Problematic Anorectal Malformation Cases: Pediatric Colorectal Controversies...

Standard follow-up after ARM repair includes seeing patients at 2 weeks to start dilations, then at 1 month, 3 months, 6 months, and yearly thereafter for local patients

For remote patients in Alaska or Montana, local follow-up is arranged with efforts to bring patients back at 3 and 6 months

Dilatation protocol involves starting at 2 weeks, teaching parents to dilate at home with Hagar dilators up to size 12 or 13 depending on patient size

First-year follow-up occurs every 3 months with strict protocol for constipation management, advising parents not to let child go more than 1.5-2 days without stool

Weekly in-clinic calibration for 6 weeks without parental home dilatation shows no difference in stricture rate, perforation rate, or enterocolitis rate compared to daily parental dilatation

Approximately 10% of patients managed with weekly calibration develop narrowing and require home dilatation

Daily dilatation by parents is a psychological hardship and not necessary most of the time

Patients should be kept around Toronto for at least 3-4 weeks postoperatively for weekly follow-up

Children aged 3-4 years who missed early anoplasty window cannot be dilated by parents at home but do fine with clinic dilatation every 1-2 weeks

European centers are considering a trial protocol starting with 6 weeks of dilatations to potentially reduce current protocols

Retained vestibular fistula after ARM repair is of no consequence if the neoanal opening is adequate, but can be problematic if large and extending behind the perineal body

Surgical repair goal for dehisced perineal body is to position healthy rectum down, healthy vagina up, and create muscular perineal body structure in between

Postoperative management options include colostomy for diversion or keeping patient NPO

Most common problem in cloacal repairs is addressing only the rectum without managing the urogenital sinus

Misidentification of bladder neck as rectum during pull-through can occur if anatomy is not understood preoperatively

Staged hemi-anoplasty for rectal prolapse, with second half done 3 months later as ambulatory procedure, eliminates need for dilatations

Half-circumferential anoplasty heals quickly and does not stricture, unlike full circumferential dissection

Posterior urethral diverticulum represents retained original distal rectum after inadequate distal dissection during pull-through

If uncertain of anatomy during laparoscopic pull-through, the colon should be opened to identify the fistula from inside

Posterior urethral diverticulum with colonic mucosa bathed in urine for 30 years developed into adenocarcinoma in one case