Colorectal Quiz Episode 29: Female ARM-Post Op Management
With Dr. Mark Levitt & Dr. Jason Fisher · hosted by Dr. Amanda Jensen · Colorectal Channel
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Podcast
Colorectal Quiz Episode 29: Female ARM
Marc Levitt · 25 min · Published Mar 2022
Podcast
Colorectal Quiz Episode 29: Female ARM
Marc Levitt · 25 min · Published Mar 2022
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What the experts said
At Children's National, many surgeons start breast milk on post-op day 0 or 1 after primary perineal fistula repair, advance diet as tolerated, and discharge on post-op day 2-3.
Alberto Pena's original protocol mandated 7 days NPO with central line and hyperalimentation after ARM repair, feeding only on day 7 if healed.
A study by Carlos Reck (now in Vienna, Austria) compared NPO for 7 days versus clear liquids for 7 days and found the same amount of stool output in both groups.
The problem is not stool passage itself but hard stool passage that can disrupt the perineal body anastomosis.
Dr. Levitt's current protocol is regular IV (no PICC line), clear liquids or breast milk for 5 days, with very low dehiscence rate. Day 5 provides better healing than day 1-2.
There is no published article showing post-op day 1 regular diet (not breast milk, but actual food or formula) with a very low dehiscence rate.
Phoenix group (14 surgeons) performs most ARM repairs before children are on anything except breast milk or formula, does early repairs with early discharge home on ad lib PO intake, and reports very low dehiscence rate with close post-op follow-up.
Perineal body dehiscence usually leads to no perineal body over several months, requiring redo surgery because the anterior anoplasty has no sphincter around it (it's split).
Nearly every redo case Dr. Levitt sees for perineal body dehiscence involved patients who were fed right away and discharged home.
Dr. Fisher's protocol for perineal body primary repair (no stoma) is 5-7 days NPO on D10 via midline catheter (not PICC line) until the repair is confirmed healed.
A randomized controlled trial by Richard Wood and Dr. Levitt compared dilation versus non-dilation for primary PSARP (cloacas excluded). Families were randomized and knew the backup plan for stricture was dilation ± Heineke-Mikulicz anoplasty.
In the dilation trial, both groups (dilation and non-dilation) had stricture rates somewhere between 10 and 20%.
Many patients' anoplasties look absolutely fine 8 weeks later at colostomy closure if they were never touched with a dilator, provided the anoplasty was healthy with no tension and good blood supply.
The dilation study was prompted by asking families their biggest concern about ARM care, and by far number one was dilations. This was family-driven research, not doctor-driven problem-solving.
The non-dilation protocol offers families a choice: dilate twice daily for 4 months, or accept a 10-15% risk of stricture requiring Heineke-Mikulicz anoplasty, with the child already going under anesthesia in 8 weeks for colostomy closure.
Dilations can drive couples apart. Often one family member does the dilations and over time doesn't want to come to clinic anymore. Parents feel guilty and find it traumatic to hold their child down for dilations.
Jack Langer's protocol is to see patients weekly in clinic and pass a dilator himself rather than having families do it at home.
Full continence can be restored with a redo operation for stricture, and data is available showing this. One indication for redo is stricture.
The vast majority of patients needing intervention for stricture in the non-dilation protocol are already undergoing surgery for colostomy closure, making the intervention relatively minor.
Dr. Levitt has yet to meet a family that has chosen dilation when presented with the non-dilation option and its risks/benefits.
Some families at Phoenix have chosen dilation after being presented with the study data and options, preferring the known approach since long-term continence outcomes of non-dilation are not yet established.
In Ghana, a colleague makes anoplasties slightly bigger knowing patients won't return for follow-up, anticipating some contraction will occur.
For redo ARM cases, Dr. Levitt makes the anoplasty a little bigger knowing there will be contraction. Redos are not dilated at all, but are examined under anesthesia at one month to check for early stricture.
For primary repairs, Dr. Levitt makes the lumen match what the maximal rectal lumen can be. With good mobilization (not overdoing it, throwing away as little rectum as possible), the anoplasty is usually a good size, about Hegar 13 or 14 at the end.
In the dilation trial, 4 patients required redo operations for stricture: 2 in the dilation arm (who didn't actually dilate) and 2 in the non-dilation arm. Additional patients required Heineke-Mikulicz procedures (3 in one group, 47 total procedures mentioned).