# Anorectal Malformations & Cloacal Reconstruction — GCMD Library living collection

Updated: n/a · 24 episodes · 300 cited statements

## Episodes
### Fundamentals & Diagnosis
- [Sacral Curvature in Addition to Sacral Ratio to Assess Sacral Development and the Association With the Type of Anorectal Malformations](https://library.globalcastmd.com/watch/sacral-curvature-in-addition-to-sacral-ratio-to-assess-sacral-development-and-the-association-with-the-type-of-anorectal-malformations-13798) — article · [machine version](https://library.globalcastmd.com/watch/sacral-curvature-in-addition-to-sacral-ratio-to-assess-sacral-development-and-the-association-with-the-type-of-anorectal-malformations-13798.md)
- [Corrigendum: Sacral Curvature in Addition to Sacral Ratio to Assess Sacral Development and the Association With the Type of Anorectal Malformations](https://library.globalcastmd.com/watch/corrigendum-sacral-curvature-in-addition-to-sacral-ratio-to-assess-sacral-development-and-the-association-with-the-type-of-anorectal-malformations-13797) — article · [machine version](https://library.globalcastmd.com/watch/corrigendum-sacral-curvature-in-addition-to-sacral-ratio-to-assess-sacral-development-and-the-association-with-the-type-of-anorectal-malformations-13797.md)
- [VACTERL Screening in Newborns With Anorectal Malformations - An Opportunity to Optimize Screening Practices, add Gynecologic and Spinal Conditions, and Utilize a New Acronym: VACTE(G)RLS](https://library.globalcastmd.com/watch/vacterl-screening-in-newborns-with-anorectal-malformations-an-opportunity-to-optimize-screening-practices-add-gynecologic-and-spinal-conditions-and-utilize-a-new-acronym-vacte-rls-10610) — article · [machine version](https://library.globalcastmd.com/watch/vacterl-screening-in-newborns-with-anorectal-malformations-an-opportunity-to-optimize-screening-practices-add-gynecologic-and-spinal-conditions-and-utilize-a-new-acronym-vacte-rls-10610.md)
- [A Genetics-First Approach Revealed Monogenic Disorders in Patients With ARM and VACTERL Anomalies](https://library.globalcastmd.com/watch/a-genetics-first-approach-revealed-monogenic-disorders-in-patients-with-arm-and-vacterl-anomalies-13802) — article · [machine version](https://library.globalcastmd.com/watch/a-genetics-first-approach-revealed-monogenic-disorders-in-patients-with-arm-and-vacterl-anomalies-13802.md)
- [Fetal and Newborn Management of Cloacal Malformations](https://library.globalcastmd.com/watch/fetal-and-newborn-management-of-cloacal-malformations-13765) — article · [machine version](https://library.globalcastmd.com/watch/fetal-and-newborn-management-of-cloacal-malformations-13765.md)
- [The tethered spinal cord in patients with anorectal malformations](https://library.globalcastmd.com/watch/the-tethered-spinal-cord-in-patients-with-anorectal-malformations-13816) — article · [machine version](https://library.globalcastmd.com/watch/the-tethered-spinal-cord-in-patients-with-anorectal-malformations-13816.md)
- [Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856) — podcast · 16:18 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856.md)

### Surgical Techniques
- [The cutback revisited - The posterior rectal advancement anoplasty for certain anorectal malformations with rectoperineal fistula](https://library.globalcastmd.com/watch/the-cutback-revisited-the-posterior-rectal-advancement-anoplasty-for-certain-anorectal-malformations-with-rectoperineal-fistula-6150) — article · [machine version](https://library.globalcastmd.com/watch/the-cutback-revisited-the-posterior-rectal-advancement-anoplasty-for-certain-anorectal-malformations-with-rectoperineal-fistula-6150.md)
- [Colorectal Quiz  Episode 1 - Low Bulbar Fistua](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824) — video · 15:45 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824.md)
- [Factors predicting the need for vaginal replacement at the time of primary reconstruction of a cloacal malformation](https://library.globalcastmd.com/watch/factors-predicting-the-need-for-vaginal-replacement-at-the-time-of-primary-reconstruction-of-a-cloacal-malformation-13805) — article · [machine version](https://library.globalcastmd.com/watch/factors-predicting-the-need-for-vaginal-replacement-at-the-time-of-primary-reconstruction-of-a-cloacal-malformation-13805.md)
- [Colorectal Quiz Episode 29: Female ARM](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858) — podcast · 25:08 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858.md)
- [Colorectal Quiz Episode 18: Cloaca Part 2](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862) — podcast · 23:10 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862.md)
- [Colorectal Quiz Episode 17: Cloaca Part 1](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863) — podcast · 27:32 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863.md)
- [Colorectal Quiz Episode 33: Cloaca Exstrophy](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819) — video · 22:24 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819.md)
- [Laparoscopic Approach in Anorectal Malformations: How We Do It](https://library.globalcastmd.com/watch/laparoscopic-approach-in-anorectal-malformations-how-we-do-it-13799) — article · [machine version](https://library.globalcastmd.com/watch/laparoscopic-approach-in-anorectal-malformations-how-we-do-it-13799.md)
- [The Role of Laparoscopy in Anorectal Malformations](https://library.globalcastmd.com/watch/the-role-of-laparoscopy-in-anorectal-malformations-13803) — article · [machine version](https://library.globalcastmd.com/watch/the-role-of-laparoscopy-in-anorectal-malformations-13803.md)
- [Preliminary Use of Indocyanine Green Fluorescence Angiography and Value in Predicting the Vascular Supply of Tissues Needed to Perform Cloacal, Anorectal Malformation, and Hirschsprung Reconstructions](https://library.globalcastmd.com/watch/preliminary-use-of-indocyanine-green-fluorescence-angiography-and-value-in-predicting-the-vascular-supply-of-tissues-needed-to-perform-cloacal-anorectal-malformation-and-hirschsprung-reconstructions-13804) — article · [machine version](https://library.globalcastmd.com/watch/preliminary-use-of-indocyanine-green-fluorescence-angiography-and-value-in-predicting-the-vascular-supply-of-tissues-needed-to-perform-cloacal-anorectal-malformation-and-hirschsprung-reconstructions-13804.md)
- [Colorectal Quiz Episode 2: When to redo a PSARP](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845) — video · 18:15 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845.md)
- [Colorectal Quiz: Episode 2](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865) — podcast · 18:15 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865.md)

### Postoperative Care & Outcomes
- [Global Strategies for Postoperative Care and Bowel Management in Patients With Anorectal Malformations: Varied Practices and Barriers](https://library.globalcastmd.com/watch/global-strategies-for-postoperative-care-and-bowel-management-in-patients-with-anorectal-malformations-varied-practices-and-barriers-13760) — article · [machine version](https://library.globalcastmd.com/watch/global-strategies-for-postoperative-care-and-bowel-management-in-patients-with-anorectal-malformations-varied-practices-and-barriers-13760.md)
- [APSP Online Webinar | Marc Levitt & team | Bowel Management Program for Fecal incontinence](https://library.globalcastmd.com/watch/apsp-online-webinar-marc-levitt-team-bowel-management-program-for-fecal-incontinence-13826) — video · [machine version](https://library.globalcastmd.com/watch/apsp-online-webinar-marc-levitt-team-bowel-management-program-for-fecal-incontinence-13826.md)
- [Anorectal Malformations Complications](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872) — podcast · 48:08 · [machine version](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872.md)

### More resources
- [Colorectal Quiz: Episode 40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852) — podcast · 18:43 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852.md)
- [The Colorectal Quiz: Episode 1](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868) — podcast · 15:45 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868.md)

## Chapters
- [0:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=4) Introduction: The Challenge of Redo Anorectoplasty (Ep 18)
- [2:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=161) Case Presentations and Prognostic Factors (Ep 18)
- [4:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=241) Case 1: Seven-Year-Old with Posterior Misplacement (Ep 18)
- [7:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=430) Technical Discussion: Identifying Correct Sphincter Location (Ep 18)
- [10:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=621) Case 2 and Anatomic Variations (Ep 18)
- [11:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=661) Evidence for Redo Surgery: JPS Study Results (Ep 18)
- [13:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=801) Timing and Indications for Redo Surgery (Ep 18)
- [16:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=963) Summary and Conclusions (Ep 18)
- [0:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=8) Case Introduction and Prenatal Diagnosis (Ep 14)
- [2:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=137) Initial Workup and Timing of Intervention (Ep 14)
- [5:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=331) Surgical Decision Points and Orthopedic Considerations (Ep 14)
- [7:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=463) Intraoperative Anatomy and Traditional Approach (Ep 14)
- [10:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=617) Novel Surgical Technique: Auto-augmentation Approach (Ep 14)
- [16:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=977) Case Outcome and Technical Details (Ep 14)
- [19:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1180) Long-term Planning and Multidisciplinary Coordination (Ep 14)
- [0:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=0) Introduction to the Colorectal Quiz Series (Ep 9)
- [1:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=112) Case Presentation and Initial Workup (Ep 9)
- [3:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=235) Cross-Table Lateral Imaging and Decision Making (Ep 9)
- [6:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=366) Radiographic Findings and Prognostic Indicators (Ep 9)
- [8:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=505) Primary Repair Versus Colostomy Decision (Ep 9)
- [11:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=660) Unexpected Fistula Discovery and Management (Ep 9)
- [14:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=840) Case Summary and Closing (Ep 9)
- [0:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=0) Case presentation and initial colostomy decision-making (Ep 23)
- [3:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=203) Physical examination findings and Meyer-Rokitansky-like anatomy (Ep 23)
- [6:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=383) Imaging findings and surgical planning challenges (Ep 23)
- [7:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=477) Staged surgical approach and vascular anomaly management (Ep 23)
- [10:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=628) Rationale for avoiding diversion and vaginal reconstruction (Ep 23)
- [14:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=849) Future vaginal reconstruction considerations and surgical wisdom (Ep 23)
- [16:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=1004) Long-term prognosis and case summary (Ep 23)
- [0:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=0) Introduction and Guest Reveal (Ep 7)
- [2:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=127) Case Presentation: Newborn with TOF and ARM (Ep 7)
- [5:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=323) Management Options: Dilation vs Primary Repair vs Colostomy (Ep 7)
- [8:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=509) VACTERL Workup and Surgical Decision (Ep 7)
- [10:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=650) Laparoscopic Technique in Cardiac Patients (Ep 7)
- [12:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=730) Definitive Repair and Prognosis (Ep 7)
- [15:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=905) Closing and Joke (Ep 7)
