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 perineal fistula repair, contrasting early feeding (post-op day 0-1) with conservative NPO protocols lasting 5-7 days. Levitt presents data showing clear liquids produce equivalent stool output to NPO status, while hard stool passage remains the primary concern for anastomotic dehiscence.
6:27Dilation Protocols and the Randomized Trial — Presentation of a randomized controlled trial comparing routine dilation versus selective dilation for primary PSARP repairs. The study found 10-20% stricture rates in both groups, with family burden of dilations identified as the primary patient concern driving the research. Discussion includes management of strictures with Heineke-Mikulicz anoplasty and the unknown impact on long-term continence outcomes.
19:37Technical Considerations in Anoplasty Sizing — Technical discussion of anoplasty construction, including the practice of making slightly larger anoplasties in resource-limited settings where follow-up is uncertain, and the evolution of this technique based on international surgical experience.
22:09Patient-Centered Decision Making and Future Directions — Reflection on shared decision-making with families, the role of patient crowdsourcing and online education, and the importance of remaining flexible as new outcome data emerges over time.

Key claims

4:32In Phoenix, most perineal fistula repairs are performed before infants are on anything except breast milk or formula, with early discharge on post-op day 2-3 — Christine
1:13Alberto Pena's original protocol required mandatory NPO for 7 days with central line and hyperalimentation, feeding only on day 7 if healed — Mark Levitt
2:31A study comparing NPO for 7 days versus clear liquids for 7 days found the same amount of stool output in both groups — Mark Levitt
3:30The problem is not pooping itself but passage of hard stool that can disrupt the perineal body anastomosis — Mark Levitt
1:13Breast milk does not cause constipation, while regular diet or formula causes more constipation — Mark Levitt
5:23Perineal body dehiscence usually leads to no perineal body over several months and requires redo surgery because the anterior anoplasty has no sphincter around it — Mark Levitt
6:10Patients who required redo surgery for dehiscence were invariably fed right away and discharged home — Mark Levitt
8:22NPO patients still stool very thin and liquidy stool that does not disrupt the anastomosis — Mark Levitt
9:05A randomized controlled trial of dilation versus non-dilation for primary PSARP (excluding cloacas) showed stricture rates of 10-20% in both groups — Mark Levitt
9:40The backup plan for strictures in the non-dilation group was aggressive dilations under anesthesia or Heineke-Mikulicz anoplasty — Mark Levitt
10:40Many patients' anoplasties look absolutely fine 8 weeks later at colostomy closure if never touched with a dilator — Mark Levitt
11:20When families were asked their biggest concern about anorectal malformation care, dilations were number one by far — Mark Levitt
14:04Four patients in the dilation study required redo operations for stricture: two in the dilation arm (both chose not to dilate) and two in the non-dilation arm — Mark Levitt
15:02Approximately 20% of patients in the dilation study required either local or total redo operations, mostly local procedures — Jason Frisher
16:30Full continence can be restored with a redo operation for stricture, based on available data — Jason Frisher
12:06Dilations can drive couples apart, with one family member typically responsible for performing them, leading to guilt and trauma — 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
13:14In the Phoenix protocol, families are seen twice weekly in clinic for physician-performed dilations if they are not comfortable doing home dilations — Christine
19:37Making anoplasties slightly larger in resource-limited settings where patients will not return for follow-up accounts for expected contraction — Mark Levitt
20:30For redo operations, anoplasties are intentionally made larger knowing there will be contraction, and these are not dilated but examined under anesthesia at one month — Mark Levitt
20:30For primary repairs, the anoplasty lumen is made to match what the maximal rectal lumen can be, filling the sphincter, typically resulting in size 13-14 Hegar — Mark Levitt

Cases discussed

0:00Female infant with perineal fistula who underwent primary repair without colostomy, managed postoperatively without home dilations

Points of disagreement

0:48Postoperative feeding timing and diet restrictions
- Christine: Early feeding starting post-op day 0 or 1 with breast milk or formula, advancing as tolerated, with discharge by post-op day 2-3
- Mark Levitt: Conservative approach with clear liquids or breast milk only for 5 days, avoiding regular diet or formula to prevent hard stool passage and dehiscence
- Jason Frisher: NPO on D10 via midline catheter for 5-7 days for older patients, citing concern about hard stool through new anastomosis
7:05Routine dilation versus selective dilation protocol
- Mark Levitt: Selective dilation based on randomized trial showing equivalent stricture rates, offering families choice to avoid routine dilation burden with 10-20% risk of needing intervention
- Jason Frisher: Concern about unknown long-term continence outcomes in non-dilated patients who require redo operations, questioning whether avoiding dilation negatively affects continence three years later

Open questions

What are the long-term continence outcomes at 3+ years for patients who did not receive routine dilations versus those who did, particularly for the subset who required redo operations for stricture?
Does early feeding (post-op day 0-1) with formula or regular diet result in higher dehiscence rates compared to conservative feeding protocols, and if so, what is the magnitude of difference?
For patients who develop strictures in the non-dilation protocol, does the need for redo anoplasty negatively impact ultimate continence compared to patients who never developed a stricture?
What is the optimal anoplasty size to balance immediate function with long-term outcomes, and does this differ between primary repairs and redo operations?

