Colorectal Quiz Episode 29: Female ARM

Published: 2022-03-14

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Amanda Jensen — host
Christine — guest
Mark Levitt — guest
Jason Frisher — guest
Kathy — guest

Chapters

0:00Postoperative Feeding Protocols — Discussion of feeding approaches after primary perineal fistula repair, contrasting early feeding (POD 0-1) with conservative protocols (clear liquids 5-7 days), including historical evolution from mandatory 7-day NPO with TPN to current evidence-based approaches.
4:32Dehiscence Risk and Referral Patterns — Debate on perineal body dehiscence rates related to feeding timing, with discussion of how referral center populations (older patients, redos) versus local populations (younger, primary repairs) influence protocol choices.
6:27Dilation Protocol Paradigm Shift — Presentation of randomized controlled trial data comparing routine dilation versus no dilation, showing equivalent 10-20% stricture rates in both groups, with backup plan of Heineke-Mikulicz anoplasty or aggressive dilation under anesthesia.
11:52Family-Centered Care and Clinical Outcomes — Discussion of dilations as the top family concern in ARM care, the trauma of home dilations on families, and the need for long-term continence data comparing dilation versus non-dilation approaches.
18:45Technical Considerations and Future Directions — Technical discussion of anoplasty sizing, the role of patient crowdsourcing and social media in decision-making, and the importance of flexibility in surgical practice based on evolving evidence.

Key claims

1:13Alberto Pena historically kept patients mandatory NPO for seven days with central line and hyperalimentation, feeding on day seven if healed — Mark Levitt
2:31A study comparing NPO for seven days versus clear liquids for seven days showed the same amount of stool output in both groups — Mark Levitt
3:30Hard stool passage, not stool passage itself, is the primary risk factor for perineal body dehiscence — Mark Levitt
4:00Current protocol uses regular IV (no PICC line) and clear liquids or breast milk for five days, with better healing observed by day five than day one or two — Mark Levitt
4:32Phoenix group performs early repairs before infants are on anything except breast milk or formula, with early discharge (POD 2-3) and very low dehiscence rate — Christine
5:23Perineal body dehiscence usually leads to no perineal body over several months, requiring redo surgery because the anterior anoplasty has no sphincter around it — Mark Levitt
6:27Patients who required redo surgery for perineal body dehiscence were invariably fed right away and discharged home — Mark Levitt
9:05A randomized controlled trial of dilation versus non-dilation for primary PSARP (cloacas excluded) showed stricture rates of 10-20% in both groups — Mark Levitt
10:40The backup plan for stricture in the non-dilation group was aggressive dilations under anesthesia or Heineke-Mikulicz anoplasty, often performed at the time of colostomy closure — Mark Levitt
10:40Many patients' anoplasties look absolutely fine eight weeks later at colostomy closure if never touched with a dilator, when the anoplasty is healthy with no tension and good blood supply — Mark Levitt
11:52Family survey identified dilations as by far the number one concern relative to care of patients with anorectal malformation — Mark Levitt
13:04Dilations can drive couples apart, with one family member typically responsible for performing them, and that person often not wanting to attend clinic visits over time — Kathy
13:48Jack Langer's protocol involves seeing patients weekly in clinic and passing a dilator without having families do it at home — Mark Levitt
14:04In the dilation study, approximately 20% required a redo operation (either local or total), with four patients requiring total redo anoplasties for stricture (two in dilation arm who chose not to dilate, two in non-dilation arm) — Jason Frisher
16:16Data exists showing patients can be restored to full continence with a redo operation for stricture indication — Mark Levitt
17:36In the dilation study, no family has yet chosen dilation when presented with the option — Mark Levitt
19:37For redo operations, anoplasties are made slightly larger knowing there will be some contraction, and these patients are not dilated postoperatively but undergo EUA at one month to check for early stricture — Mark Levitt
21:00For primary repairs, the analplasty lumen is made to match what the maximal rectal lumen can be, filling the sphincter, typically resulting in size 13 or 14 Hegar — Mark Levitt

Cases discussed

0:00Female infant with anorectal malformation (perineal fistula) who underwent primary repair without stoma

Points of disagreement

0:48Postoperative feeding timing and type
- Christine: Start diet POD 0 or 1 (breast milk or formula), advance as tolerated, discharge POD 2-3, citing younger patient population and local (non-referral) practice
- Mark Levitt: Clear liquids or breast milk only for 5 days (no formula or regular diet due to constipation risk), citing concern about hard stool causing dehiscence and experience with redo cases that were fed early
7:17NPO duration for postoperative management
- Jason Frisher: NPO on D10 via midline catheter for 5-7 days, citing older referral patient population
- Mark Levitt: Clear liquids acceptable (not NPO) based on published data showing equivalent stool output, making families and patients happier
14:04Validity of non-dilation protocol without long-term continence data
- Jason Frisher: Concerned about 20% redo rate and lack of long-term continence outcomes comparing dilation versus non-dilation groups; wants to see functional outcomes before changing practice
- Mark Levitt: Acknowledges continence data not yet available but argues the family morbidity of dilations and minimal risk of intervention (often at time of already-planned colostomy closure) justifies offering non-dilation option