- [0:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=0) Postoperative Feeding Protocols After Perineal Fistula Repair (Ep 11)
- [4:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=272) Referral Patterns, Patient Age, and Dehiscence Risk (Ep 11)
- [9:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=545) Dilation Protocols: Randomized Trial Results and Clinical Implications (Ep 11)
- [18:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=1125) Technical Considerations: Anoplasty Sizing and Stricture Prevention (Ep 11)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Perineal fistulas in males are commonly missed in the newborn period because the baby passes meconium through the small fistulous opening, and no one notices the abnormal anal anatomy. These patients typically present in the first year of life with severe constipation. — Marc Levitt (clinical) [Ep 22 · 2:55](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=175)
- By the time a missed perineal fistula is diagnosed, the rectum and sigmoid have dilated because stool has been passing through a very tiny fistulous orifice which is not normal anal or rectal mucosa. — Marc Levitt (clinical) [Ep 22 · 3:43](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=223)
- The current standard is to check temperature on the forehead or in the ear rather than rectally, so if you don't look at the anus, you might not know there is a malformation. — Marc Levitt (clinical) [Ep 22 · 4:03](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=243)
- Relocating a perineal fistula into the sphincters does not completely fix the constipation, though it improves the anatomy by making the hole adequately sized and lined by mucosa. — Marc Levitt (clinical) [Ep 22 · 4:53](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=293)
- Patients with uncorrected perineal fistulas can have some semblance of continence with formed stool, but with loose stool or athletic activity they will soil because they cannot completely close the anteriorly located hole when squeezing their sphincters. — Marc Levitt (clinical) [Ep 22 · 5:23](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=323)
- A newborn anus should accept a size 12 Hagar dilator, and a one-year-old should accept a size 15. — Marc Levitt (clinical) [Ep 22 · 6:05](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=365)
- A bucket handle (a lifted skin tag that you can pass a probe underneath) is consistent with a perineal fistula even if you cannot see the fistula itself. — Marc Levitt (clinical) [Ep 22 · 6:41](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=401)
- Perineal fistula in females is probably the most confounding diagnosis in pediatric colorectal surgery, with many patients either being missed or overdiagnosed. — Marc Levitt (opinion) [Ep 22 · 7:28](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=448)
- Diagnostic criteria for perineal fistula in females: inadequate perineal body (hole too close to vagina), inadequate hole size, and hole not centered in the sphincter. — Marc Levitt (clinical) [Ep 22 · 7:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=470)
- If the anal opening in a female is adequate size and centered in the sphincter, even if it appears slightly anterior with a short perineal body, that patient does not need surgery. The perineal body will lengthen with growth. — Marc Levitt (clinical) [Ep 22 · 8:25](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=505)
- An anesthesia nerve stimulator ($150) with appropriate needle probes works as well as a dedicated Pena stimulator ($15,000) for intraoperative sphincter mapping. — Marc Levitt (clinical) [Ep 22 · 10:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=650)
- The vast majority of male ARM patients have a rectourethral fistula. It is important not to approach these primarily because you don't know where the rectum is—it could be at bladder neck, prostatic, or bulbar level. — Marc Levitt (clinical) [Ep 22 · 12:38](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=758)
- If you open posterior sagittal looking for a rectourethral fistula without knowing the location, you will find something midline, white, and shiny that might be the urinary tract, not the rectum. — Marc Levitt (clinical) [Ep 22 · 13:20](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=800)
- Cloacas can be missed in the newborn period. Dr. Levitt saw a six-month-old who presented with constipation and was found to have an undiagnosed cloaca with no hint of an anal opening. — Marc Levitt (clinical) [Ep 22 · 14:04](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=844)
- Ambiguous genitalia (clitoromegaly from endocrine stimulation) presents with a urogenital sinus but a completely normal anus. This is different from a cloaca, which has no anus and no endocrine problem. — Marc Levitt (clinical) [Ep 22 · 15:49](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=949)
- The most common colostomy error is opening too distal in the sigmoid, which restricts the ultimate pull-through by the location of the colostomy or mucous fistula. — Marc Levitt (clinical) [Ep 22 · 16:44](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1004)
- Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections. — Marc Levitt (clinical) [Ep 22 · 17:20](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1040)
- Transverse colostomies are problematic because they can prolapse, and if there is a large rectourethral fistula, the left colon absorbs all the urine (which doesn't come out the mucous fistula), causing acidosis. — Marc Levitt (clinical) [Ep 22 · 17:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1070)
- Dr. Levitt's preference is a very proximal sigmoid colostomy with separated stomas, leaving the entire sigmoid loop for the pull-through. He makes the mucous fistula very tiny and flat. — Marc Levitt (clinical) [Ep 22 · 18:35](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1115)
- Prolapse is related to where in the colon you choose to do the colostomy. Mid-transverse: both sides can prolapse. Hepatic flexure: only distal can prolapse. Proximal sigmoid: only distal (mucous fistula) can prolapse because left colon is fixed to retroperitoneum. — Marc Levitt (clinical) [Ep 22 · 19:58](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1198)
- Dr. Levitt marks the anoplasty location by drawing a circle around the pinkish ellipse where it stimulates on the skin surface BEFORE making the incision, to avoid getting lost when looking at jumping muscles from the stimulator. — Marc Levitt (clinical) [Ep 22 · 21:10](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1270)
- Really good surgeons have put anuses in crazy places because they don't have a sense of what's the center once everything is disrupted and open. — Marc Levitt (clinical) [Ep 22 · 22:36](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1356)
- The distal colostogram is an absolutely vital study. Many mistakes are made because of a poorly done study and misinterpretation. — Marc Levitt (clinical) [Ep 22 · 23:29](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1409)
- The basic questions the distal colostogram must answer: Where is the rectum? How low is it? Is it reachable posterior sagittally or better approached laparoscopically? What is its relationship to the urinary tract? — Marc Levitt (clinical) [Ep 22 · 23:55](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1435)
- The common colostogram mistake is not giving enough contrast and pressure into the distal segment, giving a false impression that the rectum is high or that there is no fistula. — Marc Levitt (clinical) [Ep 22 · 24:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1470)
- If you see a straight line flattening of the rectum corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure. You need to overcome the PC line (the sphincters compressing the distal rectum) to see the bulging rectum and fistula. — Marc Levitt (clinical) [Ep 22 · 25:00](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1500)
- Fistula classification: if the fistula is at the urethral 'elbow' or below, it's bulbar. Above the elbow is prostatic. At the bladder neck is bladder neck fistula. — Marc Levitt (clinical) [Ep 22 · 25:55](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1555)
- If the rectum is bulbous, it might be reachable posterior sagittally and hard to do laparoscopically because of the girth. If it's tapered, you're better off laparoscopically. — Marc Levitt (clinical) [Ep 22 · 25:55](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1555)
- If you don't know where the rectum is and open posterior sagittal, you will find a whitish, shiny structure and may think it's the rectum. Often it's the bladder neck. — Marc Levitt (clinical) [Ep 22 · 26:52](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1612)
- You avoid bladder neck injury by knowing exactly where the rectum is from a properly done distal colostogram. When you open posterior sagittal, you know the rectum is right under the coccyx (prostatic) or distal to the coccyx (bulbar), or it isn't posterior sagittal at all (bladder neck—do laparoscopy). — Marc Levitt (clinical) [Ep 22 · 27:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1650)
- Dr. Levitt will do posterior sagittal for bulbar fistulas and low prostatic fistulas with a bulge. High prostatic with tapered rectum and bladder neck fistulas are best served by laparoscopy. — Marc Levitt (clinical) [Ep 22 · 30:03](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1803)
- If you try laparoscopy for a rectum bulging below the peritoneal reflection at low prostatic or bulbar level, you may leave behind a remnant of the original fistula (ROOF)—the distal rectum left behind that causes trouble later. — Marc Levitt (clinical) [Ep 22 · 30:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1850)
- Laparoscopy replaces laparotomy, not PSARP. Dr. Levitt does a mini-PSARP when doing laparoscopy to safely enter the pelvis and tack the rectum to the posterior edge of the muscle complex to avoid prolapse. — Marc Levitt (clinical) [Ep 22 · 31:38](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1898)
- Dr. Levitt calls his approach 'laparoscopic-assisted PSARP' rather than pure laparoscopy. — Marc Levitt (clinical) [Ep 22 · 32:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1950)
- Prolapse prevention: put the rectum in the right location, close the levators properly, close the posterior wall to the posterior edge of the muscle complex for 3-4 stitches, don't dissect the rectum more than necessary. — Marc Levitt (clinical) [Ep 22 · 32:55](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1975)
- Prolapse occurs in about 3% of cases, particularly in those without great muscles. — Marc Levitt (epidemiological) [Ep 22 · 33:49](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2029)
- Rectal prolapse causes bleeding, mucus, and for patients with good continence potential, it inhibits bowel control because they can't close the opening with prolapsed tissue through it. — Marc Levitt (clinical) [Ep 22 · 33:54](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2034)
- Dr. Levitt trims prolapse of more than about 3mm. For circumferential prolapse, he does half the circumference in two different ambulatory settings so families don't need hospitalization and the patient doesn't need dilation (half the circumference is untouched so they won't stricture). — Marc Levitt (clinical) [Ep 22 · 34:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2070)
- Perineal body dehiscence is the most common cause of reoperation Dr. Levitt performs in female ARM repairs. — Marc Levitt (clinical) [Ep 22 · 35:27](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2127)
- The key to preventing perineal body dehiscence is mobilizing the rectum well—you must get the anterior rectal wall completely separated from the posterior vaginal wall to the areolar plane. If you don't, the anoplasty will be under tension and can pull back, leak into the perineal body space, and dehisce. — Marc Levitt (clinical) [Ep 22 · 35:55](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2155)
- Dr. Levitt uses 3-0 suture for perineal body closure in a baby and 4-0 Vicryl on the perineal skin, then watches the perineum very closely. — Marc Levitt (clinical) [Ep 22 · 36:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2210)
