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Rectal Vestibular Fistula
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Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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Doing dilations alone is probably not the correct management for rectal vestibular fistula for a number of different reasons. — Jamie Harris, Update Course Rewind 2025: Timing of PSARP: Early vs. Delayed—Does It Really Matter? · 0:59
Update Course Rewind 2025: Timing of PSARP: Early vs. Delayed—Does It Really Matter?
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In this Update Course Rewind from the 13th Annual Update Course in Pediatric Surgery, Dr. Jamie Harris—joined by Drs. Nelson Rosen, Annie Le-Nguyen, Aaron Garrison, and Elizabeth Speck—explores one of the most debated questions in colorecta
video3:45 · Apr 2026
Timing of PSARP for rectal vestibular fistulas: early versus delayed repair
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In this Update Course Rewind from the 13th Annual Update Course in Pediatric Surgery , Dr. Jamie Harris—joined by Drs. Nelson Rosen, Annie Le-Nguyen, Aaron Garrison, and Elizabeth Speck—explores one of the most debated questions in colorec
podcast3:45 · Nov 2026
Adult colleagues should be introduced to the Malone appendicostomy (which many have never heard of) and the use of Peristeen for self-controlled enemas in adults; these are tricks learned in the pediatric population. — Marc Levitt, Colorectal Quiz Episode 38: Transitional Care in Colorectal Surgery · 20:23
Colorectal Quiz Episode 38: Transitional Care in Colorectal Surgery
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Join our hosts and special international guests Dr. Stuart Hosie and Dr. Mark Malota from Germany. Together they discuss the management of a young adult with anorectal malformation, the collaborative care delivered, followed by opportunitie
video25:39 · Mar 2024
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Expert statements from the recordings in this collection.
Colorectal Quiz Episode 38: Transitional Care in Colorectal Surgery
A 27-year-old female presented with lifelong fecal incontinence following newborn repair of rectal vestibular fistula; she had been told her incontinence was normal and unavoidable until puberty when daily irrigations were introduced, which restored her social life.
clinicalMark Malota1:25 ↗
The patient had rectal prolapse 2–3 years prior to presentation, which was repaired by an adult colorectal surgeon.
clinicalMark Malota2:22 ↗
Original operation reports from the early 1990s were incomplete, making it difficult to evaluate the initial surgical situation.
clinicalMark Malota2:45 ↗
Examination under anesthesia is a valuable maneuver for ARM patients with previous surgery, allowing assessment of anoplasty prolapse, stricture, and proper location via electrical stimulation.
clinicalMarc Levitt3:37 ↗
MRI with specific protocols and endorectal ultrasound can help determine whether the anoplasty is within the muscle complex.
clinicalJason Frischer3:59 ↗
In males, cystoscopy is added to evaluation to rule out remnant fistula and assess bladder mucosa and emptying; in females, cystoscopy can identify inappropriate fistulas.
clinicalMarc Levitt4:15 ↗
The patient's anus was too ventrally located; a dimple posterior to the current anus marked where the anus should be, and electrical stimulation of the external sphincter showed the proper limits.
clinicalStuart Hosie4:52 ↗
The functional problem is absence of sphincter anterior to the anoplasty: when the patient squeezes, the sphincter cannot close the anterior aspect and stool slips out, whereas proper concentric sphincter placement would successfully close the hole.
clinicalMarc Levitt5:28 ↗
The most common problem in females requiring redo surgery is absence of a circular sphincter (an O), either from improper initial placement or dehiscence of the perineal body leaving a C-shaped sphincter; the surgical goal is to get muscle in front of the anus.
clinicalMarc Levitt5:54 ↗
Examination under anesthesia with electrical stimulation and anal ultrasound confirmed a C-shaped sphincter with the anterior part not surrounded by sphincter muscle.
clinicalMark Malota6:42 ↗
The rectal prolapse treated by the adult surgeon (mucosal plication) was interpreted as a late sign of the missing sphincter complex.
clinicalMark Malota7:12 ↗
The patient learned to manage daily life despite significant incontinence and felt her quality of life was not bad, though she recognized not everything was fine and improvement was possible.