Open questions

What are the long-term continence outcomes comparing routine dilation versus no dilation protocols in primary ARM repairs?
Does early stricture requiring Heineke-Mikulicz anoplasty or redo operation negatively affect continence outcomes three years later compared to patients who never developed stricture?
What is the optimal anoplasty size for primary repairs to minimize stricture risk while maintaining continence potential?
How will patient crowdsourcing through social media and online communities influence surgical decision-making and protocol standardization in ARM care?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Postoperative Management of Female Anorectal Malformation Without Home Dilations

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Case narrative · AI-written, human-reviewed

Presentation

A female infant with a perineal fistula underwent primary repair without diverting colostomy. The operation was technically successful, with good tissue mobilization and a well-vascularized anoplasty. The family, despite having some medical background, expressed significant anxiety about performing home dilations postoperatively.

The Decision Point

The standard protocol following primary repair of anorectal malformations has historically included routine anal dilations beginning within days of surgery and continuing for months. The rationale: preventing anastomotic stricture through mechanical dilation. The burden: twice-daily dilations performed by parents on their infant, often described by families as their primary concern in caring for a child with an anorectal malformation 11:52. One parent typically assumes responsibility for the dilations, and that parent may eventually avoid clinic visits entirely 13:04.

This family declined home dilations. The surgeon had to decide: insist on the standard protocol, or offer an alternative based on emerging evidence that routine dilation may not be necessary.

A randomized controlled trial comparing dilation versus non-dilation after primary posterior sagittal anorectoplasty (cloacas excluded) found stricture rates of 10-20% in both groups 9:05. The backup plan for strictures in the non-dilation arm was aggressive dilation under anesthesia or Heineke-Mikulicz anoplasty, often performed at the time of colostomy closure 10:40. Many patients' anoplasties appeared entirely normal weeks postoperatively if never touched with a dilator, provided the anoplasty was healthy with no tension and good blood supply 10:40.

The trial was designed in response to a family survey identifying dilations as by far the number one concern in anorectal malformation care 11:52. The psychological toll is measurable: dilations can drive couples apart, with the designated dilator often feeling guilt compounded by the need to physically restrain their child 13:04.

What Was Done

The surgeon offered clinic-based dilation rather than home dilation. The family returned twice weekly for the surgeon to pass a dilator and assess for early stricture formation. This approach — seeing patients weekly and performing dilations in clinic rather than having families do them at home — has been used by other surgeons as an alternative to the standard protocol 13:48.

For primary repairs, the anoplasty lumen was made to match the maximal rectal lumen that could fill the sphincter, typically resulting in a size 13 or 14 Hegar 21:00. The technique involves careful mobilization without overdoing it, preserving as much rectum as possible, and creating an anoplasty with good blood supply and no tension.

The family never performed dilations at home. The patient was managed entirely with surgeon-performed dilations during clinic visits until the surgeon was confident no stricture was developing.

Outcome

The discussants did not report the long-term outcome of this specific patient.

What This Case Changes

The transferable judgment is not that dilations should never be performed. It is that routine dilation is not the only defensible approach, and the decision can be individualized based on family preference and surgical technique.

In the randomized trial, approximately 20% of patients required a redo operation — either local revision or total redo anoplasty — with four patients requiring total redo for stricture (two in the dilation arm who chose not to dilate, two in the non-dilation arm) 14:04. Data exists showing patients can be restored to full continence with a redo operation for stricture 16:16. When families in the trial were presented with the option of routine dilation versus accepting a 10-20% risk of stricture requiring intervention, no family chose dilation 17:36.

For redo operations, anoplasties are made slightly larger knowing there will be some contraction, and these patients are not dilated postoperatively but undergo examination under anesthesia at one month to check for early stricture 19:37.

The case illustrates that patient-centered care sometimes means challenging established protocols when the evidence supporting them is weak and the burden on families is high. The art is in the surgical technique — a well-mobilized, tension-free anoplasty with good blood supply — and in offering families a choice grounded in honest discussion of risks rather than reflexive adherence to tradition.

Takeaways from this story

Stricture rates after primary PSARP are 10-20% whether or not routine dilations are performed, challenging the necessity of this burden on families.
Families identify dilations as their primary concern in ARM care, with the psychological toll sometimes driving couples apart over time.
Well-vascularized anoplasties with no tension often appear normal at weeks postoperatively if never dilated, suggesting surgical technique matters more than routine dilation.
When offered choice between routine dilation and 10-20% stricture risk requiring intervention, no families in one trial chose dilation.
Patients requiring redo operations for stricture can be restored to full continence, making stricture a manageable rather than catastrophic outcome.