- Traditionally Dr. Levitt kept patients NPO for 7 days on 10% dextrose after female ARM repair. Recently he has been trialing clear liquids only for a week because the major problem is hard stool—clear liquids won't make hard stool. — Marc Levitt (clinical) [Ep 22 · 37:15](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2235)
- If perineal body dehiscence is detected on days 5-8, Dr. Levitt will take the patient back to the OR and re-suture the perineal body, which can salvage the situation. This happens in maybe 1-2 cases out of about 200. — Marc Levitt (clinical) [Ep 22 · 37:47](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2267)
- Laparoscopy causes trouble if you try to dissect a rectum that's too low—you get too close to the urinary tract or you're too timid and leave behind the distal rectum (remnant of original fistula). — Marc Levitt (clinical) [Ep 22 · 38:31](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2311)
- For high rectums, particularly bladder neck fistulas, the dissection of the distal rectum is quite challenging to make it reach with good blood supply. You must preserve the IMA because the colostomy may have disrupted collaterals down the left colic, making the rectum completely dependent on the IMA. — Marc Levitt (clinical) [Ep 22 · 39:10](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2350)
- The rectum has an excellent intramural blood supply from the IMA. If you take the IMA or take branches too close to the aorta, the rectum will die because there's no collateralization down the left colic. — Marc Levitt (clinical) [Ep 22 · 39:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2380)
- The biggest problem with posterior sagittal incision is going after a rectum when you don't know where it is. You open and find the bladder neck, urethra, seminal vesicles, vas deferens, ectopic ureter—everything but the distal rectum. — Marc Levitt (clinical) [Ep 22 · 40:12](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2412)
- There are famous cases of pull-through of bladder neck made into beautiful anoplasties, and post-op the patient was draining liquid out their anoplasty—it was the bladder neck. — Marc Levitt (clinical) [Ep 22 · 40:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2450)
- To determine if an ARM patient has potential for bowel control, Dr. Levitt looks at three factors: original type of malformation, quality of sacrum and calculated sacral ratio, and quality of spine. He calls this the ARM continence index. — Marc Levitt (clinical) [Ep 22 · 42:09](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2529)
- Three A's (excellent malformation type, sacrum, and spine) predicts a continent patient. Three C's predicts an incontinent patient. Dr. Levitt's group is working on quantifying the in-between grades. — Marc Levitt (clinical) [Ep 22 · 43:10](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2590)
- A bulbar fistula with a good sacrum (sacral ratio of 1) and normal spine should absolutely have bowel control. A bladder neck fistula with poor sacrum (sacral ratio 0.4) and tethered cord or myelomeningocele has no real chance of good bowel control. — Marc Levitt (clinical) [Ep 22 · 43:45](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2625)
- For a soiling 4-year-old ARM patient, Dr. Levitt's first step is to get them clean mechanically with bowel management using enemas. For those with continence potential, when they're older and more mature, he tries to switch them to laxatives to achieve voluntary bowel movements. — Marc Levitt (clinical) [Ep 22 · 44:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2670)
- Indications for redo pull-through: any patient with potential for bowel control whose anatomy is not perfect—improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum). — Marc Levitt (clinical) [Ep 22 · 45:20](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2720)
- One of the biggest problems with ARM is that if you don't get it right, you don't know for a few years. Most surgical problems become obvious immediately, but with ARM, patients may not present with soiling until age 4, making it hard for surgeons to learn what to fix about their technique. — Marc Levitt (opinion) [Ep 22 · 46:05](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2765)
- A sacral ratio of 0.7 or greater usually indicates normal or close to normal sphincters and good muscle tone, suggesting that spine innervation of the area is probably good. — Marc Levitt (clinical) [Ep 18 · 6:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=382)
- Patients with associated spinal anomalies, most commonly tethered cord but worst being myelomeningocele, have much more trouble with continence. — Marc Levitt (clinical) [Ep 18 · 6:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=408)
- Mislocated anus is amazingly common, occurring when surgeons either miss the sphincter center during laparoscopic pull-through or open the PSARP incision before marking the sphincters. — Marc Levitt (clinical) [Ep 18 · 7:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=464)
- A key technical pitfall is opening the PSARP incision first; instead, surgeons should mark the sphincters first, then open the PSARP, to avoid confusion when placing the anoplasty in the correct location. — Marc Levitt (clinical) [Ep 18 · 8:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=482)
- Visual cues for identifying correct sphincter location include the ellipse shape, color change (pinkish), indented or raised area, and appropriate perineal body length. — Marc Levitt (clinical) [Ep 18 · 9:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=569)
- The electrical stimulator used for sphincter localization is the same one anesthesia uses for train-of-four testing, is inexpensive, and requires that anesthesiologists not give skeletal muscle relaxant because it is weaker than traditional stimulators. — Marc Levitt (clinical) [Ep 18 · 9:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=592)
- In higher anorectal malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated. — Jason Frischer (clinical) [Ep 18 · 10:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=620)
- In the JPS study on redo operations, the vast majority of indications were mislocation, followed by stricture, then less common reasons including remnant of original fistula (roof), rectal prolapse, and others. — Marc Levitt (clinical) [Ep 18 · 12:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=729)
- Patients' quality of life improved after redo surgery. — Marc Levitt (clinical) [Ep 18 · 12:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=752)
- Patients had improved ability to achieve continence after redo surgery when given the best opportunity to have nearly normal anatomy. — Marc Levitt (clinical) [Ep 18 · 12:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=755)
- Patients with good potential (good sacrum and good spine) did extremely well after redo surgery. — Marc Levitt (clinical) [Ep 18 · 12:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=776)
- 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 continence enema via Malone appendicostomy. — Marc Levitt (clinical) [Ep 18 · 13:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=781)
- If the anatomy is known to be incorrect, redo surgery should be performed, and there is an advantage to correcting the anatomy when the child is younger. — Marc Levitt (opinion) [Ep 18 · 13:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=808)
- For a 2-year-old with mislocated anus or bad prolapse, redo surgery should be offered, allowing the child to live in diapers for 1-2 years with better anatomy before attempting potty training. — Marc Levitt (opinion) [Ep 18 · 13:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=818)
- Many patients present after potty-training age because they are incontinent, and evaluation reveals the incontinence is due to suboptimal initial operation with misplaced anus. — Marc Levitt (clinical) [Ep 18 · 13:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=838)
- Patients may have great sphincters but cannot close the anal opening when they squeeze if the anus is not in the right place. — Marc Levitt (clinical) [Ep 18 · 14:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=855)
- When performing redo surgery in older incontinent patients, adding a Malone appendicostomy at the same time allows them to learn control with their new anatomy before attempting voluntary bowel movements, a process that may take 6-12 months. — Marc Levitt (clinical) [Ep 18 · 14:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=862)
- For a patient with an anoplasty 50% within the sphincter complex (half in, half out) at 3.5 years old who is fecally incontinent, one approach is to redo the surgery, add a Malone, achieve mechanical cleanliness, then see if bowel control develops. — Marc Levitt (opinion) [Ep 18 · 14:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=891)
- An alternative conservative approach for borderline anatomy is to let the child attempt potty training first and only consider redo if continence is not achieved. — Jason Frischer (opinion) [Ep 18 · 15:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=925)
- If patients have not yet declared their incontinence because they are not old enough behaviorally, they should be given a chance to succeed before considering redo surgery. — Marc Levitt (opinion) [Ep 18 · 15:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=949)
- Redo surgery improves quality of life in patients with fecal incontinence after anorectal malformation repair. — Jason Frischer (clinical) [Ep 18 · 16:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=990)
- Anorectal malformation occurs more commonly in females and has a prevalence of about one in 5,000 births. — Marc Levitt (epidemiological) [Ep 23 · 1:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=99)
- About 60% of anorectal malformation patients in Chris Westgarth-Taylor's practice were discharged home without being identified as having an anorectal malformation. — Chris Westgarth-Taylor (epidemiological) [Ep 23 · 1:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=65)
- When you look in laparoscopically and see an end of the colon with nothing else visible, you do not have to do a divided colostomy—you can bring out that distal end as your stoma rather than interfering with the blood supply for the distal segment. — Marc Levitt (clinical) [Ep 23 · 2:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=141)
- The only potential benefit of doing a divided colostomy when encountering blind-ending colon is protecting the ultimate rectal repair, but this risks the blood supply to the distal rectum. — Marc Levitt (opinion) [Ep 23 · 2:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=179)
- A single perineal orifice with no rectal or vaginal fistula must be called a cloaca. — Chris Westgarth-Taylor (clinical) [Ep 23 · 3:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=203)
- Meyer-Rokitansky-Küster-Hauser syndrome can present with anorectal malformation, creating Meyer-Rokitansky-like anatomy where ovaries and remnant tubes are present but no midline Müllerian structures. — Marc Levitt (clinical) [Ep 23 · 5:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=332)
- The more common scenario of anorectal malformation with absent vagina is a recto-vestibular fistula with completely normal urethra but no vagina in between—this is called recto-vestibular fistula with distal vaginal atresia, where the rectum ends as a fistula in the vestibule. — Marc Levitt (clinical) [Ep 23 · 6:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=397)
- In this case, the rectum ended blind and quite high in the pelvis, making it unreachable through a posterior sagittal incision. — Marc Levitt (clinical) [Ep 23 · 7:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=428)
- The foreshortened sacrum in this case suggests caudal regression, where everything below that level forgot to develop. — Marc Levitt (clinical) [Ep 23 · 7:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=438)
