Update Course Rewind: Pediatric Colorectal Consortium 2021
With Dr. Rebecca Rentia & Dr. Caitlin Smith · hosted by Dr. Todd Ponsky & Dr. Ellen Encisco · StayCurrentMD
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Dr. Rentia currently sizes the anus at 2 weeks and 1 month in practice to understand the diameter of the anoplasty so that stooling is not obstructed by an unrecognized strictured anoplasty.
Dr. Rentia would only consider initiating full dilations for slightly older children where dilations are more traumatic and if concerned about needing general anesthesia, given that HM anoplasty is an option.
About 5 to 8% of patients require a strictureplasty at the two-month period.
Dr. Rentia is a fan of doing dilations in the neonatal period for low malformations and having the family discharged as soon as possible to home.
Dr. Smith finds that for neonates and infants up to several months old, dilations are really well tolerated, but avoids them in older age groups.
Formula-fed infants who need caloric concentration have thicker stools, which might push toward earlier repair, while breastfed infants can delay until 2-3 months.
Repair should be done before infants start solids because that makes the dilation strategy at home much more difficult.
Dr. Rentia performs pull-through when the child is toilet trained for urine, typically at age 4, because waiting too long can result in horrible anal sphincter spasm and pelvic disease that makes keeping a pull-through challenging.
Dr. Smith wonders if the PCPLC, being made up of specialty centers, may miss some race and ethnic disparities since patients who can afford to travel to these centers may be captured while those without means are not.
A single institution prospective randomized controlled trial found that anal dilations after PSARP may not be needed.
There is literature suggesting a component of psychosocial, psychological dissociation in children on later testing related to anal dilations.
In the dilation study, length of follow-up was 12 months, PSARP had to be performed in a child under 24 months of age, it was primary surgery, and excluded cloaca as a diagnosis.
The average PSARP was performed at 5 months in the study.
A stricture was defined as a Hagar dilator size of less than 10.
The standard Hagar dilator size for a newborn is about size 12, so a size 10 is 2 deviations less.
In the dilation study with 25 children, the types of malformations were evenly distributed and complexity was about equal.
Strictures were non-significant between both groups (dilation vs no dilation), and a Heineke-Mikulicz anoplasty (longitudinal incision closed transversely to widen diameter) was able to be performed for stricture management.
The number of strictures, number needing anoplasties, and number of redo operations were the same between dilation and no-dilation groups.
The number of patients who had rectal prolapse is consistent with the literature.
A study of 30-day outcomes for ARM with perineal or rectovaginal fistulas divided patients into early repair (before 6 days old) and late repair (6-8 weeks), with 66 early and 231 late repairs among 291 patients.
30-day complications are not statistically different between early and late repair groups for perineal and rectovaginal fistulas.
A second study defined early repair as 14 days or younger and late as after 14 days, with 31 early and 133 late repairs among 164 patients, also showing no difference in 30-day complications.
Long segment Hirschsprung disease is defined as any disease proximal to the rectosigmoid colon for the majority of reviewed articles.
A contrast study itself is very inaccurate for Hirschsprung disease, and colonic mapping needs to be performed to determine the level of the transition zone.
There was no superior or more common operation for long segment Hirschsprung, although Duhamel and Swenson-Soave were the top operations.
There are no new novel surgical techniques for Hirschsprung disease over the past several years, though there is potential for stem cell therapy which is still in its infancy.
A hypermotility and skin rash protocol for total colonic Hirschsprung disease outlines why an early operation (around 5 months old) is possible.
If a child with an ileostomy is adequately prepared and the family can learn to thicken stool, they can have a pull-through that does not result in complete perineal skin breakdown and learn techniques helpful for this difficult-to-toilet-train group.
A PCPLC study on bowel management strategies in children with anorectal malformations looked at 624 patients in the 5-12 year old age group.
Even mild and moderate anorectal malformation patients in the 5-12 year old group need to rely on enemas and other bowel management strategies to stay clean when heading into school age.
The majority of ARM patients had constipation as their primary complaint, and only 40% were toilet trained.
A study on timing of pull-through for Hirschsprung disease required all infants to be diagnosed under 1 month of age, with primary pull-throughs performed either less than or greater than 31 days.
Preoperative enterocolitis was the same between both timing groups (before and after 31 days), postoperative enterocolitis was the same, and transition zone was the marker if a child needed treatment for constipation.
A PCPLC consortium study of 525 ARM patients found that public insurance was associated with decreased rates of urinary incontinence.
Urethral length of about 2.5 centimeters has been measured in VCUGs of normal females, and about 1.5 centimeters is needed for cloacal reconstruction.
If a urethra that is too short is pulled past the bladder neck, there is a risk for incontinence.
A short vagina, even in an otherwise shorter common channel operation, may require a vaginal replacement.
Rotational fluoroscopy and 3D reconstructions are key to being able to make reliable measurements for cloacal anatomy.