Update Course Rewind: Anal Dilation Following PSARP 2023

Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello, pediatric surgery family. I'm M. Gody, a research fellow from Cincinnati Children's Hospital Medical Center. Our 11th annual update course in pediatric surgery was held last August. In this video series, we'll recap the sessions and share the main highlights with you. Today, our topic is Anal dilation following PSARP. Joining the discussions are Dr. Stephen Lee, Caitlyn Smith, and Julia Grabowski. Let's see our case. We have a three-month old male with a history of rectobladder neck fistula presents two weeks following a laparoscopic assisted anorectoplasty. He has a colostomy and a mucus fistula. What is your next step in management? Well, I used to be an A, a protocol driven Hagar dilation sort of gal. And over time, I realized that it wasn't always necessary. In terms of the quality of life changes, dilations are really a source of stress for families. Parents feel like they're hurting their children and there's a lot of anxiety. So we've sort of moved a little bit away. This is a single institution prospective randomized control trial study from 2021. And the important thing is that these patients, the decision was made at the beginning. So you couldn't change stream partway through, which I think is really important. They were all primary patients, so no redues or cloacas were included. All patients had a diagnosis of anorectal malformation. The length of follow-up was 12 months, and the PSARP was performed at an average of five months old. And a stricture was defined as a Hagar 10 or less, which is what that picture denotes. So there are two arms, 25 patients in each arm. There were three structures in the dilation and eight structures in the non-dilation group. But I think what's important is that overall the number of procedures were relatively the same. So a lot of the patients who had structures in the non-dilated group ended up getting the stricturoplasty at the time of their colostomy closure. So only three of those patients actually got a separate anesthetic. So I think that's some of the concern with the non dilation group is that they're getting extra procedures. One of my hesitations around saying, okay, great, we're not going to dilate and we just move to a place where if they end up with a persistent structure, they get an anoplasty, but how does that impact continence? I think the important thing is to know the type of stricture that this is appropriate for. So it has to really be like a skin level structure and not anything deeper. And if you're talking about a longer structure or anything that's just below or deeper, you really shouldn't be doing a stricturoplasty. I didn't do stricturoplasty for a very long time. And then I was dilating routinely and I realized that there was this other option. It is actually a very, very satisfying operation for a skin level structure. Procedure just takes about 20 minutes and kids can usually go home the same day. And it's just sort of cutting that stricture and making your 10 into a 13 and the babies really tolerate it very well. And then I do not dilate after the stricturoplasty. And Dr. Smith shares with us that she talks to the family about the options when they're talking about doing a PSARP. According to her experience, babies generally tolerate dilations pretty well and they're not as bothered by it. It's not as problematic for the family, but I still talk about all of the options, but anyone over like getting especially close to 12 months, usually over six months, I I don't dial. I don't tend to offer dilation to those families. I agree. And I sometimes think when you're getting older than six, eight months, sometimes those dilations are actually not that successful and maybe you're going to be dealing with the structure anyway. Is your follow-up different? Because we used to have to come back every week. And I don't know about you, but all babies didn't tolerate my dilation. So I mean, or the families happier. The families seem happier. I see them about two to four weeks after the operation and then I size the anaplasty in the office. Here's the time where we can talk about what dilations look like. We can do them or not. But if it looks really good, I will skip it. I will skip the dilation. I agree. Yes. And I don't usually even really discuss dilations if they have a colostomy because I know they're going back to the operating room at some point for a colostomy closure, which is a perfect time for a stricturoplasty. Dr. Grabowski recommends considering seeing patients closely and doing the follow-ups, but not necessarily dilating them, knowing that there's a very easy day surgery as a backup plan. This conversation is really new to me, or the concept is new to me since I grew up in the era of making a small anal opening and then dilating it big. Do you feel like the stricture requiring a stricturoplasty develops because you aren't dilating them or because you are dilating them? And I'm just trying to sort out the cause of the stricture. Well, stricture can develop in either group. So anything under tension, ischemia, all those sorts of reasons. I just think sometimes it's that reaction between like the epidermis and the mucosa. It just sort of like creates this band. We're talking to an international audience. I could interpret that data differently and be like, actually, I'll recommend dilations for places where access would be an issue and just coming back to surgery a second time, most people cannot afford that. Which means it's the more reason why you should encourage dilation in that scenario. I think that's a really good point is that the care definitely, especially for this patient population, highly varies depending on your setting, the resources of the patients you're taking care of. And I agree that should be taken account into the decision making of which sort of arm you're going to fall into. In summary, there's a growing shift in the view on routinely using Hager dilation after surgery, mainly because it can be very stressful for families. Instead, stricturoplasty, an effective treatment for skin level structures, is gaining favor. While babies usually handle dilations well, its effectiveness seems to decrease for children older than six months. For patients with a colostomy, deciding on dilation can often be postponed since they'll be coming back for a colostomy closure, which is an ideal time for a stricturoplasty. Crucially, when deciding between dilation and stricturoplasty, it's essential to take into account local resources and conditions, as regular access to surgical services can determine the best strategy. Thank you for watching this video. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.