- In the past, vaginal replacement would have been done at the same time as rectal repair in these patients, but time and research have shown that colonic neovaginas are not great for patients 20 years down the road, and surgeons should try very hard to avoid them. — Marc Levitt (clinical) [Ep 23 · 11:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=664)
- In most cloacas, you should be able to get the native vagina to reach without needing vaginal replacement. — Marc Levitt (clinical) [Ep 23 · 11:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=695)
- Options for vaginal reconstruction when native vagina cannot reach include: dilating the existing introitus, opening the area and laying in a buccal graft, or waiting for tissue engineering options expected within 20 years or less. — Jason Frischer (clinical) [Ep 23 · 11:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=695)
- If a neovagina bridge is functioning well without problems, there may be no reason to remove it later. — Jason Frischer (opinion) [Ep 23 · 13:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=789)
- Vascular anomalies associated with anorectal malformation have not been much written about in the literature. — Marc Levitt (clinical) [Ep 23 · 14:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=890)
- An aberrant external iliac artery can loop up within the abdominal wall, looking very much like the obliterated umbilical artery, while actually being a blood supply to one of the extremities. — Marc Levitt (clinical) [Ep 23 · 15:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=911)
- Not diverting after limited posterior sagittal anorectoplasty is safe when you have a colocolonic anastomosis at the colostomy closure site and only an anoplasty with a couple of posterior sutures. — Marc Levitt (clinical) [Ep 23 · 10:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=612)
- The limited posterior sagittal incision was deliberately kept out of the perineal body to avoid destroying or scarring it for future incorporation of gynecologic structures after puberty. — Chris Westgarth-Taylor (clinical) [Ep 23 · 10:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=653)
- An anal dimple with raised area and good color change indicates there is probably a good sphincter. — Marc Levitt (clinical) [Ep 7 · 4:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=246)
- White beads along the scrotal raphe with meconium smear indicate the anorectal malformation is one of the less complicated lesions with an opening somewhere along the perineal body. — Megan Durham (clinical) [Ep 7 · 5:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=323)
- For ARM with external opening and no cardiac defect, primary repair in the neonatal period would be the optimal choice. — Megan Durham (opinion) [Ep 7 · 5:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=323)
- Dilation and sending baby home is a suboptimal choice in a baby with no cardiac defect, but might be a good choice in a baby you don't want to take to the OR. — Marc Levitt (opinion) [Ep 7 · 6:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=363)
- If you could dilate a perineal fistula patient, you don't need to go to the OR at all and can let them deal with the heart. — Marc Levitt (opinion) [Ep 7 · 6:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=392)
- There is no rush on a vestibular fistula in a female patient or a perineal fistula, allowing time to address cardiac issues first. — Marc Levitt (clinical) [Ep 7 · 6:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=392)
- In a male perineal fistula, the hole isn't always easy to see and dilation is more dangerous because it's near the urethra, but with care and Hagar dilators you can get egressive stool and never go to the OR. — Marc Levitt (clinical) [Ep 7 · 6:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=392)
- In a cardiac patient with an external opening from ARM, the typical approach is to dilate as long as they're evacuating okay. — Jason Frischer (clinical) [Ep 7 · 7:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=444)
- For perineal fistula or vestibular fistula in a female, one can consider just dilating with good evacuation and letting the cardiac situation play itself out. — Jason Frischer (opinion) [Ep 7 · 7:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=444)
- In a blue baby with significant cardiac lesion requiring early surgery where patient isn't oxygenating well, there is concern about healing of an ARM repair. — Jason Frischer (clinical) [Ep 7 · 7:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=468)
- There is no need to do a colostomy in a baby with perineal fistula and cardiac disease; you can dilate and then do the repair primarily later. — Marc Levitt (opinion) [Ep 7 · 8:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=493)
- Colostomy is not any more or less risky than a one-hour mini-PSARP for perineal fistula. — Marc Levitt (opinion) [Ep 7 · 8:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=493)
- A conus at L2 is normal. — Megan Durham (clinical) [Ep 7 · 8:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=513)
- A baby is too young to calculate a sacral ratio in the neonatal period. — Megan Durham (clinical) [Ep 7 · 8:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=513)
- VCUG is obtained if there are renal anomalies in ARM patients. — Megan Durham (clinical) [Ep 7 · 9:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=544)
- A turnable loop ostomy with 95-5 percentage behaves like an end colostomy, and no one knows except the surgeon that there's another side where you can do a contrast study. — Marc Levitt (clinical) [Ep 7 · 9:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=583)
- For laparoscopy in cardiac babies, initial insufflation pressure should start around 8 mmHg if possible. — Megan Durham (clinical) [Ep 7 · 10:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=623)
- Irrigating the distal rectum and evacuating stool helps keep laparoscopic pressures low in ARM patients. — Megan Durham (clinical) [Ep 7 · 10:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=623)
- If the baby has an umbilical line, consider going into Palmer's Point instead of accessing through the umbilicus, using a Hasson technique. — Marc Levitt (clinical) [Ep 7 · 11:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=660)
- For umbilical access in laparoscopy, dissect in with a mosquito, ensure you're in the peritoneum without touching any vessel before insufflation, and clear the line of air. — Jason Frischer (clinical) [Ep 7 · 11:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=668)
- Important factors for continence include sensation in the anal canal, absence of the dentate line, quality of the spine, type of anorectal malformation, and sacral anatomy. — Marc Levitt (clinical) [Ep 7 · 12:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=753)
- Sacral ratio measurement should wait until 3 months of age. — Marc Levitt (clinical) [Ep 7 · 12:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=753)
- A baby with a low ARM lesion (closely approximated perineal fistula to anal muscular complex) should do really well with continence. — Marc Levitt (clinical) [Ep 7 · 12:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=753)
- When half of the perineal fistula opening is anterior to the muscular complex, the entire opening should be formally moved back into the center around the anal muscular complex. — Megan Durham (clinical) [Ep 7 · 13:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=816)
- The white beads along the raphe should be scraped off during repair, as they can persist into teenage years and young adulthood if left alone. — Jason Frischer (clinical) [Ep 7 · 13:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=836)
- The perineal fistula tract is only one millimeter deep; do not dive in to find it as it will disappear with good anoplasty and anterior rectal wall mobilization. — Marc Levitt (clinical) [Ep 7 · 14:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=850)
- For a 50-50 perineal fistula (half within muscle complex, half anterior), leave the anterior wall as it's the danger zone, mobilize posteriorly to fill the anal sphincter, creating an 80-20 reconstruction. — Jason Frischer (clinical) [Ep 7 · 14:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=863)
- If the fistula is completely outside of the sphincteric ellipse, then full mobilization is required. — Marc Levitt (clinical) [Ep 7 · 14:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=897)
- In Phoenix, many surgeons start diet post-op day zero or post-op day one after primary perineal fistula repair, with breast milk or formula, and discharge home post-op day two or three if tolerating diet. — Christine (clinical) [Ep 11 · 0:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=48)
- Alberto Pena's historical protocol kept patients mandatory NPO for seven days with central line and hyperalimentation, feeding on day seven if healed. — Marc Levitt (clinical) [Ep 11 · 1:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=73)
- A study by Carlos Reck comparing NPO for seven days versus clear liquids for seven days found the same amount of stool output in both groups. — Marc Levitt (clinical) [Ep 11 · 1:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=73)
- The problem is not pooping itself but hard pooping that can disrupt the perineal body repair. — Marc Levitt (clinical) [Ep 11 · 1:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=73)
- Dr. Levitt's current protocol is regular IV (no PICC line) and clear liquids or breast milk for five days, based on better healing by day five compared to day one or two. — Marc Levitt (clinical) [Ep 11 · 1:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=73)
- Most repairs in Phoenix are performed before children are on anything except breast milk or formula, with early repairs and early discharge home. — Christine (clinical) [Ep 11 · 4:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=272)
- Perineal body dehiscence usually leads to no perineal body over several months and requires redo surgery because the anterior anoplasty has no sphincter around it. — Marc Levitt (clinical) [Ep 11 · 5:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=323)
- In redo cases seen by Dr. Levitt, patients were invariably fed right away and discharged home. — Marc Levitt (clinical) [Ep 11 · 5:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=323)
- Dr. Frisher uses a midline catheter (not PICC line) with D10 until the repair is confirmed healed, typically five to seven days NPO. — Jason Frischer (clinical) [Ep 11 · 7:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=437)
- A paper by Dr. Levitt found that clear liquids were no different than NPO in terms of stool output, but both groups still produced very thin, liquidy stool that would not disrupt the anastomosis. — Marc Levitt (clinical) [Ep 11 · 8:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=485)
- A randomized controlled trial by Richard Wood and Dr. Levitt compared dilation versus non-dilation for primary PSARP (cloacas excluded), with backup plan of dilation plus or minus Heineke-Mikulicz anoplasty for strictures. — Marc Levitt (clinical) [Ep 11 · 9:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=545)
- The dilation RCT found that both dilated and non-dilated groups developed strictures somewhere between 10 and 20% of the time. — Marc Levitt (clinical) [Ep 11 · 9:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=545)
- Many anoplasties that were never touched with a dilator look absolutely fine eight weeks later at colostomy closure if the repair was healthy with no tension and good blood supply. — Marc Levitt (clinical) [Ep 11 · 9:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=545)
- The dilation RCT was prompted by families identifying dilations as their biggest concern in caring for patients with anorectal malformation. — Marc Levitt (clinical) [Ep 11 · 9:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=545)
- Dilations can be traumatic for families, with one family member typically responsible for performing them, sometimes leading to relationship strain and reluctance to attend clinic visits. — Kathy (opinion) [Ep 11 · 12:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=726)
- In the presented case, the family was not comfortable doing dilations at home despite medical field experience, so the surgeon performed dilations in clinic twice weekly initially. — Christine (clinical) [Ep 11 · 13:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=794)
