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Update Course Rewind 2025: Timing of PSARP: Early vs. Delayed—Does It Really Matter?

Video Published 2026-04-20 Updated 2026-06-25

Timestops (3)

Rectal Vestibular Fistula Management Approaches

PSARP Timing and Safety Outcomes

Complications and Clinical Recommendations

Topic Overview

A panel discussion on optimal timing for posterior sagittal anorectoplasty (PSARP) in newborns with rectal vestibular fistula. Two 2021 studies—one from NSQIP and one from PCQLC—found no significant difference in outcomes between early repair (within 7-14 days) and delayed repair (1-8 months). The panel acknowledges both approaches are safe, with timing decisions driven by patient size, family access to care, and surgeon experience. Wound breakdown is the most common complication regardless of timing.

Key Takeaways

Early (≤14d) vs delayed (1-8mo) PSARP shows no difference in complications or reoperations for rectal vestibular fistula. (2:07)
Wound breakdown is the most common complication regardless of PSARP timing. (2:26)
PSARP timing should be individualized based on patient size, family access to care, and surgeon experience. (3:14)
Limit preoperative dilation to 7 Hegar to minimize fistula tract scarring before definitive repair. (1:06)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — host
Jill Knepprath — host
Jamie Harris — guest
Speaker 4 — guest
Speaker 5 — guest
Speaker 6 — guest

Chapters

0:01Case Presentation — Introduction of a full-term newborn with rectal vestibular fistula, 3 kg, negative VACTERL workup.
0:47Initial Management Poll and Dilation Technique — Audience poll favors delayed PSARP with dilations. Panel discusses limiting dilation to 7 Hegar to minimize scarring.
1:26Timing Debate — Panel members express differing preferences: some favor early neonatal repair, others prefer waiting 1-3 months.
1:56Evidence Review — Two 2021 studies (NSQIP and PCQLC) showed no outcome differences between early and delayed repair, with wound breakdown the most common complication in both groups.
2:52Practical Considerations and Summary — Discussion of drawbacks to delayed repair (fistula fibrosis, rectal distension, additional admission) and social determinants of health. Conclusion that both approaches are safe.

Key claims

0:37Full-term newborn baby girl with rectal vestibular fistula weighs 3 kg with completely negative VACTERL workup — Jamie Harris
0:59Dilations alone is probably not the correct management for rectal vestibular fistula — Jamie Harris
1:06Recommend only dilating to a 7 Hagar to decrease the potential scarring along the track for future PARPs — Jamie Harris
1:12If keeping the fistula open, only need to keep it open enough for soft mustardy poop to pass through — Speaker 4
1:31One surgeon prefers doing PSARP at one month of age so the baby could grow a little bit bigger — Speaker 5
1:36One surgeon likes getting babies a little bit older and letting them go home before PSARP — Speaker 6
1:45One surgeon likes to get PSARP done on the neonatal admission, not necessarily the next day — Speaker 4
1:49It's safe to perform the PSARP either early before discharge or later around 1 to 3 months of age — Jill Knepprath
1:56Two important studies on PSARP timing both came out in 2021 — Jamie Harris
2:00NSQIP study defined early repair as 7 days and delayed repair as between 6 weeks and 8 months — Jill Knepprath
2:07NSQIP study found no difference in overall outcomes including re-operations and readmissions between early and delayed PSARP — Jill Knepprath
2:12Second 2021 study looked at 30-day outcomes comparing neonatal versus delayed anoplasty through PCQLC multi-institutional retrospective study — Jamie Harris
2:22PCQLC study defined early repair as 14 days versus late after 14 days — Jamie Harris
2:26Wound breakdown and dehiscence was the most common complication for both early and delayed repair groups — Jill Knepprath
2:33No significant difference in postoperative complications between early and delayed PSARP groups — Jill Knepprath
2:40There is discrepancy in the literature regarding timing of delayed repair, ranging from a couple of months to multiple months of age — Jamie Harris
2:55Theoretical fibrosis of the fistula tract can make dissection more difficult during PSARP — Jamie Harris
3:00If not completely decompressing the fistula, the rectum can get distended and make PSARP technically more difficult — Jamie Harris
3:07Early repair during newborn period avoids an additional admission for the surgery — Jill Knepprath
3:14Social determinants of health affect families' ability to make multiple trips for care; long distance travel can be expensive — Jamie Harris
3:23Both early and delayed PSARP repairs are safe for patients with rectal vestibular fistulas — Jill Knepprath
3:29What matters most for timing is the circumstances, family access to care, patient size, and surgeon comfort and experience — Jill Knepprath