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:

Primary Perineal Fistula Repair Without Home Dilations: A Family-Centered Approach

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 an anorectal malformation — specifically a perineal fistula — presented for primary repair without colostomy. The surgery was performed successfully, but the postoperative course raised a question that challenges standard practice: must every family perform daily anal dilations at home?

The Decision Point

The family had medical background but was anxious and uncomfortable with the idea of performing dilations on their infant at home 4:32. The surgeon faced a choice: insist on the traditional protocol of parent-performed dilations twice daily for months, or offer an alternative that acknowledged both the family's distress and emerging evidence that routine dilations may not be necessary.

The tension here is real. Perineal body dehiscence — the breakdown of the repair between rectum and vagina — typically leads to loss of the perineal body over several months and requires redo surgery, because the anterior anoplasty ends up with no sphincter around it 5:23. Patients who required redo surgery for dehiscence were invariably fed right away and discharged home 6:10. The traditional safeguard against stricture has been aggressive dilation. But a randomized controlled trial comparing dilation versus non-dilation for primary PSARP showed stricture rates of 10-20% in both groups 9:05.

The question families were asked in that study is instructive: what is their biggest concern about anorectal malformation care? Dilations were number one by far 11:20. Dilations can drive couples apart, with one family member typically responsible for performing them, leading to guilt and trauma 12:06. The parent holding the child down already feels guilty — irrationally but powerfully — that their child has this anomaly.

What Was Done

The family was seen twice weekly in clinic for physician-performed dilations until the surgeon was confident no stricture was developing 13:14. The infant was not subjected to home dilations. The anoplasty was made to match what the maximal rectal lumen could be, filling the sphincter, typically resulting in size 13-14 Hegar 20:30.

This approach rests on several principles. First, many patients' anoplasties look absolutely fine 8 weeks later at colostomy closure if never touched with a dilator 10:40. Second, the backup plan for strictures in a non-dilation protocol is aggressive dilations under anesthesia or Heineke-Mikulicz anoplasty 9:40 — interventions that can restore full continence based on available data 16:30. Third, in this case without a colostomy, the risk of needing an additional anesthetic for stricture management was weighed against the certain morbidity of months of home dilations.

One surgeon's protocol involves seeing patients weekly in clinic and passing a dilator without having families do it at home 13:48. Another makes anoplasties slightly larger in resource-limited settings where patients will not return for follow-up, accounting for expected contraction 19:37. For redo operations, anoplasties are intentionally made larger knowing there will be contraction, and these are not dilated but examined under anesthesia at one month 20:30.

Outcome

The surgery went well per initial description, and no stricture developed with the twice-weekly clinic-based dilations [case1]. The family avoided the trauma of home dilations.

What This Changes

The transferable judgment is this: routine home dilations are not mandatory. Approximately 20% of patients in the dilation study required either local or total redo operations, mostly local procedures 15:02. Four patients required redo operations for stricture: two in the dilation arm (both chose not to dilate) and two in the non-dilation arm 14:04. The rates are similar.

The conversation with families should present the choice: dilate twice daily for months, or accept a 10-20% risk of stricture requiring a minor revision, often at a time when the child is already undergoing anesthesia for colostomy closure. This is research driven by family concern, not by a problem surgeons invented. When families understand the parameters, they decide. The long-term continence outcomes after stricture revision in this context are not yet known, but full continence can be restored with redo operations for stricture 16:30.

What matters is that the family's distress is not dismissed as non-clinical. Patient-centered approach equals good outcomes. Challenging dogma when the evidence permits it is not just intellectually honest — it is surgical care.

Takeaways from this story

Stricture rates after primary PSARP are 10-20% whether you dilate or not — the choice is between certain dilation morbidity vs. possible revision.
Families rank dilations as their top concern in ARM care; offering clinic-based dilation or non-dilation protocols addresses real distress.
Perineal body dehiscence requiring redo is associated with early feeding and discharge; the problem is hard stool, not stool itself.
Full continence can be restored after redo operations for stricture, though long-term outcomes in non-dilation protocols need more data.