- Jack Langer's routine is to see patients every week in clinic and pass a dilator without having families do it at home. — Marc Levitt (clinical) [Ep 11 · 13:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=828)
- In the dilation RCT, four patients required redo operations for stricture: two in the dilation arm (both chose not to do dilations) and two in the non-dilation arm. — Marc Levitt (clinical) [Ep 11 · 14:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=844)
- Approximately 20% of patients in the dilation study required a redo operation, either local or total, with most being local procedures. — Jason Frischer (clinical) [Ep 11 · 15:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=902)
- There is existing data showing that full continence can be restored with a redo operation, including for stricture as an indication. — Marc Levitt (clinical) [Ep 11 · 16:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=990)
- Dr. Levitt has yet to meet a family that has chosen dilation when presented with the option of non-dilation with selective intervention. — Marc Levitt (clinical) [Ep 11 · 16:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=990)
- Some families do choose dilation after being informed of the study results and uncertainties. — Kathy (clinical) [Ep 11 · 17:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=1056)
- A surgeon in Ghana taught Dr. Levitt to make anoplasties a little bigger in cases where patients will not return for follow-up, knowing there will be some contraction. — Marc Levitt (clinical) [Ep 11 · 19:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=1177)
- In redo cases, Dr. Levitt makes the anoplasty a little bigger knowing there will be contraction, and does not dilate redos but performs EUA at one month to check for early stricture. — Marc Levitt (clinical) [Ep 11 · 19:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=1177)
- In primary repairs, Dr. Levitt makes the lumen match what the maximal rectal lumen can be, filling the sphincter, which is usually about a 13 or 14 Hegar size at the end. — Marc Levitt (clinical) [Ep 11 · 19:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=1177)
- Definitive diagnostic workup for cloaca is usually performed at about 5-6 months of age — Jason Fisher (clinical) [Ep 12 · 1:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=105)
- The workup includes multidisciplinary team evaluation (urology, gynecology, colorectal) followed by cystovaginoscopy and examination under anesthesia — Richard Wood (clinical) [Ep 12 · 1:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=116)
- Preoperative urodynamics catheter is placed in the bladder as part of the examination — Richard Wood (clinical) [Ep 12 · 2:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=151)
- During cystoscopy of the common channel, the easiest structure to enter is usually the vagina or vaginas; entering the urethra and bladder is challenging because it requires pointing very far up — Richard Wood (clinical) [Ep 12 · 3:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=188)
- During endoscopy, surgeons measure the length of the urethra, common channel, and vagina, and assess for the presence of a septum and location of the rectal fistula — Richard Wood (clinical) [Ep 12 · 3:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=210)
- 3D cloacogram is acquired by injecting contrast into all three structures (urethra, vagina, rectum) and using vascular C-arm software to reconstruct three-dimensional images — Richard Wood (clinical) [Ep 12 · 4:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=240)
- During cystoscopy it is important to look for cervices to determine if there is one or two vaginas and assess Müllerian development — Jason Fisher (clinical) [Ep 12 · 4:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=274)
- Surgeons should look for ureteral orifices during cystoscopy because in complex malformations there can be anomalous ureteral attachments to the bladder or bladder neck that come in very low and could be treacherous — Jason Fisher (clinical) [Ep 12 · 5:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=300)
- Endoscopy performed by general pediatric surgeons has value in determining whether a cloaca is straightforward or complex, helping surgeons decide whether to refer to a specialized center — Jason Fisher (opinion) [Ep 12 · 7:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=461)
- As recently as 10-15 years ago, there was much more redoing of cloacas required because surgeons attempted repairs without adequate evaluation and realized the cases were more complicated than imagined — Jason Fisher (clinical) [Ep 12 · 8:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=510)
- Lower confluence cloacas are elegant operations if the surgeon knows how to perform them, while higher confluence cases with vaginal replacements and ectopic ureters should be done at specialized centers — Jason Fisher (opinion) [Ep 12 · 9:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=540)
- For common channel less than 1 cm (type one cloaca), the malformation is essentially a hypospadiac urethra with a rectovaginal fistula — Richard Wood (clinical) [Ep 12 · 10:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=607)
- In type one cloaca (common channel <1 cm), the hypospadiac urethral orifice is not touched, and the plan is vaginoplasty, introitoplasty, and PSARP — Richard Wood (clinical) [Ep 12 · 10:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=640)
- Even in type one cloaca with short common channel, the true rectum can still be high, so knowing rectal height is important — Richard Wood (clinical) [Ep 12 · 11:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=670)
- A normal urethra should be at least 1.5 cm in length — Richard Wood (clinical) [Ep 12 · 11:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=690)
- For common channel 1-3 cm with urethral length >1.5 cm, the patient is amenable to total urogenital mobilization (TUM) and PSARP — Richard Wood (clinical) [Ep 12 · 11:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=700)
- For common channel >3 cm, patients often have urethral length <1.5 cm, and urogenital separation with repair of the common channel as the urethra is advocated — Richard Wood (clinical) [Ep 12 · 12:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=766)
- If the rectum is high, surgeons may want to consider an abdominal approach to mobilize first, changing the PSARP approach to LARP (laparoscopic-assisted PSARP) — Richard Wood (clinical) [Ep 12 · 13:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=812)
- Hardy Hendren was the father of cloacal management in the late 1960s and 70s with specific focus on urology and urethral reconstruction — Marc Levitt (clinical) [Ep 12 · 14:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=844)
- Alberto Pena made a major advance in cloacal care in 1996 with development of total urogenital mobilization (TUM), which kept the urethra and vagina together as a unit for mobilization — Marc Levitt (clinical) [Ep 12 · 14:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=870)
- Prior to 1996, all cloaca patients had urogenital separation — Marc Levitt (clinical) [Ep 12 · 14:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=890)
- The next major change in cloaca protocol after TUM came 21 years later in 2017 with the algorithmic approach incorporating urethral length measurement — Marc Levitt (clinical) [Ep 12 · 15:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=914)
- Hardy Hendren at age 91 attended the 2017 APSA presentation of the new algorithm and stated he agreed with everything presented — Marc Levitt (clinical) [Ep 12 · 16:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=970)
- The 2017 algorithm is the first time cloacal management has been reproducible — Marc Levitt (opinion) [Ep 12 · 16:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1010)
- Following the algorithm, 116 consecutive patients have been managed without needing to change the surgical plan — Richard Wood (clinical) [Ep 12 · 17:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1056)
- The major change in the 2017 algorithm was ensuring measurement of urethral length, whereas previously only common channel length (<3 cm or >3 cm) was considered — Marc Levitt (clinical) [Ep 12 · 18:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1093)
- Urethral length is defined as the distance from where the common channel splits (where urethra leaves the common channel) to where it enters the bladder, not from the single orifice to the bladder neck — Richard Wood (clinical) [Ep 12 · 19:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1149)
- Measuring urethral length accurately with cystoscopy is difficult because of the curve behind the pubis, which can lead to significant under- and over-reading — Richard Wood (clinical) [Ep 12 · 19:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1180)
- The goal is to position the bladder neck above the urogenital diaphragm where the external sphincter complex lies, so that intra-abdominal pressure does not compromise continence — Richard Wood (clinical) [Ep 12 · 20:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1210)
- The most accurate urethral measurement comes from 3D imaging rather than cystoscopy because imaging does not straighten the structures and falsely measure them — Richard Wood (clinical) [Ep 12 · 20:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1220)
- The original malformation in case 1 was a prostatic fistula and the patient has a tethered cord with a sacral ratio of 0.66 — Marc Levitt (clinical) [Ep 19 · 3:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=201)
- The higher the malformation, the worse the prognosis for bowel control — Marc Levitt (clinical) [Ep 19 · 5:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=331)
- Sacral ratio 0.7 or greater usually means normal sphincters and good muscle tone — Marc Levitt (clinical) [Ep 19 · 5:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=331)
- Patients with myelomeningocele have much more trouble with continence than those with tethered cord — Marc Levitt (clinical) [Ep 19 · 5:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=331)
- A key pitfall is opening the PSARP incision first; instead, mark the sphincters first with electrical stimulation, then open the PSARP — Marc Levitt (clinical) [Ep 19 · 7:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=449)
- The electrical stimulator used for sphincter mapping is the same one anesthesia uses for train of four — Marc Levitt (clinical) [Ep 19 · 9:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=569)
- Anesthesiologists should not give skeletal muscle relaxant when using the stimulator because it is weaker than traditional stimulators — Marc Levitt (clinical) [Ep 19 · 9:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=569)
- In higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated — Jason Frischer (clinical) [Ep 19 · 10:19](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=619)
- If anatomy is off, redo should be done, and there is an advantage to getting anatomy right when the child is younger — Marc Levitt (opinion) [Ep 19 · 13:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=808)
- For a two-year-old with mislocated anus or bad prolapse, offer redo and let them live in diapers for a year or two with better anatomy before potty training — Marc Levitt (opinion) [Ep 19 · 13:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=808)
- For patients presenting after potty training age with incontinence due to mislocated anus, do the redo and usually add a Malone at the same time — Marc Levitt (opinion) [Ep 19 · 13:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=808)
- After redo with Malone, patients learn to get control with new anatomy before stopping Malone flushes and trying voluntary bowel movements; this process may take six to twelve months — Marc Levitt (clinical) [Ep 19 · 13:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=808)
- For a patient with anus 50% within sphincter complex at age three and a half with incontinence, one approach is to redo and add Malone, get them clean mechanically, then see if they develop bowel control — Marc Levitt (opinion) [Ep 19 · 14:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=888)
