Update Course Rewind 2025: Do We Still Need Routine Anal Dilations After PSARP?

Who's speaking

• Speaker 1
• Speaker 2
• Jill Knerath — host
• Speaker 4 — guest
• Speaker 5 — guest
• Speaker 6 — guest

Chapters

• 0:01Introduction and Question Framing — Introduction to the update course series and the central question of whether routine anal dilations after PSARP remain necessary.
• 0:28Evidence Review — Review of data on parental anxiety, PTSD, and comparative outcomes from Spanish and single-institution studies showing similar stricture rates with and without dilations.
• 1:12Heineke-Mikulicz Anoplasty — Description of the Heineke-Mikulicz anoplasty technique as a minimally invasive alternative to long-term dilations for skin-level strictures.
• 1:44Panel Practice Patterns — Panelists describe their individual approaches, with age of patient and access to elective procedures influencing decision-making.

Key claims

• 0:21For decades, every child received anal dilations after PSARP — Jill Knerath
• 0:30Data support parental anxiety associated with anal dilations — Speaker 4
• 0:33PTSD occurs for both patients and caregivers related to anal dilations — Speaker 4
• 0:37Families are worried that they're going to hurt their babies and hurt the repair — Speaker 4
• 0:40Spanish study followed historical dilation protocol starting two weeks after PSARP — Jill Knerath
• 0:45Spanish protocol involved dilations twice daily with Hagar size increased by 1 millimeter each week until optimal size reached — Jill Knerath
• 0:53Single institution review in children under 2 years showed half received dilations and half did not — Speaker 4
• 1:02Two children in each group (dilations vs no dilations) required reoperation for neoanal stricture — Speaker 4
• 1:02Approximately 15% of children required Heineke-Mikulicz anoplasty — Speaker 4
• 1:12Heineke-Mikulicz anoplasty is a procedure for skin-level strictures in PSARP patients — Jill Knerath
• 1:20HMA is performed by making incisions at 12, 3, 6, and 9 o'clock positions creating a rhomboid shape that opens the strictured area — Jill Knerath
• 1:30HMA does not require flaps or mobilization of the rectum — Jill Knerath
• 1:34HMA is safe, effective, and minimally invasive — Jill Knerath
• 1:38HMA can be done outpatient as an alternative to long-term dilations after PSARP — Jill Knerath
• 1:46Neonates typically receive dilations in one surgeon's practice — Speaker 5
• 1:49Older children, redo cases, and ambulatory patients may not receive dilations due to trauma concerns — Speaker 5
• 1:57Neonatal cases usually receive dilations in Canadian practice — Speaker 6
• 2:00Limited access to schedule elective cases in Canada influences preference to dilate all cases up front — Speaker 6
• 2:09There isn't strong evidence to support mandatory anal dilation after PSARP — Jill Knerath
• 2:09Anal dilations can cause stress for families — Jill Knerath
• 2:17Age of patient and access to returning for outpatient procedure are considerations when deciding on dilations — Jill Knerath

Open questions

• What is the optimal patient selection criteria for omitting routine anal dilations after PSARP?
• How can healthcare systems with limited access to elective procedures balance dilation protocols with family stress?