial treatment. — Amanda Jensen summarizing the discussion [Ep 10 · 9:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=550) - The study 'Measure twice and cut once: comparing endoscopy and 3D cloacogram for common channel and urethral measurements in patients with cloacal malformations' was published in the Journal of Pediatric Surgery, October 2019. — Amanda Jensen summarizing the discussion [Ep 11 · 6:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=418) - In low anorectal malformations, dissecting a small portion of the anterior rectal wall and carefully lifting it off the urinary tract will usually rule out a fistula. — Rod Gerardo summarizing the discussion [Ep 1 · 12:17](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=737) - A normal anus must meet three criteria: appropriate size, centered in the sphincter, and presence of a perineal body. — Amanda Jensen summarizing the discussion [Ep 13 · 3:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=182) - In the dilation trial, 4 patients required redo operations for stricture: 2 in the dilation arm (who didn't actually dilate) and 2 in the non-dilation arm. Additional patients required Heineke-Mikulicz procedures (3 in one group, 47 total procedures mentioned). — Jason Frischer summarizing a resource [Ep 14 · 14:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=860) - Anorectal malformations occur in 1 in 5000 live births — Rod Gerardo summarizing the discussion [Ep 6 · 0:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=36) - ARM occurs when the anus, rectum, and nerves do not develop properly during fetal growth — Rod Gerardo summarizing the discussion [Ep 6 · 0:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=41) - In male ARM, rectourethral fistulas are categorized by location on the urethra: bulbar, prostatic, or bladder neck — Rod Gerardo summarizing the discussion [Ep 6 · 4:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=245) - The presence of a flat bottom (absence of a normal midline groove) is usually associated with a very high located rectum and usually associated with a bad prognosis — Rod Gerardo summarizing the discussion [Ep 6 · 5:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=358) - In male patients with a perineal fistula, the fistula is always located anterior to the center of the sphincter — Rod Gerardo summarizing the discussion [Ep 6 · 9:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=580) - No surgical repair should be done before the first 24 hours because a patient may pass meconium through the tiny orifice and allow identification of their perineal fistula — Rod Gerardo summarizing the discussion [Ep 6 · 9:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-6890?t=590) - When examining a patient with ARM, assess: (1) can you locate the perineal fistula, (2) is it in the correct location, (3) is it too big or too small, (4) is it within the sphincter, and (5) what is the size of the perineal body. — Amanda Jensen summarizing the discussion [Ep 7 · 2:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=178) - Congenital perineal groove is an exposed wet sulcus of non-keratinized mucous membrane that usually epithelializes on its own by age 2. — Amanda Jensen summarizing the discussion [Ep 7 · 6:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=371) - Perineal groove can be misdiagnosed as contact dermatitis, trauma, or sexual abuse. — Amanda Jensen summarizing the discussion [Ep 7 · 6:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=371) - When considering surgery for ARM, evaluate three qualities: anal size, location (whether surrounded by sphincter muscle complex), and the perineal body that separates it from genital or urinary structures. — Amanda Jensen summarizing the discussion [Ep 7 · 9:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=552) - Recto-vestibular fistula has three openings: the urethra, the vagina, and a fistula within the vestibule. — Amanda Jensen summarizing the discussion [Ep 7 · 11:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=672) - Urogenital sinus plus a normal anus is an endocrine problem, but no anus and a urogenital sinus is a cloaca. — Rod Gerardo summarizing the discussion [Ep 7 · 12:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=737) - Use Hagar dilators starting low and working up to get accurate anal size measurement; do not use fingers because every surgeon has a different size glove. — Rod Gerardo summarizing the discussion [Ep 7 · 13:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=818) - Female ARM classification is based on the number of perineal orifices: if three, determine perineal vs. vestibular fistula; if two, determine presence of fistula, vaginal atresia, or recto-vaginal fistula; if one, it is a cloaca. — Amanda Jensen summarizing the discussion [Ep 7 · 15:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-6891?t=903) - A 5 millimeter trochar is used for umbilical access to begin the case — The host summarizing the discussion [Ep 18 · 0:24](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=24) - The camera is moved to a port site at the right upper quadrant to maximize exposure to the view of the pelvis — The host summarizing the discussion [Ep 18 · 0:32](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=32) - The operating surgeon should stand at the patient's right shoulder — The host summarizing the discussion [Ep 18 · 0:40](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=40) - Laparoscopy is used to do the leveling biopsy, bringing the sigmoid out the umbilical port for an extracorporeal full thickness biopsy — The host summarizing the discussion [Ep 18 · 1:00](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=60) - Once the level is confirmed, laparoscopy is used to take down the attachments of the left colon from the left retroperitoneum and dissect into the deep pelvis — The host summarizing the discussion [Ep 18 · 1:10](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=70) - The mesenteric arcade distal to the biopsy site is taken while preserving the sigmoid arcade to the location of the intended pull through — The host summarizing the discussion [Ep 18 · 1:23](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=83) - The purple line of Lee is traced 0.5 centimeters proximal to the crypts, preserving the anal canal — The host summarizing the discussion [Ep 18 · 1:56](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=116) - Silk sutures are placed which facilitate a circumferential dissection into the Swenson plane — The host summarizing the discussion [Ep 18 · 2:05](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=125) - The bowel is mobilized full thickness until the prior laparoscopic dissection is reached, allowing the rectosigmoid to be pulled through to the biopsy site — The host summarizing the discussion [Ep 18 · 2:17](https://library.globalcastmd.com/watch/laparoscopic-pull-through-for-hirschsprung-disease-updated-2024-8895?t=137) --- Educational content from recorded physician discussions — not medical advice. 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