- Alternative approach for borderline anatomy: let the child try their current anatomy first; if it works well, stay with it; if not, consider redo — Jason Frischer (opinion) [Ep 19 · 15:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=920)
- If patients haven't declared continence yet because they're not old enough behaviorally, give them a chance as they may succeed with current anatomy — Marc Levitt (opinion) [Ep 19 · 15:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=945)
- A single perineal orifice in a newborn indicates cloaca, where the vagina, urethra, and rectum are fused together inside creating a single common channel. — Richard Wood (clinical) [Ep 13 · 2:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=125)
- Hydrocolpos is the distension of the vagina caused by accumulation of fluid. — Richard Wood (clinical) [Ep 13 · 2:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=145)
- Cloaca or anorectal malformation is associated with VACTERL and needs to be worked up as such. — Richard Wood (guideline) [Ep 13 · 2:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=165)
- VACTERL association requires three or more anomalies: vertebral, imperforate anus, cardiovascular, tracheoesophageal fistula, esophageal atresia, renal/radial, and limb defects. — Amanda Jensen (clinical) [Ep 13 · 3:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=190)
- The diagnostic yield for cloaca on prenatal ultrasound is still much lower than desired. — Richard Wood (epidemiological) [Ep 13 · 3:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=224)
- Hydrocolpos on prenatal ultrasound should alert to the possibility of cloaca. — Richard Wood (clinical) [Ep 13 · 4:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=240)
- Prenatal findings suggestive of cloaca include abnormal kidneys, single kidney, and two-vessel cord association. — Richard Wood (clinical) [Ep 13 · 4:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=252)
- A smart perinatologist seeing a female fetus with pelvic mass and kidney abnormalities should consider cloaca diagnosis, which influences delivery location. — Marc Levitt (opinion) [Ep 13 · 4:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=283)
- Neonatologists might incorrectly conclude cloaca is ambiguous genitalia and do unnecessary endocrine workup. — Marc Levitt (clinical) [Ep 13 · 5:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=357)
- Good physical exam with good lighting is the first step in evaluating suspected cloaca. — Richard Wood (clinical) [Ep 13 · 6:19](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=379)
- On exam, distracting the labia reveals more of a clitoral hood than real labia minora, with a single perineal orifice posterior to the clitoral hood. — Richard Wood (clinical) [Ep 13 · 6:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=388)
- A perineal groove behind the labia structures and dimpling representing muscle complex suggests the perineum is not completely flat. — Richard Wood (clinical) [Ep 13 · 6:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=400)
- Children with cloacal malformation who do not have an anus do not need investigation for ambiguous genitalia or disorders of sexual differentiation because they are known to be female. — Richard Wood (guideline) [Ep 13 · 7:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=440)
- Initial urgent management priorities are ensuring kidney decompression/urine drainage, diagnosing hydrocolpos, and confirming safety for OR (ruling out TEF and cardiac issues). — Richard Wood (guideline) [Ep 13 · 7:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=476)
- Initial workup should consist of NG tube and chest x-ray, cardiac echo, and pelvic and renal ultrasound to assess for TEF, cardiac anomalies, hydrocolpos, and hydronephrosis. — Richard Wood (guideline) [Ep 13 · 8:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=510)
- Bilateral hydronephrosis with hydrocolpos requires management of the hydrocolpos as part of initial treatment. — Richard Wood (clinical) [Ep 13 · 8:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=530)
- The modern approach has moved heavily away from vaginostomy toward clean intermittent catheterization through the common channel for hydrocolpos drainage. — Richard Wood (guideline) [Ep 13 · 9:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=551)
- To perform CIC for hydrocolpos, pass a tube through the common channel, drain fluid, get ultrasound to confirm the tube is in the hydrocolpos/vagina, confirm decompression, then continue recurrently. — Richard Wood (clinical) [Ep 13 · 9:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=564)
- If CIC effectively drains the hydrocolpos, proceed with colostomy only and continue drainage postoperatively; if unsuccessful, can return to formal vaginostomy. — Richard Wood (guideline) [Ep 13 · 9:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=595)
- Seattle Children's (Paul McGarrian, Jeff Evan Sino, Caitlin Smith) demonstrated that many hydrocolpi can be drained perineally, changing the previous dogma of routine vaginostomy. — Marc Levitt (clinical) [Ep 13 · 10:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=606)
- When catheterizing for hydrocolpos drainage, you are more likely to get into the vagina than the bladder due to the anatomy of the urethral takeoff to the bladder neck. — Marc Levitt (clinical) [Ep 13 · 10:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=640)
- The modern hydrocolpos drainage approach is published in a Seminars in Pediatric Surgery article but not yet in textbooks. — Marc Levitt (clinical) [Ep 13 · 11:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=705)
- To confirm proper catheter placement, pass the tube, leave it in, get bedside ultrasound within first 24 hours to confirm it's in the hydrocolpos and decompressing it. — Richard Wood (guideline) [Ep 13 · 12:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=753)
- During ultrasound-guided drainage, when you drain the hydrocolpos, the bladder immediately fills, demonstrating the physiology where hydrocolpos obstructs the ureters. — Marc Levitt (clinical) [Ep 13 · 13:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=791)
- A vesicostomy is the wrong move in almost every cloaca; the hydrocolpos needs to be drained instead. — Marc Levitt (opinion) [Ep 13 · 13:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=820)
- Once hydrocolpos is drained, ureters are no longer compressed at the trigone and can empty into the bladder, which then empties out the common channel or back into hydrocolpos for sequential drainage. — Marc Levitt (clinical) [Ep 13 · 13:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=839)
- Catheterization frequency is typically three times daily initially, then twice daily when family takes over, with serial ultrasounds every 2-3 days initially, then weekly, then monthly after discharge. — Richard Wood (guideline) [Ep 13 · 15:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=901)
- The most important measure of successful hydrocolpos drainage is kidney decompression, not the hydrocolpos itself; if kidneys are completely normal, the hydrocolpos doesn't matter. — Richard Wood (clinical) [Ep 13 · 15:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=901)
- Even with vaginostomy tubes, you must continue checking that kidneys remain decompressed; don't assume the tube is doing its job without verification. — Richard Wood (guideline) [Ep 13 · 16:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=980)
- Newborn management bullet points: good exam with good light to diagnose, no endocrine workup for cloaca, renal/pelvic ultrasound plus tests for anesthesia safety, drain hydrocolpos by CIC, and colostomy within 24-48 hours. — Richard Wood (guideline) [Ep 13 · 17:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1022)
- Colostomy should be done as proximally as possible (descending-sigmoid junction) to ensure enough length for distal work, rather than lower sigmoid. — Richard Wood (guideline) [Ep 13 · 17:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1073)
- Laparoscopy for newborn colostomy in non-distended patients provides good pelvic anatomy visualization, allows precise colostomy site selection, and avoids wound between stomas. — Richard Wood (clinical) [Ep 13 · 18:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1122)
- Laparoscopic technique: mobilize lateral attachments of descending colon, bring bowel up through mucous fistula site, staple it, wash out distal limb completely, then make separate incision for proximal stoma with no surrounding incision for clean skin and easy bagging. — Richard Wood (clinical) [Ep 13 · 19:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1165)
- For vaginostomy in patients with vaginal septum, open the anterior wall of the hydrocolpos vagina and remove a small portion of septum to drain both sides through one hole. — Richard Wood (clinical) [Ep 13 · 20:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1215)
- Vaginostomy can be done with or without tubes; tubes can become encrusted and colonized, so tubeless has some advantage if anatomy allows easy reach to abdominal wall. — Richard Wood (opinion) [Ep 13 · 20:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1245)
- For massive hydrocolpos requiring open approach, use lower midline incision to get above the hydrocolpos, which is very adherent to anterior abdominal wall and inflamed; standard left lower quadrant incision will cause trouble. — Marc Levitt (clinical) [Ep 13 · 21:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1297)
- For large hydrocolpos via midline: open into dome, remove bit of septum, close it, put in tube to drain both sides, or suture to abdominal wall like vesicostomy/gastrostomy to avoid indwelling tube as nidus for infection. — Marc Levitt (clinical) [Ep 13 · 22:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1340)
- Critical distinction: single perineal orifice with no anal opening is cloaca (female, no endocrine workup); completely normal anus with perineal orifice is urogenital sinus (needs endocrine workup for CAH, electrolyte check). — Marc Levitt (clinical) [Ep 13 · 22:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1371)
- Urogenital sinus patients can also have hydrocolpos and hydronephrosis with similar management, but no colostomy needed since they have an anus. — Marc Levitt (clinical) [Ep 13 · 23:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1435)
- Post-discharge follow-up focuses on ensuring kidneys are well decompressed, patient is growing well, following kidney function tests, and ensuring parents manage stoma effectively. — Richard Wood (guideline) [Ep 13 · 24:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1476)
- With effective urine and stool drainage, patients should be thriving unless other underlying issues exist. — Richard Wood (clinical) [Ep 13 · 25:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1520)
- VACTERL workup for anorectal malformations includes: V (vertebral abnormalities via plain x-ray), A (anorectal malformations), C (cardiac abnormalities via exam and echo), E (esophageal atresia via NG tube passage), R (renal abnormalities via kidney ultrasound), and L (limb abnormalities via physical exam) — Marc Levitt (guideline) [Ep 24 · 3:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=181)
- Sacral ratio should be measured at three months of age for true measurement, though early measurement gives a feel for how normally the pelvis has developed — Marc Levitt (clinical) [Ep 24 · 3:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=181)
- Pre-sacral masses are rare in typical imperforate anus but occur in almost half of anal stenosis or rectal atresia cases, requiring MRI — Jason Frischer (epidemiological) [Ep 24 · 4:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=255)
- Cross-table lateral x-ray should be obtained at approximately 24 hours of life to assess gas column height and guide surgical planning — Jason Frischer (guideline) [Ep 24 · 5:05](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=305)
- Sacral ratio greater than 0.7 connotes very good prognosis for bowel control and provides peace of mind for families regarding potty training at age four — Marc Levitt (clinical) [Ep 24 · 7:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=428)