Questioning Protocol: Evidence-Based Evolution in Perineal Fistula Management

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

From Dogma to Data: The NPO Question

The seven-day NPO protocol with central line and hyperalimentation was Alberto Pena's standard — mandatory, unquestioned, resource-intensive 1:13. The shift began not with a hypothesis but with a constraint: surgeons in resource-limited settings had no access to TPN, forcing adaptation to D10 1:13. Then a fellow asked the foundational question: *why* are we keeping these patients NPO? The answer — to prevent stooling and reduce perineal body dehiscence risk — seemed obvious until the fellow observed that NPO patients still stool 2:31. A study comparing seven-day NPO to seven-day clear liquids found identical stool output in both groups 2:31. The insight that followed was more precise than the original protocol: the problem is not stool passage itself but passage of hard stool that can disrupt the perineal body anastomosis 3:30. Breast milk does not cause constipation; regular diet and formula do 1:13. This distinction — between any stool and *hard* stool — allowed protocols to evolve from mandatory TPN to clear liquids or breast milk with early discharge, provided families understand perineal care and follow-up is reliable [c1, c2].

Research Driven by Family Experience

The dilation randomized trial began by asking families what concerned them most about anorectal malformation care. Dilations ranked first by a wide margin 11:20. This represents a different research architecture: not physicians solving problems they have identified, but families naming the burden they carry. The psychological cost is concrete — dilations can drive couples apart, with one family member typically responsible for performing them, accumulating guilt and trauma over months 12:06. The trial compared routine twice-daily dilations for four months against no routine dilations, accepting a 10-20% stricture risk in both groups 9:05. Many anoplasties examined eight weeks post-repair look entirely normal if never touched with a dilator 10:40. The backup plan for strictures in the non-dilation arm — aggressive dilations under anesthesia or Heineke-Mikulicz anoplasty — often coincides with already-planned colostomy closure, avoiding an additional anesthetic 9:40.

Shared Decision-Making With Incomplete Data

When presenting dilation versus non-dilation to families, the honest framing is: routine dilations for four months versus 10-20% risk of stricture requiring intervention 9:05. Four patients in the trial required redo operations for stricture — two in each arm, though both in the dilation arm had chosen not to dilate 14:04. Approximately 20% required either local or total redo operations, mostly local procedures 15:02. The question that remains unanswered is whether stricture requiring revision affects long-term continence. Available data suggest full continence can be restored with redo operations for stricture 16:30, but the denominator is small and follow-up limited. Some families, understanding these parameters, choose dilation; most do not 4:32. For families uncomfortable with home dilations, weekly or twice-weekly clinic visits for physician-performed dilations preserve the option without the home burden 4:32.

Anoplasty Sizing: Matching Lumen to Anatomy

For primary repairs, the anoplasty lumen should match the maximal rectal lumen achievable with proper mobilization, filling the sphincter complex — typically resulting in size 13-14 Hegar 20:30. Avoid excessive rectal resection. In resource-limited settings where patients will not return for follow-up, making the anoplasty slightly larger accounts for expected contraction 19:37. For redo operations, anoplasties are intentionally made larger knowing contraction will occur; these are not dilated but examined under anesthesia at one month 20:30. The principle learned from international surgical experience: when follow-up is uncertain, build the expected outcome into the initial repair rather than relying on postoperative intervention to achieve it.

Takeaways from this story

The problem is not stool passage but hard stool disrupting the anastomosis — breast milk and clear liquids avoid this risk.
Routine dilations were families' top concern; 10-20% stricture risk with no dilations may be acceptable given psychological burden.
Many primary anoplasties remain patent at 8 weeks if never dilated; strictures can be managed at planned colostomy closure.
For primary repairs, match anoplasty lumen to maximal rectal lumen filling the sphincter (typically 13-14 Hegar); avoid excess resection.
In settings without reliable follow-up, make anoplasties slightly larger to account for expected contraction.

Primary Perineal Fistula Repair Without Home Dilations: Clinic-Based Alternative

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 specialists · Case narrative · AI-written, human-reviewed

Presentation

A female infant with an anorectal malformation — perineal fistula type — presented for primary repair without colostomy [case1]. The surgical repair was performed successfully [case1].

The Decision Point

Postoperatively, the family expressed significant anxiety about performing home dilations despite having medical backgrounds 13:14. This created a management fork: proceed with the standard protocol of teaching families to dilate at home, or find an alternative that addressed both the family's psychological burden and the clinical need to prevent stricture.