Questioning Dogma in Anorectal Malformation Care: From NPO Protocols to Dilation Practice

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Distinguishing Stool Volume from Stool Consistency

The evolution from mandatory seven-day NPO with central line and hyperalimentation to clear liquids began with a fellow's simple question: why keep these patients NPO? 1:13 The assumption was that preventing stool would reduce perineal body dehiscence risk. A study comparing seven days NPO versus seven days of clear liquids showed identical stool output in both groups 2:31. The critical insight emerged: hard stool passage, not stool passage itself, is the primary risk factor for perineal body dehiscence 3:30. This distinction — volume versus consistency — led to protocol change to regular IV with clear liquids or breast milk for five days, with better healing observed by day five than earlier postoperative days 4:00. The lesson is not that all feeding restrictions are unnecessary, but that understanding the mechanism of complication allows you to target the intervention precisely.

Research Driven by Family Experience

The randomized trial of dilation versus non-dilation originated from asking families their biggest concern in caring for children with anorectal malformation — dilations ranked first by far 11:52. This represents a fundamental shift in research priority: not the surgeon identifying a technical problem, but families identifying what creates the most burden in their lives. Dilations can drive couples apart, with one family member typically responsible for performing them, and that person often not wanting to attend clinic visits over time 13:04. The psychological toll of holding down your child while performing a procedure you feel guilty about — even though the malformation was not caused by anything the parents did — compounds over months. When research questions come from patient experience rather than surgical curiosity, the answers matter differently.

Accepting Uncertainty When the Alternative Carries Known Harm

The dilation trial showed stricture rates of 10-20% in both dilation and non-dilation groups 9:05. The backup plan for stricture in the non-dilation group was aggressive dilations under anesthesia or Heineke-Mikulicz anoplasty, often performed at the time of colostomy closure 10:40. Many patients' anoplasties look absolutely fine eight weeks later at colostomy closure if never touched with a dilator, when the anoplasty is healthy with no tension and good blood supply 10:40. The trade-off is clear: routine daily trauma for all families versus a 10-20% chance of needing a procedure under anesthesia that was already scheduled. When presented with this choice, no family in the ongoing trial has yet chosen dilation 17:36. The willingness to accept some uncertainty when the alternative is known harm to every patient represents mature surgical judgment.

Technique Adapted from Resource-Limited Settings

The approach to sizing redo anoplasties came from operating in Ghana, where a colleague explained he makes anoplasties slightly larger knowing patients will not return for follow-up and the anoplasty will contract somewhat 19:37. This technique — making the anoplasty larger to account for expected contraction — was brought back and applied to redo operations in the developed world. For primary repairs, the anoplasty lumen is made to match what the maximal rectal lumen can be, filling the sphincter, typically resulting in size 13 or 14 Hegar 21:00. Resource-limited settings force clarity about what is essential versus what is convenient, and techniques developed there often prove superior when examined critically.

The Limits of Published Evidence

Approximately 20% of patients in the trial required a redo operation (either local or total), with four patients requiring total redo anoplasties for stricture — two in the dilation arm who chose not to dilate, two in the non-dilation arm 14:04. The valid concern raised is that continence outcomes are not yet known. Data exists showing patients can be restored to full continence with a redo operation for stricture indication 16:16, but the denominator for this specific cohort remains unknown. The discussants emphasized that challenging dogma requires tracking outcomes rigorously, and that patient-centered approaches — where families understand the parameters and decide — consistently lead to good outcomes even when all the data is not yet available.

Takeaways from this story

Hard stool passage, not stool volume, causes perineal body dehiscence — target consistency, not complete bowel rest
Stricture rates are 10-20% whether you dilate or not; routine dilation subjects all families to trauma for uncertain benefit
Research questions driven by family concerns (dilations ranked #1) produce more meaningful practice changes than surgeon-identified problems
Techniques from resource-limited settings (larger anoplasty for expected contraction) often prove superior when examined critically

Postoperative Feeding and Dilation Protocols After Primary Anorectal Malformation Repair

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The feeding question

When can an infant eat after primary repair of an anorectal malformation without a diverting colostomy? The disagreement turns on whether early feeding increases the risk of perineal body dehiscence through passage of hard stool 3:30 6:27.

One position, practiced in a high-volume local referral setting, starts breast milk or formula on postoperative day zero or one, advances as tolerated, and discharges patients by day two or three 4:32. The rationale rests on patient age — most repairs occur before infants are on solid food — and close early follow-up to detect problems quickly 4:32. The dehiscence rate is reported as very low 4:32.