Cases discussed

0:37Full-term newborn girl with rectal vestibular fistula

Points of disagreement

1:31Optimal timing for PSARP
- Speaker 5: Prefers one month of age to allow baby to grow bigger
- Speaker 6: Prefers getting babies older and letting them go home first
- Speaker 4: Prefers getting it done during neonatal admission

Open questions

What is the optimal definition of 'delayed' repair timing given the wide range (6 weeks to 8 months) in the literature?
How much does fistula tract fibrosis actually impact technical difficulty of PSARP in practice?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Keywords

rectal vestibular fistula wound breakdown dehiscence fibrosis rectal distension PSARP posterior sagittal anorectoplasty anal rectoplasty anoplasty dilation VACTERL workup Cincinnati Children's Hospital Global Cat MD Stay Current MD NSQIP

Hashtags

#PediatricSurgery #AnorectalMalformation #PSARP #NeonatalSurgery

Transcript

Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. I'm Jill Knepprath with Stay Current MD. In this video series, we will be recapping some of the key highlights from our 13th annual update course in pediatric surgery. This is on timing of PSARP, early versus delayed. Does it really matter? for patients with rectal vestibular fistulas, some surgeons still insist on performing anal rectoplasties right away. Others say, wait till after discharge. So what's right? The data may surprise you. In this session. Doctor Jamie Harris presents a full-term newborn baby girl with rectal vestibular fistula. She weighs 3 kg, and they've done the workup in the NICU and her Vactral workup is completely negative. Let's see what the audience thinks the next step should be. So on the poll, it looks like dilations and then delayed PARP is leading by a substantial margin. Doing dilations alone is probably not the correct management of this for a number of different reasons, but certainly dilations initially will allow for decompression. I would recommend only dilating to a 7 Hagar to decrease the potential scarring along the track for future Parps. Jamie, you brought up a really important point about that if you're gonna just try to keep it open, you just have to keep it open enough for little soft, mustardy poop to be able to make it through there. There's no reason. To drive that dilation up big. This leads us to the next question. What is the ideal timing to do the PSAP? I would rather do it at one month of age so the baby could grow a little bit bigger. I think Nelson and I disagree a little bit on this. He likes doing them up front, but I like getting them a little bit older, let the babies go home. It doesn't have to be the next day, but I like to get it done on the neonatal admission. The panel agreed that it's safe to perform the PSARP either early before discharge or later around 1 to 3 months of age. There were two important studies that both came out in 2021. The first is a Nisquip study that defined early repair as 7 days. Delayed repair was between 6 weeks and 8 months. They found no difference in overall outcomes, including. Re-operations and readmissions. There was another study in 2021. This one looked at 30-day outcomes and it was neonatal versus delayed anoplasty and a multi-institutional retrospective study through the PCPLC. Their early repair was defined as 14 days versus a late after 14 days. Wound breakdown and dehiscence was the most common complication for both early and delayed repair groups. However, there was no significant difference in postoperative complications between the groups. So they concluded the same thing. This slide shows the discrepancy in terms of delayed repair from A couple of months to multiple months of age, so there's no right timing of delayed repair in the literature. What are the drawbacks to delayed repair in practice? One, that theoretical fibrosis of the fistula tract, making your dissection a little bit more difficult on the PSARP. The other is if you're not completely decompressing it, the rectum can get distended and make it technically more difficult to perform that PSARP. An early repair during the newborn period also Avoids an additional admission for the surgery. With some of the social determinants of health that have been looked at recently, it's not always easy for families to make that trip multiple times. It's a long distance and can also be expensive. Let's summarize. Both early and delayed PSR repairs are safe for patients with rectal vestibular fistulas. What matters most is the circumstances, family access to care, patient size, and importantly, your comfort and experience as a surgeon. Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.

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