Background
Routine post operative anal dilatations have been standard practice in the management of anorectal malformations (ARM) since 1982. Recent studies, however, have questioned their necessity and effectiveness. This systematic review aimed to synthesise the available literature pertaining to the effectiveness of routine post operative dilatations in preventing anal strictures following ARM surgery.
Methods
A systematic search of Cochrane Library, PubMed, Medline, and EMBASE databases was conducted for English-language articles published between January 1990 and December 2023. Studies reporting on children with ARM who underwent reconstructive surgery, followed by anal dilatations, were included. The primary outcome was the development of anal strictures.
Results
Seven studies met the inclusion criteria. Of the 400 patients, 311 (77.7 %) patients received routine post operative dilatations (RPD). Stricture rates ranged widely, with the Peña protocol, considered standard practice, resulting in stricture rates between 0 % and 39 %. Alternative approaches showed similar outcomes: daily non-Hegar dilatations (using digital manipulation or candles) resulted in stricture rates of 0–22 %, while weekly dilatations performed by surgeons showed rates of 15–18 %. In the single randomised controlled trial that included a non-dilatation group, comparable stricture rates were observed between patients who received dilatations (21 %) and those who did not (24 %). The heterogeneity in study designs, populations, and outcome measures limited direct comparisons.
Conclusion
While RPDs have been the standard of care, the available evidence suggests that their universal necessity may be questioned. Alternative approaches appear to achieve comparable outcomes, however the variability in available evidence and lack of large-scale randomised trials both highlight the need for further research to guide evidence-based practice in post operative care for ARM patients.