The alternative protocol restricts intake to clear liquids or breast milk only (no formula or regular diet) for five days, using a standard IV rather than central access 4:00. This approach stems from direct experience: patients requiring redo surgery for perineal body dehiscence were invariably fed right away and discharged home 6:27. The concern is specific to hard stool, not stool volume 3:30. A study comparing NPO for seven days versus clear liquids for seven days showed identical stool output in both groups 2:31, leading to the conclusion that hard stool passage, not stool passage itself, drives dehiscence risk 3:30. Formula causes more constipation than breast milk; regular diet more than either 4:00.

The disagreement reflects different patient populations 4:32 6:27. The early-feeding group operates on younger infants in a local practice with minimal referrals 4:32. The restricted-feeding group sees older referral patients and bases protocol on patterns observed in revision cases 6:27. A third position — NPO via midline catheter for five to seven days — persists in some referral centers managing older patients 13:48, though this has been challenged as unnecessarily conservative given published data showing clear liquids produce no more stool than complete bowel rest 2:31.

All parties agree that passage of hard stool through a fresh perineal body repair creates risk 3:30 6:27. The disagreement is whether early introduction of formula or regular diet materially increases that risk in the first postoperative week, and whether patient age and follow-up intensity modify that risk enough to justify different protocols 4:00 4:32 6:27.

The dilation question

Should the neoanal opening be dilated routinely after primary PSARP, or should families be offered a non-dilation protocol with intervention reserved for stricture 9:05?

Routine dilation has been standard practice for decades 9:05. The concern driving this protocol is stricture formation, which can compromise long-term continence 9:05. Families dilate at home, typically twice daily for months 11:52. The protocol is published, widely taught, and represents current practice at most centers 9:05.

A randomized controlled trial compared dilation versus non-dilation for primary PSARP, excluding cloacas 9:05. Stricture rates were similar in both groups 9:05. The backup plan for the non-dilation arm was aggressive dilation under anesthesia or Heineke-Mikulicz anoplasty, often performed at the time of already-planned colostomy closure 10:40. Many patients' anoplasties appeared entirely normal at eight weeks if never touched with a dilator, when the repair was healthy with good blood supply and no tension 10:40. The study was prompted by family survey data identifying dilations as by far the number one concern in caring for children with anorectal malformations 11:52.

The objection to abandoning routine dilation is straightforward: some patients in the non-dilation study required redo operations — four needed complete redo anoplasties for stricture (two from each arm), with additional patients requiring local revision 14:04. The continence outcomes comparing dilated versus non-dilated patients are not yet available 14:04. Without that data, the question remains whether accepting stricture and intervening when it occurs produces equivalent functional outcomes to routine dilation 14:04. As one discussant put it: "all the parents want is their kid pooping in the potty. And we don't know that answer" [q10].

The counterargument acknowledges the missing continence data but weighs the known family burden of dilations against the risk profile of intervention 11:52 13:04. Dilations drive couples apart, with one family member typically responsible and often unwilling to attend clinic visits over time 13:04. The psychological toll of restraining a child for daily dilations, compounded by parental guilt over the malformation itself, represents real morbidity 11:52 13:04. The interventions required for stricture — often performed at the time of colostomy closure the child is already undergoing — may be an acceptable trade for eliminating routine dilation 10:40. Data exists showing patients can be restored to full continence with redo operations performed for stricture 16:16.

When presented with the option in the study setting, no family has yet chosen dilation 17:36.

Both positions agree that stricture is a real risk and that continence is the outcome that matters 9:05 14:04. The disagreement is whether the family burden of routine dilation is justified without evidence that it improves continence compared to selective intervention for stricture 11:52 14:04. One side argues the current protocol is proven and should not be abandoned without long-term functional data 14:04. The other argues that patient-centered care requires offering families a choice when the stricture rates are equivalent and the intervention for stricture is manageable 9:05 10:40 11:52.

Long-term continence data comparing the two approaches would resolve the question 14:04. Until then, the choice turns on how heavily one weighs the known burden of dilations against the unknown functional impact of selective intervention for stricture 11:52 13:04 14:04.

Takeaways from this story

Clear liquids produce the same stool volume as NPO, shifting the concern from stool frequency to stool consistency
Stricture rates after primary PSARP are similar whether or not routine dilation is performed
Family survey identified dilations as the number one concern in ARM care, driving research into non-dilation protocols
Continence outcomes comparing routine dilation versus selective intervention for stricture remain unknown

Topic overview

A panel discussion on postoperative management of female anorectal malformations following primary perineal fistula repair. The core clinical debate centers on two protocols: early feeding (postoperative day 0-1 with breast milk or formula) versus conservative feeding (clear liquids or breast milk for 5-7 days), with speakers presenting data that NPO status and clear liquids produce equivalent stool output. The second major topic addresses a paradigm shift away from routine home dilations, based on a randomized controlled trial showing similar stricture rates (10-20%) whether patients dilate or not, with the option of Heineke-Mikulicz anoplasty or aggressive dilation under anesthesia if stricture develops. Speakers emphasize that dilations are the top family concern in ARM care and that eliminating routine dilations significantly reduces family stress, though long-term continence outcomes comparing the two approaches remain unknown.

