Colorectal Quiz Episode 29: Female ARM

Phoenix group starts diet (breast milk or formula) post-op day 0 or 1 after perineal fistula repair, with discharge by post-op day 2-3 if tolerating diet.

Alberto Pena's historical protocol mandated 7 days NPO with central line and hyperalimentation, feeding on day 7 if healed.

Carlos Reck (Vienna) studied stool output in NPO versus clear-liquid groups for 7 days and found the same amount of stool in both groups.

Levitt's current protocol is IV fluids (no PICC line) with clear liquids or breast milk for 5 days, based on conclusion that hard stool passage (not stool volume) causes dehiscence.

Phoenix group performs early repairs before infants are on solid food, with most repairs done by 14 surgeons in younger age group compared to referral centers.

Perineal body dehiscence usually leads to loss of perineal body over several months, requiring redo surgery because the anterior anoplasty has no sphincter around it.

In Levitt's redo cases for perineal body dehiscence, patients were invariably fed right away and discharged home.

Frischer uses midline catheter (not PICC line) with D10 for 5-7 days NPO after primary perineal body repair.

Wood-Levitt randomized controlled trial compared dilation versus non-dilation for primary PSARP (cloacas excluded), with backup plan of dilation under anesthesia plus/minus Heineke-Mikulicz anoplasty for strictures.

In the dilation RCT, stricture rate was 10-20% in both dilation and non-dilation groups.

Many patients' anoplasties look absolutely fine 8 weeks later at colostomy closure if never touched with a dilator, assuming good technique (healthy tissue, no tension, good blood supply).

Family surveys identified dilations as the number one concern for families of patients with anorectal malformations, prompting the dilation RCT.

Dilations can drive couples apart, with one family member typically responsible for performing them, leading to guilt and trauma.

Jack Langer's protocol involves seeing patients weekly in clinic and passing a dilator in office rather than having families dilate at home.

In the dilation RCT, four patients required redo operations for stricture: two in the dilation arm (both chose not to dilate) and two in the non-dilation arm.

Long-term continence outcomes are unknown for patients who developed strictures and underwent revision in the non-dilation group.

Full continence can be restored with redo surgery for stricture, based on available data for longer strictures requiring full redo.

Levitt has yet to meet a family that chose dilation when presented with the option of non-dilation with 10-15% stricture risk and Heineke-Mikulicz backup.

Some families choose dilations after being informed of the study results and unknown long-term outcomes.

In Ghana, surgeons make anoplasties slightly larger knowing patients will not return for follow-up, accounting for expected contraction.

For redo anoplasties, Levitt makes the opening larger knowing there will be contraction; redo patients are not dilated but undergo EUA at one month to check for early stricture.

For primary anoplasties, Levitt makes the lumen match the maximal rectal lumen that fills the sphincter, typically resulting in Hegar size 13-14.