clinicalStuart Hosie7:58 ↗
Redo PSARP was performed with formal colon prep, preoperative antibiotics continued for a few days, and no diversion.
clinicalStuart Hosie8:36 ↗
The redo PSARP was performed collaboratively with adult general surgeons who had never seen such a procedure, providing an opportunity to show them pediatric ARM surgery techniques.
clinicalStuart Hosie9:01 ↗
Postoperatively, the patient was kept NPO for 5 days then started feeding; everything healed well.
clinicalStuart Hosie9:18 ↗
The strategy of non-diversion with postoperative clear liquids (not NPO/TPN) produces soft watery stool that does not harm the perineal repair, whereas real food produces harder stool that can disrupt the repair; patients and families are much happier avoiding PICC lines and TPN.
clinicalMarc Levitt9:52 ↗
At 5 days, if perineal healing looks good, diet is advanced with laxatives to keep stool liquidy; the problem is hard stool going through the repair, not stool itself, as long as the wound is kept clean.
clinicalMarc Levitt10:55 ↗
In Germany, pediatric surgeons are not allowed to treat patients over age 18, necessitating transition to adult care.
guidelineMark Malota12:00 ↗
The German transition model begins at age 12 by informing parents that the patient cannot stay in pediatric surgery forever; a network is built with adult colorectal surgeons interested in pediatric procedures, and connections are made to adult physiotherapists, urologists, and gynecologists.
clinicalMark Malota12:00 ↗
During annual visits, the adult surgeon is present so both patient and surgeon get to know each other; the adult surgeon learns the patient's past medical history and the pediatric surgeon explains procedures. This 'soft transition' lasts 3–4 years with the goal that the patient eventually sees only the adult colorectal surgeon.
clinicalMark Malota13:04 ↗
The transition model includes joint clinic visits and collaborative operating, which is key to successful handoff.
opinionJason Frischer14:05 ↗
The German hospital is a general hospital with both adult and pediatric departments and separate operating theaters; this 27-year-old patient was operated on in the adult OR with adult surgeons and stayed in the adult surgical ward.
clinicalStuart Hosie14:26 ↗
Freestanding children's hospitals face greater challenges than integrated hospitals because they are completely separate entities both physically and financially.
opinionJason Frischer14:54 ↗
In Cincinnati, ARM patients still come to the colorectal center at the children's hospital whether they are 12 or 40 years old, partnering with an adult colorectal surgeon; collaborative operating occurs at the University of Cincinnati with adult colorectal surgeons, adult neurologists for urology, and pediatric urologists who have privileges at the university.
clinicalJason Frischer15:14 ↗
The ideal transition model begins psychologic discussion in early teenage years, engages friendly adult colleagues, and involves joint clinic visits and collaborative operating; most pediatric surgeons understand this because they have received calls from adult surgeons encountering unfamiliar pediatric conditions like malrotation.
opinionMarc Levitt16:03 ↗
Not all pediatric colorectal surgeons need to physically operate in the adult setting if there are interested adult colleagues; in Jason Frischer's model, he has privileges at the adult hospital but functions primarily as an assistant while the adult surgeon (Ian Piquette) provides adult care expertise.
opinionMarc Levitt17:16 ↗
In the United States, the age line for pediatric vs. adult care is very blurry, which is problematic; patients over age 21 (or possibly 18) at children's hospitals face credentialing issues where pediatric nurse practitioners cannot write orders due to licensing restrictions.
clinicalMarc Levitt18:00 ↗
If a 40-year-old at a children's hospital needs ICU care, the intensivists are pediatric-trained, not adult-trained, creating a safety concern.
clinicalMarc Levitt18:46 ↗
Adult hospitals are much more adept and skilled at managing perioperative complications like pulmonary embolism or myocardial infarction; such events in a children's hospital lead to many meetings and potential for poor outcomes.
opinionJason Frischer18:58 ↗
Physicians and surgeons are making progress on transition, but the greater struggle is providing intensive bowel management training for 35-year-old patients; pediatric centers are adept at bowel management for patients of any age, but currently adult patients requiring intensive outpatient bowel management are still being seen at children's hospitals.
clinicalJason Frischer19:33 ↗
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