Key takeaways

Early feeding (breast milk/formula POD 0-1) shows low dehiscence rates; NPO vs clear liquids produce equivalent stool output. (2:31)
RCT shows 10-20% stricture rate whether dilating or not; backup is EUA dilation or Heineke-Mikulicz anoplasty at colostomy closure. (9:05)
Dilations are families' top ARM concern and can strain relationships; weekly clinic-based dilation is an alternative to home protocol. (11:52)
Perineal body dehiscence from hard stool passage typically requires redo surgery as anterior anoplasty lacks sphincter support. (3:30)

Keywords

anorectal malformation perineal fistula anal stricture perineal body dehiscence constipation primary repair PSARP posterior sagittal anorectoplasty Heineke-Mikulicz anoplasty colostomy closure anal dilation EUA redo anoplasty cystoscopy diagnostic laparoscopy

Hashtags

#AnorectalMalformation #PediatricSurgery #ColorectalSurgery #SurgicalEducation

Transcript

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Hey there listeners, it's Amanda Jensen at Riley Children's. Welcome to the colorectal quiz. Today we are going to pick up where we left off. Last week we discussed female anal rectal malformations and this week we are going to discuss the postoperative management of that patient. We'll start off with Dr. Levitt from Children's National. So here we have a situation where you guys have done a primary repair of a perineal fistula in a girl. The surgery went well. Christine and Kathy, very happy, great job today. What are your postoperative feeding orders, Christine? So we are, I guess, not as conservative as some people in terms of keeping our patients NPO here and many of our surgeons would either start a diet post-op day zero or start a diet post-op day one. And in this breast milk post-op day one and then advances tolerated and go home pretty early post-op day two or three as long as they're tolerating diet. So are you trying to say that I am a conservative surgeon because I may have a different protocol because I will tell you that in my opinion, breast milk is perfectly fine. The issue for me is a regular diet or formula, which is going to cause more constipation. Breast milk won't cause constipation. And let me tell you in the old days, Alberto Pena, who obviously I worked with a long, long time, used to keep the patient mandatory NPO for seven days, would place a central line and put the patient on Hyper-L. And on day seven, if all was healed, the baby would be fed. Traveling to somewhere in the developing world that said, we can't do that. We don't have TPN. And then I said, oh, that's an interesting problem that I hadn't thought about, but they did have D10. So then the practice changed to D10. And of course, at that point, PICC lines started to become more common. And then I had a fellow. It's wonderful to have a fellow. Christine, you epitomize the second favorite part of my day. You and Amanda epitomize first part, patient care number two, paying it forward to the next generation. And I had a fellow that said, why exactly are you keeping these patients NPO? And I said, well, because I don't want them to stool. Because if they stool, they're more likely to dehisc their perineal body. And the fellow said, you know, they still stool, even if they're NPO. And I said, yes, but not as much. And he said, this was Carlos Reck, who's now the premier colorectal surgeon in Austria. He's in Vienna. He said, I think it's about the same. And we studied it. And Carlos recorded stool output in two groups, NPO for seven days. And we gave them clear liquids. That was our test, clear liquids for seven days. And guess what? Same amount of poop. So then I came to the conclusion that it's not the pooping that's the problem. It's the hard pooping that's the problem. And therefore the protocol changed to a regular old IV, no PICC line and clear liquids or breast milk for five days. This is my protocol. I'm not saying everyone needs to do it, but on the fifth day, usually get a lot better healing than you do on the first or second day. And we have a very, very low dehiscence rate. So anyone who does feeding right away needs to keep track of their dehiscence rate and publish it. And I have yet to see an article that says post-up day one, regular diet, not breast milk, regular diet, like, you know, food or formula and a very low dehiscence rate. I remain very concerned about passage of hard stool. And I believe that one way to keep people from, kids from passing hard stool is to keep them on clear liquids. But in your case, breast milk and discharge home, no problem. Well, so Mark, I think one of the things is, remember, we're talking about Phoenix, local care, not a lot of referrals. So the age group, I think overall is lower. And so you're getting more referrals from outside the age, the kids are a little bit older. So most of the repairs that the Phoenix group is going to do, we're 14 surgeons now, are going to be before a kid is on anything except breast milk or formula. We don't restrict them, which one they can have. We do early repairs and early discharge home, POI lip and our dehiscence rate is very low, but we see them very quickly post-op. If there's any question, we teach the families how to care for this bottom, as I'm sure you do, because you just cannot have people scrubbing at these stitches. They have to, you have to be very, very careful about the way the care of the perineum. You don't want to do these surgeries after these kids are on your hip. You know, you want to be sure that these kids are not straddling anything. Well, you can say that. I think the key to this will be as minimal amount of perineal body injury by surgery as possible. I will tell you the other thing that influences me for sure is, is the redos that I am asked to do. Right. And invariably a perineal body dehiscence usually leads to no perineal