- Well-formed buttocks, good muscle, true sphincter mechanism area, and well-developed sacrum together indicate likely good prognosis — Jason Frischer (clinical) [Ep 24 · 7:36](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=456)
- With air column 8.8mm from skin, primary posterior sagittal anorectoplasty is a reasonable option based on imaging — Jason Frischer (opinion) [Ep 24 · 8:25](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=505)
- The key to deciding whether to approach perineally via posterior sagittal is knowing where the rectum is—must be confident the first structure encountered will be rectum, not urethra, bladder neck, or bladder — Marc Levitt (clinical) [Ep 24 · 9:11](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=551)
- Colostomies are done to know exactly where the rectum is via distal colostogram and to determine whether to approach perineally or laparoscopically — Marc Levitt (clinical) [Ep 24 · 9:11](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=551)
- Should never try to go in blind—must know what structure will be encountered before making posterior sagittal incision — Jason Frischer (guideline) [Ep 24 · 9:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=597)
- Colostomy is the safe choice and was the right decision in this case, though it carries its own complications including those from colostomy closure — Marc Levitt (opinion) [Ep 24 · 10:16](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=616)
- The anal repair is made safer by having a colostomy, though everything in medicine is a balance — Marc Levitt (opinion) [Ep 24 · 10:16](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=616)
- Very good surgeons have done beautiful anoplasties but ignored fistulas, resulting in children urinating out their anus postoperatively — Marc Levitt (clinical) [Ep 24 · 10:54](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=654)
- During primary posterior sagittal approach, open the posterior wall of rectum and inspect the anterior wall to rule out fistula — Marc Levitt (clinical) [Ep 24 · 12:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=720)
- Bulbar fistula nomenclature refers to anatomic location at the elbow of the urethra — Jason Frischer (clinical) [Ep 24 · 12:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=754)
- Fistula can be very close to rectum, making proper plane dissection along urethra important — Jason Frischer (clinical) [Ep 24 · 12:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=754)
- 95% of Down syndrome patients with imperforate anus have no fistula, but 5% do have a fistula — Marc Levitt (epidemiological) [Ep 24 · 13:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=795)
- Distal colostogram should still be performed in Down syndrome patients with imperforate anus despite 95% having no fistula — Marc Levitt (guideline) [Ep 24 · 13:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=795)
- Prenatal ultrasound and MRI findings of small bladder and sacral dysgenesis should raise concern for cloacal exstrophy — Payam Sadai (clinical) [Ep 14 · 1:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=70)
- Cloacal exstrophy is the most complicated condition managed in the colorectal world and requires collaboration with urology and gynecology — Levitt (opinion) [Ep 14 · 1:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=112)
- Cloacal exstrophy patients almost always need a neurosurgeon in addition to colorectal, urology, orthopedics, and gynecology — Levitt (clinical) [Ep 14 · 2:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=172)
- Like any anorectal malformation, cloacal exstrophy is not an emergency; surgeons have 24-48 hours to complete workup and decide on operative plan — Payam Sadai (clinical) [Ep 14 · 4:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=264)
- Essential preoperative workup includes echocardiogram to rule out congenital cardiac anomalies, spinal ultrasound, and abdominal ultrasound to assess kidneys — Payam Sadai (clinical) [Ep 14 · 4:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=282)
- Cloacal exstrophy patients often have stool coming from the fecal plate/ileum, so there is not always a component of obstruction or dilated bowel loops — Payam Sadai (clinical) [Ep 14 · 5:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=312)
- Key NICU management focuses on preventing dehydration through fluid loss management, using plastic covering (saran wrap) over hemibladders, keeping patient NPO, and placing nasogastric tube — Payam Sadai (clinical) [Ep 14 · 5:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=336)
- The most devastating complication of cloacal exstrophy closure is dehiscence — Payam Sadai (clinical) [Ep 14 · 6:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=375)
- Orthopedic surgeons believe the best time to bring the pelvis together is within the first 2-3 days because there is enough maternal relaxin on board — Payam Sadai (clinical) [Ep 14 · 6:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=410)
- Two major decision points in cloacal exstrophy are: (1) whether the omphalocele is large or small enough to close the abdominal wall, and (2) the staging of the exstrophy procedure — Jason (clinical) [Ep 14 · 7:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=425)
- The fecal plate represents more colon downstream from the cecum, not the end of the bowel; it is essentially a colonic atresia in the deep pelvis with good bowel that needs to be rescued — Levitt (clinical) [Ep 14 · 8:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=537)
- Creating an ileostomy and leaving behind a blind-ending fecal plate and hindgut is an unfortunate surgical error that has occurred in multiple cases — Levitt (clinical) [Ep 14 · 9:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=544)
- The traditional approach to cloacal exstrophy is to extract the fecal plate from within the two hemibladders, tubularize the fecal plate, and bring out the end of the hindgut as an end colostomy — Levitt (clinical) [Ep 14 · 10:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=628)
- The overriding principle in cloacal exstrophy management is bowel preservation, as small intestine can be shortened and patients may have long-term nutritional concerns — Jason (clinical) [Ep 14 · 10:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=646)
- The traditional reason for separating the fecal plate from hemibladders was to avoid absorption of urine into the fecal plate and resulting acidosis — Levitt (clinical) [Ep 14 · 11:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=709)
- Many patients with colonic mucosa absorbing urine (bladder augmentation situations) do not develop acidosis, making this concern a non-issue — Levitt (clinical) [Ep 14 · 12:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=724)
- The tubularized fecal plate often becomes a boggy, fairly useless piece of bowel where ileum enters, stool sits, and then empties through the hindgut — Levitt (clinical) [Ep 14 · 12:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=741)
- Dr. Levitt's new approach leaves the fecal plate between the hemibladders as an auto-augmentation, connects distal ileum to hindgut as a primary anastomosis, with the cecum staying connected to the bladder — Levitt (clinical) [Ep 14 · 13:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=793)
- In the novel approach, the ileum and hindgut are the same size and make a nice match for anastomosis — Levitt (clinical) [Ep 14 · 13:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=803)
- Dr. Levitt learned the hindgut pull-through to anus technique from Ivo de Blaauw in the Netherlands — Levitt (clinical) [Ep 14 · 13:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=833)
- When leaving the fecal plate behind and separating the ileum, the hole in the fecal plate is oversewn — Levitt (clinical) [Ep 14 · 14:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=848)
- One reason for not pulling through cloacal exstrophy patients early is concern about rash and managing a perineal stoma — Jason (clinical) [Ep 14 · 14:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=882)
- The decision to perform early pull-through should be based on how much hindgut is present; patients with substantial hindgut (like entire right colon) can develop good stool consistency — Levitt (clinical) [Ep 14 · 15:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=918)
- Patients who cannot develop thickened stool should never have a pull-through — Levitt (clinical) [Ep 14 · 15:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=927)
- In cloacal exstrophy cases, the mesentery can be so confusing and problematic that mobilizing the hindgut up and out of the pelvis risks losing the hindgut, which would result in permanent ileostomy — Levitt (clinical) [Ep 14 · 15:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=949)
- A loop ileostomy is preferred over separated stomas because some passage across the stoma is acceptable, particularly when there is no long suture line from a tubularized fecal plate — Levitt (clinical) [Ep 14 · 17:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1078)
- When there is a tubularized fecal plate with many distal stitches, a loop ileostomy can be created with purse-string closure of the distal segment to protect the suture line — Levitt (clinical) [Ep 14 · 18:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1091)
- Refeeding the distal segment helps the skin handle stool, and once the skin is ready, the ileostomy can be closed — Levitt (clinical) [Ep 14 · 18:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1116)
- It is very important that urology not manage the bladder independent of the decision to pull through the colon — Levitt (clinical) [Ep 14 · 19:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1180)
- Cases have occurred where urologists performed augmentation, Mitrofanoff, and bladder neck closure at age 5 without considering colonic pull-through, making it very difficult to pull a colostomy behind an augment — Levitt (clinical) [Ep 14 · 19:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1188)
- Leaving the cecal plate on the bladder makes future Mitrofanoff creation easier because the appendix is already connected and easy to bring up — Payam Sadai (clinical) [Ep 14 · 20:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1259)
- Managing cloacal exstrophy patients when they are older is very difficult; spending extra time in the newborn period for comprehensive reconstruction can save significant future work — Payam Sadai (opinion) [Ep 14 · 20:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1237)
- Reoperation in the pelvis of an older child or teenager with cloacal exstrophy is an experience surgeons want to avoid — Payam Sadai (opinion) [Ep 14 · 17:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1051)
- Patients with anorectal malformations require evaluation for associated VACTERL anomalies: vertebral abnormalities (plain X-ray), cardiac defects (exam and echo), esophageal atresia (NG tube passage), renal abnormalities (kidney ultrasound), and limb abnormalities (physical exam). — Marc Levitt (guideline) [Ep 9 · 3:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=181)
- Sacral ratio measurements should wait until the child is 3 months of age for true accuracy, though early imaging gives a preliminary sense of pelvic development. — Marc Levitt (clinical) [Ep 9 · 3:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=235)
- Presacral masses are rare in typical imperforate anus but occur in almost half of patients with anal stenosis or rectal atresia defects, requiring MRI evaluation. — Marc Levitt (epidemiological) [Ep 9 · 4:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=273)
- Cross-table lateral X-ray should be obtained at approximately 24 hours of life (give or take a few hours) to assess gas column location, with the baby positioned prone to allow air to rise to the buttocks. — Jason Frischer (clinical) [Ep 9 · 5:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=308)
- The 24-hour waiting period allows the baby to declare whether they need a colostomy or might benefit from primary repair if a perineal fistula develops. — Marc Levitt (clinical) [Ep 9 · 5:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=344)
