Colorectal Quiz Episode 29: Female ARM-Post Op Management

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 post-operative. Management of that patient. We'll start off with Doctor Levitt from Children's National. We, so here we have a situation where we've, 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 post-operative 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 1. And then this, so breast milk post-op day 1, and then advances tolerated and go home pretty early post-op day 2 or 3, 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 I, let me tell you, in the old days, um, Alberto, uh Pena, who obviously I worked with a long, long time, used to keep the patient mandatory NPO for 7 days, would place a central line, um, and put the patient on Hyperal. And on day 7, if all was healed, the baby would be fed. Traveling to, uh, 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 uh more common. And then, we, I had a fellow. It's wonderful to have a fellow. Christine, you are an, you epitomize the second favorite part of my day, you and Amanda epitomize first part, patient care, number 2, 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 hiss 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 7 days, and we gave them clear liquids, that was our test, clear liquids for 7 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 5 days. This is my protocol, I'm not saying, everyone needs to do it, but on the 5th day, you usually get a lot better healing than you do on the 1st or 2nd 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-op 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, um, and I believe that one way to keep people from uh 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's gonna do, we're 14 surgeons now, are gonna 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, um, PO ad lib, and our dehiscence rate is very low, but we see them very quickly post-op, um, 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, um, you know, you want to be sure that these kids are not, uh, straddling anything. Well, you can say that for newborn. I think the key to this will be, um, as minimal amount of perineal body. Um, injury by surgery as possible. Um, I will tell you the other thing that influences me for sure is, is the redos that I am asked to do. And invariably, a perineal body dehiscence usually leads to no perineal body over several months, and needing for a redo because the anterior anoplasty 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 ask them what was the feeding protocol, and in 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, the number of times we'll see the family in 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 going to dilate. Let's talk about that first, Jason. I, I, what is your uh 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? 5 to 7. All right, my friend, give them clear liquids. You're gonna make a lot happier families and kids. We tested it. We have a nice paper about clear liquids. Clear liquid papers. There's a lot of papers out there, and I'm this is a good one. This is a good paper. This is a good, I, I'm 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. Um, but I do agree with you with no food, um, but, 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, I would, 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 gonna disrupt the anastomosis and therefore adding clear liquids, most of which is absorbed by the stomach, it just makes, it just pacifies the nurse, parent, and the child, um, um, is, is fine. All right, let's, let's, let's finish up with a brief discussion but I do want to talk about the dilation paper because I do have. I do wanna 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 controlled trial of dilation and non-dilation for primary PSAP. Cloacass 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, uh, 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 Heinekemulitz 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 6 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 Heinekemulitz 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' anoplasties look absolutely fine, 8 weeks later at the time of the 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, cause this is 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 4 months, or we can roll the dice a little bit, and take about a 10 to 15% risk of developing a stricture. And if you do, we're gonna do a Heineken Mulli anoplasty and improve the size of the anus, and your kid's going under anesthesia in 8 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 8 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 4, it can be 6, it can be 8, it can be 10, that's not, that's not important. What you've just described is a game changer, and it is, it is important because it is like you said, driven by a patient experience, 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 want to come to see you anymore. I mean, the, the other person will bring the kid in. There 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 they, this is something that takes so much stress off of them to say, you know what, I've, 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 we're coming to that, or I'll do it myself. So in this case, Christine, you want to describe how this, this family has never put a dilator in this kid. So, you wanna 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 postoperatively, they were not comfortable at all with considering doing dilations themselves despite having some experience in the medical field. And so uh we had them come to clinic twice a week, I believe, Doctor Van, you know, just until I was sure that we weren't developing a stricture, but like Mark said, you could, we could have developed a stricture even with my dilations. I was just doing them in clinic, uh, you know, initially was, by the way, that, that routine, Jack Langer does that. He has sees them every week in clinic and, uh, passes a dilator and doesn't have them do it at home and, um, anyway, Jason, what is, uh, Was that a bad paper or is that a good paper or my only concern is what's the continence rate of your patients? You have a percent of looking at, right, you, you're, you're somewhere in the order of 15 to 20, 22% got redo operations, mostly local. I think you had 4 patients that had total redo anoplasties. No, not, not that many, but, but 4. I'm reading the paper, 4 patients required to redo operation for stricture. 2 in a dilation arm, not to do dilations, and 2 in a non-dilation arm. Oh yeah, so, but 2 in the total of 4, but 2 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 gonna 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 out 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, that, that answer is not known. That's my problem. Until I know that answer and compare it to, 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, I, 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 anoplasty for that purpose. Have you negatively affected their continence 3 years hence? And I don't know the answer to that question. That's gonna take a lot of patience because again, there were only 2 in the non-dilation group and 2 in the dilation group, um, I don't know. No, there were 2 and 2 that required total re-operation. Yes, right, I, I, I believe 3 and 47 in, in the other group that required Heineke Mikolliz. All I, all I can, 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, 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. 100% 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, 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, what I think is so great about what you tried to do is, first of all, you challenge dogma, which I think in surgery is really important to do. 2, you have a patient centered approach, OK? And that, and, and there, 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 gonna 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 etc. etc. I, 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, uh, this is a great thing to expand. I. Agree. I, uh, that's a really good way to, um, 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, uh, improve lives as best we can. So, do you wanna, Jason, just sort of summarize what we, yeah, no, I think there's a great discussion. I think Cathy, you, you summarized it awesomely. I, I don't wanna say I don't wanna do this, and I 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 redos on, used to teach me to make the anoplasty maybe a little larger. To try to do that. And so there was, uh, my question is, was there in some inherent bias of, do you make your, if, if you, if you're gonna put one more perineal stitch or one more posterior sagittal stitch versus an anoplasty stitch, have you changed your Approach from, I mean, we're talking millimeters here, but a Hagar's size from 12 to 14 is millimeters. Yes, that's a, that's a very good question. I will tell you where that, that idea came from, and I was operating with a, uh, a good friend and colleague in Ghana, and we were talking about that part of the procedure, and I asked him where, 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 anoplasty, and I know you've probably had this experience when you've been, been in the developing world, when he says, I make my anoplasties a little bit bigger, so that I know everything's gonna 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 gonna 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. Um, 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 anoplasty. And if you do a nice mobilization, and not overdo the mobilization, I try to throw away as little rectum as possible, that anoplasty 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, 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 anoplasty, 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, but my, um, so you have these amazing experts in Jason, uh, you know, Jason Fisher and Mark Levitt, and I am the sort of like. Alternative view at times, you know, um, but you two, I think as time will go on, you'll, you'll take all these expert opinions. But how much do you think that patients and crowdsourcing will decide this, these 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, that parents will come with opinions, uh, if, especially if, like, in this case, where they came with a 2nd or 3rd opinion, so they've already found out something, and then, you know, Doctor 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 Uh, 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 to, you know, shared decision-making that we're seeing more and more in Now, 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 Doctor 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 gonna be a dilator, but it's the more conservative approach. Um, 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 gonna be the more conservative person the right to be flexible, so you're, you wanna see flexibility in chunks of time throughout your career and be ready to change, and I think that's a huge, um, compliment to Doctor Fisher and Doctor 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 anorectal 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. Doctor Fisher, take it away. Knock knock. Who's there? Who's there. I eat mop. I eat my poo. I eat mop. I don't get it. Oh my, I, I eat my poo. poo. I, 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.