body over several months and needing for a redo because the anterior analplasty has no sphincter around it. It's split. So you need to redo them to get a sphincter complex in the perineal body. And every single one of those that I see nearly, I asked them what was the feeding protocol and invariably they were fed right away and discharged to home. Well, again, it's the, it's referral versus local. And I think that's, that's what we still have is sort of a local team that we, we can control, you know, our connection to the family, the number of times we'll see the family and clinic, that kind of thing. And so we should move on to your favorite topic, Mark, because it has been a huge influence on us in Phoenix, or at least me. And it may be, yes, dilations. And this may be not only an influence on me and my partners, but on the boards, because I was letting my group at the boards know that if a, if a candidate now answers that, well, you know, we say to them, what are you going to do after, you know, after post-op, what's your, what's your post-op regimen? We used to say dilation regimen. And I told everybody, I'm not sure we can say that anymore. You guys, there might be some very legitimate candidates who are going to tell you that they're not. Let's talk about that first, Jason. What is your current protocol for perineal body, primary repair, no stoma? When do you feed? I am a slow feeder. So I am in the old school, depending on the patient. Again, most of our patients are older. So I will put in a midline catheter often and not a PICC line and then use D10 until I know that is repaired. And then. So wait, so how long do you wait on D10 NPO? Five to seven. All right, my friend, give them clear liquids. You're going to make a lot happier families and kids. We tested it. We have a nice paper about clear liquids. I read papers. There's a lot of papers out there. And I'm getting ready. This is a good one. This is a good paper. This is a good. I, I glad you, you recognize there are a lot of not good papers just because it's published. Doesn't mean it works. Anyway, we, we found that clear liquids was no different than NPO. So, um, but I do agree with you with no food. Um, but I think I agree with you that the concept of passing, passing a hard stool through a new anastomosis is going to be a problem. How you get to that. But I would, I would challenge, I would challenge you to check your own group of patients and you will recognize that the NPO patient is still stooling. So, but they're stooling very, very thin and liquidy stool. That's not going to disrupt the anastomosis and therefore adding clear liquids, most of which is absorbed by the stomach and just makes, it just pacifies the nurse. Sure. Parent and the child, um, um, is, is fine. I would buy that. Let's, let's finish up with a brief discussion. But I do want to talk about the dilation paper because I do have, do want to bring up some questions about that as well. As some of you know, what Kathy's alluding to is that, um, Richard Wood and I ran a randomized control trial of dilation and non-dilation for primary PSARP. Cloacas were excluded and families knew that they were going to be randomized into one of two groups. And the backup plan, if a patient developed, um, a stricture was dilation plus or minus a Heineke-McCulitz anoplasty. Um, and essentially it came down to the, the data came down to the fact that if you dilated, you sometimes got a stricture. And if you didn't dilate, you sometimes got a stricture somewhere between 10 and 10 and 20%. But the backup plan of aggressive dilations under anesthesia, when you're already there for the colostomy closure or Heineke-McCulitz anoplasty was a pretty good option to offer a family as a non-dilation possibility. The more complicated scenario is a case like this, where there is no anesthetic looming in the next six to 10 weeks for a colostomy closure. And if they were to develop a stricture, you would then have to put them under anesthesia to either aggressively dilate them or do a Heineke-McCulitz anoplasty. But I have found that, um, if you do a good anoplasty that's healthy and, um, no tension, good blood supply, a lot of patients' anoplasty look absolutely fine eight weeks later at the time of colostomy closure if they were never touched with a dilator. And the other thing that's really important to keep in mind relative to this paper is what prompted the paper. And what prompted the paper was, and this was Richard's idea, was to ask the families what is their biggest concern relative to care of patients with an anorectal malformation. And by far, number one was dilations. So in response to that, which I really like, because this was research in response to a family concern. It wasn't the doctor trying to solve a problem that the families don't necessarily worry about. This was a real family-driven research. And if we can eliminate routine dilations from a patient, and you can then tell a family, we can dilate twice a day for the next four months, or we can roll the dice a little bit and take about a 10 to 50% risk of developing a stricture. And if you do, we're going to do a Heineke-McCulitz anoplasty and improve the size of the anus and your kids going under anesthesia in eight weeks anyway for the colostomy closure. So that's- Which is not always the case where we are. So we don't have a routine with eight weeks, and we don't have- And I think you guys have that partly because it's a referral center, so it's kind of like- It can be four, it can be six, it can be eight, it can be 10. That's not important. What you've just described is a game changer. And it is important because it is, like you said, driven by a patient experience. And this can drive couples apart. You will find that one of the family members is the one that has to do the dilations. That that person, over