Dilations after Posterior Sagital Anorectoplasty

Infographic · Nov 2021 · 1 min read

In brief

Randomized trial of 49 patients challenges four decades of routine postoperative anal dilations following PSARP, finding no significant difference in stricture rates between dilated and non-dilated groups. Results support selective dilation with strictureplasty as backup, potentially reducing psychological burden on families.

Routine daily anal dilations after PSARP do not significantly reduce stricture formation (21% vs 32%, p=0.21)
Non-dilation is a viable alternative approach, reducing psychological burden on patients and families
Heineke-Mikulicz anoplasty remains effective for managing strictures if they develop (13% vs 16% required intervention)
Stricture rates requiring reoperation were similar between groups (8% each), suggesting dilations may be unnecessary
This RCT challenges four decades of standard practice, offering evidence-based alternative to routine postoperative dilations

Written by the GCMD Library team from the infographic.

The infographic uses a clean layout with a red header banner and three main comparison columns. On the left is a simple anatomical diagram showing the surgical site with a red arrow indicator. The three columns contain icons representing reoperation (circular arrows and scalpel), postoperative stenosis (hourglass shape with measurement arrows), and Hegar dilator size (circle with diameter measurement). Teal bars below each column suggest data comparison between groups.

Aim of the Study

For the past four decades, routine daily postoperative anal dilation by parents has been the standard treatment following a primary posterior sagittal anorectoplasty (PSARP). However, the clinical benefit of this practice has never been formally investigated. It is known that dilations can have a significant negative psychological impact on patients and families, and therefore, we aimed to study if routine dilations after a PSARP are necessary.

Methods

A prospective, single institution randomized controlled clinical trial was conducted on patients with anorectal malformations (ARM) at our institution between 2017 and 2019. Patients were randomized to either a dilation or non-dilation group following their PSARP. Inclusion criteria included age less than 24 months and all patients undergoing primary repair of their ARM (except for cloaca). Patient characteristics, type of ARM, presence of colostomy, postoperative stricture, need for a skin level revision (Heineke-Mikulicz anoplasty (HMA)), and need for redo PSARP were recorded. The primary outcome of the trial was stricture formation. The secondary outcome included strictures requiring interventions. A p-value of less than 0.05 was considered statistically significant. Institutional approval was obtained for this study and informed consents were obtained from all the patients.

Results

49 patients were included in our study. 5 (21%) in the dilation group and 8 (32%) in the non-dilation group developed strictures (p=0.21). Of these, 3 (13%) patients in the dilation group required HMA, and 4 (16%) patients in the non-dilation group required HMA (p=0.72). 4 patients required a redo operation for strictures: 2 in the dilation arm (these patients despite the plan to do dilations, chose not to do them consistently) and 2 in the non-dilation arm (p=0.59).

Conclusion

Routine dilations after PSARP do not significantly reduce stricture formation. Based on these results, non-dilation is a viable alternative, and HM anoplasty remains a good back-up plan if a stricture develops.

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