- Marking the expected anal location on cross-table lateral X-ray allows measurement of the distance between the air column and perineal skin to guide surgical planning. — Jason Frischer (clinical) [Ep 9 · 6:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=389)
- 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 age 4 years. — Marc Levitt (clinical) [Ep 9 · 7:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=440)
- Well-formed buttocks with visible sphincter mechanism location, combined with well-developed sacrum, indicate likely good prognosis for continence. — Jason Frischer (clinical) [Ep 9 · 7:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=466)
- The key to deciding whether to perform primary posterior sagittal anorectoplasty is knowing where the rectum is located—the first structure encountered should be rectum, not urethra, bladder neck, or bladder. — Marc Levitt (clinical) [Ep 9 · 9:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?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 9 · 9:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=582)
- Never attempt posterior sagittal approach blind—only proceed when confident the first structure encountered will be the air pocket of the distal rectum. — Jason Frischer (clinical) [Ep 9 · 9:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=598)
- Performing a colostomy is the safe choice and was the right decision in this case, though it subjects the child to colostomy-related complications and later colostomy closure with its own complications. — Marc Levitt (opinion) [Ep 9 · 10:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=624)
- Colostomy makes the definitive anoplasty safer, representing a balance of risks in medical decision-making. — Marc Levitt (opinion) [Ep 9 · 10:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=648)
- Very good surgeons have performed primary anorectoplasty on low defects without knowing about a fistula, resulting in children who later urinate through the anus. — Marc Levitt (clinical) [Ep 9 · 11:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=680)
- During primary posterior sagittal repair, the surgeon should open the posterior wall of the rectum and inspect the anterior wall to rule out a fistula. — Marc Levitt (clinical) [Ep 9 · 12:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=729)
- When a fistula is very close to the rectum, proper plane dissection along the urethra is critical because the two structures are not far apart. — Jason Frischer (clinical) [Ep 9 · 12:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=754)
- A bulbar fistula is defined by its anatomic location at the elbow of the urethra, using pure anatomic nomenclature. — Jason Frischer (clinical) [Ep 9 · 12:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=775)
- 95% of patients with Down syndrome and imperforate anus have no fistula, but 5% do have a fistula, so distal colostogram is still indicated. — Marc Levitt (epidemiological) [Ep 9 · 13:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=824)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- In anorectoplasty, the first surgical attempt might be the only opportunity to give the patient good outcomes and correct anatomy. — Rod Gerardo summarizing the discussion [Ep 18 · 0:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=23)
- In the study, 20% of patients with poor sacrum or poor spine developed bowel control after their redo surgery. — Rod Gerardo summarizing the discussion [Ep 18 · 12:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-6845?t=758)
- Anorectal malformation is defined as a birth defect that occurs when a baby's anus and rectum don't develop normally during pregnancy, causing abnormalities in the anal opening, rectum, and occasionally surrounding structures. — Thomas Hsu summarizing the discussion [Ep 23 · 1:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=84)
- Performing colostomy laparoscopically has the advantage of potentially identifying incidental findings like malrotation that might remain undiagnosed with a standard left lower quadrant colostomy. — Thomas Hsu summarizing the discussion [Ep 23 · 4:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=293)
- A theoretical approach proposed by gynecologist Alison May for cloaca cases where native vagina doesn't reach is to provide a neovagina as a bridge so the patient can menstruate through it, then potentially remove it 20 years later. — Marc Levitt summarizing the discussion [Ep 23 · 12:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=766)
- Using the colon in this case for vaginal replacement would be very risky due to blood supply concerns from the original divided stoma procedure that already disrupted the blood supply once. — Thomas Hsu summarizing the discussion [Ep 23 · 13:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=801)
- Fred Reichman used to say 'you are judged by what you are willing to stop for'—surgeons must be willing to stop when uncertain, get more information or help, rather than plowing through. — Jason Frischer summarizing the discussion [Ep 23 · 15:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=957)
- The visualization of the bladder neck will not predict its competency and ability to hold back urine; urodynamics will be needed in the future. — Thomas Hsu summarizing the discussion [Ep 23 · 17:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=1059)
- If diversion were needed in this case, an ileostomy would be the preferred choice. — Thomas Hsu summarizing the discussion [Ep 23 · 10:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=628)
- In Hirschsprung's disease, there is concern about distal obstruction from non-relaxing sphincters causing backup pressure into the anastomosis and blowing it out, which is why diversion would be more important in that context than in anorectal malformation repair. — Thomas Hsu summarizing the discussion [Ep 23 · 10:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=628)
- When a baby in Georgia gets diagnosed with prenatal cardiac disease, the Sibley cardiology group gets called early and involved, including reviewing echocardiogram and meeting with high-risk OB. — Rod Gerardo summarizing the discussion [Ep 7 · 2:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=164)
- For hospitals that take care of many pediatric cardiac patients, an ostomy is probably the standard choice for ARM with really significant cardiac anomaly. — Rod Gerardo summarizing the discussion [Ep 7 · 6:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=373)
- Starting flow rate at 1 liter per minute for laparoscopy in babies is a cautious approach. — Rod Gerardo summarizing the discussion [Ep 7 · 10:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=650)
- Dr. Tim Jackson's technique involves looking laparoscopically while passing a tube into the distal segment to perform irrigation under direct visualization. — Rod Gerardo summarizing the discussion [Ep 7 · 11:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=681)
- The common channel takes a very significant turn as it gets behind the pubis, which is visible on lateral view imaging — Amanda Jensen summarizing the discussion [Ep 12 · 6:26](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=386)
- Cystoscopy significantly undermeasures anatomical structures compared to 3D reconstruction because the straight scope cannot measure the turn behind the pubis — Amanda Jensen summarizing the discussion [Ep 12 · 6:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=405)
- A study comparing endoscopy to 3D cloacogram showed that cystoscopy significantly under-reads the length of the common channel — Amanda Jensen summarizing the discussion [Ep 12 · 7:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=440)
- If urethral length is less than 1.5 cm, urogenital separation is advocated because performing TUM would result in the bladder neck sewn near the perineum, potentially rendering the patient incontinent — Amanda Jensen summarizing the discussion [Ep 12 · 11:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=717)
- The majority of 1-3 cm common channel cloacas have normal length urethra and are amenable to TUM and PSARP — Amanda Jensen summarizing the discussion [Ep 12 · 12:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=760)
- If the vagina or vaginas cannot reach the perineum after urogenital separation, the patient may need vaginal replacement to bridge the gap — Amanda Jensen summarizing the discussion [Ep 12 · 13:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=788)
- After anorectoplasty, your first shot might be your only shot to give the patient a good outcome — Rod Gerardo summarizing the discussion [Ep 19 · 0:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=0)
- In the JPS study, the vast majority of reoperations were for mislocation, followed by stricture — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 19 · 11:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=698)
- Less common reasons for redo included remnant of original fistula (roof), rectal prolapse, and others — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 19 · 11:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=698)
- Quality of life improved with redo operations — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 19 · 11:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=698)
- Patients had improved ability to achieve continence after redo — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 19 · 11:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=698)
- Twenty percent of patients with a poor sacrum or poor spine developed bowel control after their redo — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 19 · 11:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=698)
- Patients with good potential (good sacrum and spine) did extremely well after redo — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 19 · 11:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=698)
- Patients who did not develop voluntary bowel movements after redo were still able to be clean with bowel management program using enemas or antegrade Malone — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 19 · 11:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=698)
- The average age of patients in the JPS study was about three and a half years — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 19 · 11:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=698)
- In the large majority of cloaca patients, diagnosis is made at birth rather than prenatally. — Hira Ahmad summarizing the discussion [Ep 13 · 5:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=341)
- Definitive imaging and reconstructive planning should wait until the patient is growing and thriving. — Hira Ahmad summarizing the discussion [Ep 13 · 25:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1543)
- For cross-table lateral, baby is positioned prone with buttocks at highest point where air will rise, can be done at bedside with bump under buttocks — Em Gootee summarizing the discussion [Ep 24 · 6:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=361)
- In patients with low rectum, inspecting anterior rectal wall by dissecting a little bit and carefully lifting it off the urinary tract will usually rule out fistula — Em Gootee summarizing the discussion [Ep 24 · 12:16](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=736)
- In patients with low rectum, 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 9 · 12:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=737)
- Complete workup for anorectal malformations includes evaluation for associated anomalies, preoperative cross-table lateral X-ray to evaluate air column, and surgical planning that considers colostomy as a reasonable and safe choice even when imaging suggests straightforward primary repair. — Rod Gerardo summarizing the discussion [Ep 9 · 14:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=842)
- If proceeding with primary posterior sagittal anorectoplasty, the surgeon must rule out a fistula intraoperatively. — Rod Gerardo summarizing the discussion [Ep 9 · 14:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=870)

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