time, doesn't even want to come to see you anymore. I mean, the other person will bring the kid in. It is so traumatic to people to have to do the dilations. When they're holding their child down, they already feel guilty for no reason that their child had an anomaly that they somehow feel like they created. Even though they didn't, right? We know that by development, they didn't create it. But this is something that takes so much stress off of them to say, you know what? I'll do it. I'll do it in the office. I'll calibrate it. I'll tell you whether or not I need you to do dilations. If I think that we're coming to that, or I'll do it myself. So in this case, Christine, you want to describe how this family has never put a dilator in this kid. So you want to describe how that came about? So as we know from our initial visit with the family, they're fairly, I guess, anxious and worried about their child. And so post-operatively, they were not comfortable at all with considering doing dilations themselves, despite having some experience in the medical field. And so we had them come to clinic twice a week, I believe. You know, just until I was sure that we weren't developing a stricture. But like Mark said, we could have developed a stricture even with my dilations. I was just doing them in clinic, you know, initially. By the way, that routine, Jack Langer does that. He sees them every week in clinic and passes a dilator and doesn't have them do it at home. And anyway, Jason, what is, was that a bad paper or is that a good paper? My only concern is what's the continence rate of your patients? You have a percent of looking at, right? You're somewhere in the order of 15 to 20, 22% got redo operations, mostly local. I think you had four patients that had total redo analplasties. No, not that many, but. Four, I'm reading the paper. Four patients required a redo operation for stricture. Two in a dilation arm, both chose not to do dilations, and two in a non-dilation arm. Oh yeah, so, but two in the total of four, but two in the non-dilation group. Because in theory, the dilation group was what the current protocol is. Right, but they, but you made a comment that they didn't do the dilations. So yeah, the, yes, but that's going to happen. Yeah, no, it's intent to treat. So if you look at intent to treat, that's how it fell out. So, so. But I guess my question is somewhere around 20% required a redo either local or total operation. Most just like local. But what did a functional, in the end of the game, all the parents want is their kid pooping in the potty. And we don't know that answer. Yeah, so yes, that answer is not known. That's my problem. Until I know that answer and compare it to our family. So that's a very, so that's a very valid point. So what you're saying. Wait, wait, Mark agreed with me. I love it. No, no, no. We don't know the answer to that question. That's a more longer term follow-up. So what you're, what you're basically saying is if you don't dilate someone because you agree that this is a good idea to try a new protocol. And they end up developing a stricture and you revise the analplasty for that purpose. Have you negatively affected their continence three years hence? And I don't know the answer to that question. That's going to take a lot of patience because, again, there were only two in the non-dilation group and two in the dilation group. I don't know. No, there were two in two that required total re-operations. Yes, right. I believe. Three in four, seven in the other group that required Heinecke-Micklitz analplasties. All I can tell you is that I do know that you can restore a patient to full continence with a redo. We have that data available to us. And one of the indications is a stricture. And that's a very different stricture than what we're dealing with. So that's a longer stricture. And a longer stricture. That's a full redo. You can have full continence after a redo for stricture. But we do not know the denominator. A hundred percent valid concern. But I personally have come to the conclusion that the amount of morbidity that we're putting families through by dilating them and the minimal risk to them of even needing an intervention. And then if they do need an intervention, it's relatively minor. And the vast majority of those, they're already undergoing surgery for their colostomy closure. I think it's a valid discussion with the family. And as a family understands what are the parameters, they will decide. And I can tell you, I have yet to meet a family that has chosen dilation. So, Mark, I have had families that chose dilation. And not to, like, shut down this Jason Mark smackdown. But what I think is so great about what you tried to do is, first of all, you challenged dogma, which I think in surgery is really important to do. Number two, you have a patient-centered approach. Okay? And every hospital will tell you that's important. But I think as surgeons, as pediatric surgeons, we know how really important that is. Patient-centered approach equals good outcomes. That's how that's going to go down every single time. So, we have had families choose dilations because when we describe your study and we tell them the numbers in the study and we tell them everything, they say, since I still don't know, since we don't know for sure and this needs to be validated and et cetera, et cetera, I feel like I can dilate and I'll go ahead and do that. Everyone should track their outcomes on this. PCPLC should track the outcomes on this. This is a great thing to expand. I agree. That's a really good way to conclude. I think the good news is that there's no right answer. We just have to all work together and suffer together on these difficult problems and try to improve lives as best we can. So, do you want to, Jason, just sort of summarize what we did today? Yeah, no. I think