The tension here is real. When families were surveyed about their greatest concern in anorectal malformation care, dilations ranked first by a wide margin 11:20. The psychological toll is measurable: "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" [q10]. Families carry unwarranted guilt about their child's anomaly, and forcing them to inflict daily discomfort compounds that burden 12:06.

But the clinical stakes matter too. A randomized trial comparing routine dilation versus no dilation after primary PSARP found stricture rates of 10-20% in both groups 9:05. Four patients across both arms required redo operations for stricture — two who were randomized to dilation but chose not to perform it, and two from the non-dilation arm 14:04. Approximately 20% of patients required either local or total redo operations, though most were local procedures 15:02. The backup plan for strictures in the non-dilation group was aggressive dilations under anesthesia or Heineke-Mikulicz anoplasty 9:40.

The counterargument: many anoplasties examined eight weeks later at colostomy closure look entirely normal if never touched with a dilator 10:40. And available data suggest full continence can be restored even after redo operations for stricture 16:30.

What Was Done

The team offered the family clinic-based dilations rather than home dilations 13:14. The patient was seen twice weekly in clinic, where the surgeon passed a dilator until confident no stricture was developing 13:14. This approach mirrors Jack Langer's protocol of weekly clinic visits with physician-performed dilations, eliminating home dilation entirely 13:48.

The reasoning was explicit: if a 10-20% stricture risk exists regardless of dilation strategy, and if that stricture can be managed with a relatively minor procedure (often at a time when the patient is already undergoing colostomy closure), then the family's psychological burden becomes the deciding factor. "I have yet to meet a family that has chosen dilation" when presented with this trade-off [q13].

Outcome

No stricture developed [case1]. The surgery went well per initial assessment, and the twice-weekly clinic-based dilation protocol successfully prevented stricture formation without requiring the family to perform dilations at home [case1].

What This Changes

The transferable judgment is not that dilations are unnecessary — the stricture rate is real. It is that the locus of responsibility can shift. Families do not need to be the ones performing dilations if clinic-based alternatives are feasible. The protocol requires infrastructure: twice-weekly access, a team willing to absorb that visit burden, and a local patient population rather than distant referrals 4:32. But where those conditions exist, it removes what families consistently identify as their greatest source of distress 11:20.

The approach also reframes the risk discussion. Instead of presenting dilation as mandatory, it becomes a choice: accept a 10-20% stricture risk with a backup plan of minor revision, or commit to months of daily home dilations with the same stricture risk 9:05. "Patient-centered approach equals good outcomes. That's how that's going to go down every single time" [q15].

The unanswered question is whether strictures requiring revision affect long-term continence differently than strictures prevented by dilation. That data does not yet exist [c14, c15]. Until it does, the decision rests on whether the known psychological cost of home dilations outweighs the uncertain functional cost of a possible revision. This case suggests that when families are given that choice clearly, and when clinic-based alternatives are available, many will choose to avoid home dilations entirely.

Takeaways from this story

Stricture rates after primary PSARP are 10-20% whether you dilate or not; the backup plan matters more than the protocol.
Clinic-based dilations twice weekly eliminate home dilation burden while preventing stricture in selected cases.
When surveyed, families rank dilations as their top concern in ARM care — above surgery, stomas, or continence outcomes.
Full continence can be restored after redo operations for stricture, making the risk-benefit calculation less absolute.

Topic overview

A multidisciplinary discussion of postoperative management following primary repair of female anorectal malformations, focusing on two key controversies: feeding protocols (immediate feeding versus NPO with clear liquids) and the role of routine anal dilations. The discussants present data from a randomized controlled trial showing no difference in stricture rates between routine dilation and selective dilation, with approximately 10-20% of patients developing strictures regardless of approach. The conversation emphasizes patient-centered care and the significant psychological burden dilations place on families, while acknowledging that long-term continence outcomes comparing these approaches remain unknown.

Key takeaways

RCT showed 10-20% stricture rate after PSARP whether routinely dilated or not; selective dilation is a viable alternative. (9:05)
Dilations are families' #1 concern in ARM care, causing significant psychological burden and relationship strain. (11:20)
Hard stool—not stooling itself—disrupts perineal body; breast milk feeding may reduce constipation risk post-repair. (1:13)
Perineal body dehiscence typically requires redo surgery as anterior anoplasty lacks sphincter support. (5:23)
Redo operations for stricture can restore full continence; ~20% of patients required local or total redo procedures. (15:02)

Keywords

anorectal malformation perineal fistula anal stricture perineal body dehiscence constipation fecal incontinence cloaca vaginal agenesis primary repair PSARP posterior sagittal anorectoplasty Heineke-Mikulicz anoplasty anal dilation colostomy closure redo anoplasty

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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