this is a great discussion. I think, Kathy, you summarized it awesomely. I don't want to say I don't want to do this. And just one other question for Mark because this is a technical question. And when I was working with Mark here, I know, especially in the older patients that we were doing redoes on, used to teach me to make the analplasty maybe a little larger to try to do that. And so, my question is, was there some inherent bias of do you make your – if you're going to put one more perineal stitch or one more posterior sagittal stitch versus an analplasty stitch, have you changed your approach? I mean, we're talking millimeters here. But a Hagar size from 12 to 14 is millimeters. Yes, that's a very good question. I will tell you where that idea came from. And I was operating with a good friend and colleague in Ghana. And we were talking about that part of the procedure. And I asked him when would the patient come back for clinic to start dilation. And he said, this patient will not be coming back for any follow-up. So, therefore, he likes to make the analplasty. And I know you've probably had this experience when you've been in the developing world. When he says, I make my analplasties a little bit bigger so that I know everything's going to be fine when it contracts a little bit. So, there's no question in my mind on redos that I do that. I try to make it a little bit bigger knowing there's going to be a little contraction. We don't dilate the redos, period. We EUA them at a month just to make sure no early stricture is developing. But in the primaries, I basically make the lumen what the rectum needs, what the maximal rectal lumen can be. And whatever that is that fills the sphincter, that's how I make the analplasty. And if you do a nice mobilization and not overdo the mobilization, I try to throw away as little rectum as possible. That analplasty is a good size usually. And it is about a 13 or 14 at the end. I watched that evolution when you were going to Ghana and you brought that technique back to Cincinnati. Because I think about that when, you know, you've done your mobilization, everything looks great. You're like, it reaches, you're all happy. But the art of making that analplasty, I think, has something to do with it. And so, thank you for describing that. Can I ask one question of Christine and Amanda real quick? And this is, Amanda, you can choose whether or not to put this in. So, you have these amazing experts in Jason, you know, Jason Frisher and Mark Leavitt. And I am the sort of like alternative view at times, you know. But you two, I think, as time will go on, you'll take all these expert opinions. But how much do you think that patients and crowdsourcing will decide this? The patients will come to you and they will already know that there are several issues to be discussed. Colostomy or no. The timing of surgery. Dilations or no. And do you think that in general, there will be a right answer in a family's mind based on how they've crowdsourced it? Oh, I think you're absolutely right. The parents will come with opinions. Is, especially if, like, in this case where they came with a second or third opinion. So, they've already found out something. And then, you know, Dr. Google, for better or worse, people are going to be finding out more. I think it's, in some ways, it's good for the families to be educated. I think things like the Facebook groups or places like that are hopefully a little bit more educated than just, you know, going down a deep Google search. But not always. But I think we're definitely going to have to deal with that. And, you know, we're seeing that maybe there's not one right way or wrong way with some of these things that were surgical dogma. And maybe need to be more willing to allow parents this, you know, shared decision making that we're seeing more and more in. Amanda, what do you think? With all the surgical education you guys are doing online, which you're doing an amazing job. How does it affect this? So, I would say that you're exactly right with parents and families being able to see Facebook and Dr. Google. I think a lot of this, you have to make the best judgment for your patient for the recommendation. I think that I am going to be a dilator, but it's the more conservative approach. That being said, I think that that's the reason that we do research and data and look at outcomes. And so, I think looking at this 10 years from now and saying, what are our numbers and what have we found with trying this different approach may change the way I view it. But I probably am going to be the more conservative person. You preserve the right to be flexible. So, you want to see flexibility in chunks of time throughout your career and be ready to change. And I think that's a huge compliment to Dr. Fisher and Dr. Levitt is that they've been willing to change on what they were taught when they started and made progress for patients. All right. And I think we're out of time. Thank you for joining us for the colorectal quiz where we discussed female anal rectal malformation postoperative management, specifically diving into feeding protocols postoperatively and also utilization of dilation versus operative approach for postoperative strictures. I think we have time for one colorectal joke of the day. Dr. Fisher, take it away. Knock, knock. Who's there? I eat mop. I eat mop poo. I eat mop. I don't get it. Oh, my. I eat mop poo. I eat mop poo. Mop poo. A kid told me that. I almost fell on the floor. It was awesome. All right. That wraps up the colorectal quiz. Remember, knowledge should be free. Next, be it. We are. We are. We are. We are. We are. We are. We are. We are. We are. We are. We are. We are. We are. We are. We are. And I. we are. we are. e, you,. Remember, knowledge should be free.

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