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Problematic Anorectal Malformation Cases: Pediatric Colorectal Controversies...

Video Published 2019-01-11 Updated 2026-06-10

Timestops (6)

Standard follow-up and dilatation protocols

Panelists describe their postoperative follow-up schedules and dilatation practices for ARM repair, ranging from 2-week …

Debate on parental dilatation necessity

One panelist presents a minority opinion that weekly in-clinic calibration without daily parental dilatation yields equi…

European perspective and trial considerations

European representative discusses ongoing debate about reducing postoperative dilatation protocols, with consideration o…

Complications: retained fistulas and mislocation

Case presentations of retained vestibular fistulas, posterior mislocation of the neoanal opening, and missed urogenital …

Rectal prolapse management

Discussion of staged hemi-anoplasty approach for rectal prolapse, performed as ambulatory procedures 3 months apart to a…

Posterior urethral diverticulum complications

Presentation of posterior urethral diverticulum as a complication of laparoscopic pull-through for bulbar fistula, inclu…

Topic Overview

A panel discussion on postoperative management and complications following anorectal malformation (ARM) repair in females. The discussants debate dilatation protocols, with one panelist advocating weekly in-clinic calibration rather than daily parental dilatation at home, citing comparable stricture rates and reduced psychological burden. Common complications presented include retained vestibular fistulas, posterior mislocation of the neoanal opening, rectal prolapse managed with staged hemi-anoplasty, and posterior urethral diverticula after laparoscopic pull-through for bulbar fistulas—one case progressing to adenocarcinoma after 30 years.

Key Takeaways

Weekly in-clinic calibration for 6 weeks shows no difference in stricture/perforation rates vs daily home dilatation, sparing families burden. (2:16)
Retained vestibular fistula post-ARM repair is benign if neoanal opening adequate, but problematic if large and extends behind perineal body. (6:41)
Staged hemi-anoplasty for rectal prolapse eliminates need for dilatations; half-circumferential repair heals without stricture. (10:36)
Posterior urethral diverticulum after laparoscopic pull-through represents retained distal rectum from inadequate dissection. (12:00)
Colonic mucosa in posterior urethral diverticulum bathed in urine for 30 years progressed to adenocarcinoma in one reported case. (12:50)

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
Jeff — guest
Speaker 3 — guest
Speaker 4 — guest
Ivo — guest

Chapters

0:00Standard follow-up and dilatation protocols — Panelists describe their postoperative follow-up schedules and dilatation practices for ARM repair, ranging from 2-week to 6-month intervals, with geographic challenges noted for remote patients.
3:18Debate on parental dilatation necessity — One panelist presents a minority opinion that weekly in-clinic calibration without daily parental dilatation yields equivalent outcomes with less psychological burden, citing a comparative study.
4:44European perspective and trial considerations — European representative discusses ongoing debate about reducing postoperative dilatation protocols, with consideration of a trial starting at 6 weeks.
6:21Complications: retained fistulas and mislocation — Case presentations of retained vestibular fistulas, posterior mislocation of the neoanal opening, and missed urogenital sinus in cloacal repairs.
9:23Rectal prolapse management — Discussion of staged hemi-anoplasty approach for rectal prolapse, performed as ambulatory procedures 3 months apart to avoid stricture and dilatation requirements.
11:29Posterior urethral diverticulum complications — Presentation of posterior urethral diverticulum as a complication of laparoscopic pull-through for bulbar fistula, including one case of adenocarcinoma development after 30 years.

Key claims

0:23Standard 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 — Speaker 1
0:46For remote patients in Alaska or Montana, local follow-up is arranged with efforts to bring patients back at 3 and 6 months — Speaker 1
1:06Dilatation 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 — Jeff
1:35First-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 — Jeff
2:16Weekly 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 — Speaker 3
3:01Approximately 10% of patients managed with weekly calibration develop narrowing and require home dilatation — Speaker 3
3:10Daily dilatation by parents is a psychological hardship and not necessary most of the time — Speaker 3
3:38Patients should be kept around Toronto for at least 3-4 weeks postoperatively for weekly follow-up — Speaker 3
3:56Children 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 — Speaker 3
5:18European centers are considering a trial protocol starting with 6 weeks of dilatations to potentially reduce current protocols — Ivo
6:41Retained 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 — Speaker 4
7:27Surgical repair goal for dehisced perineal body is to position healthy rectum down, healthy vagina up, and create muscular perineal body structure in between — Speaker 4
7:49Postoperative management options include colostomy for diversion or keeping patient NPO — Speaker 4
8:53Most common problem in cloacal repairs is addressing only the rectum without managing the urogenital sinus — Speaker 4
9:33Misidentification of bladder neck as rectum during pull-through can occur if anatomy is not understood preoperatively — Speaker 4
10:36Staged hemi-anoplasty for rectal prolapse, with second half done 3 months later as ambulatory procedure, eliminates need for dilatations — Speaker 4
11:09Half-circumferential anoplasty heals quickly and does not stricture, unlike full circumferential dissection — Speaker 4
12:00Posterior urethral diverticulum represents retained original distal rectum after inadequate distal dissection during pull-through — Speaker 4
12:25If uncertain of anatomy during laparoscopic pull-through, the colon should be opened to identify the fistula from inside — Jeff
12:50Posterior urethral diverticulum with colonic mucosa bathed in urine for 30 years developed into adenocarcinoma in one case — Speaker 4

Cases discussed

6:24Patient with previous ARM pull-through with retained vestibular fistula
7:04Adult with dehisced perineal body after episiotomy resembling mislocated anus
8:18Patient with posterior mislocation of neoanal opening
8:53Cloaca patient with only rectal component addressed
9:30Misidentified anatomy during pull-through resulting in bladder neck pull-through
11:45Posterior urethral diverticulum after laparoscopic pull-through for bulbar fistula
12:4430-year-old with adenocarcinoma arising from posterior urethral diverticulum

Points of disagreement

2:06Necessity of daily parental dilatation after ARM repair
- Jeff: Teaches parents to dilate at home with Hagar dilators, following strict protocol with frequent follow-up
- Speaker 3: Performs weekly in-clinic calibration for 6 weeks without parental home dilatation, citing equivalent outcomes and reduced psychological burden

Open questions

What is the optimal dilatation protocol after ARM repair—daily parental dilatation versus weekly in-clinic calibration?
Should a randomized trial be conducted comparing daily parental dilatation to weekly in-clinic calibration?
What is the minimum duration of postoperative dilatation that maintains acceptable stricture rates?
What is the true incidence and long-term malignancy risk of retained posterior urethral diverticula after ARM repair?

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.

Written for:

Postoperative Management and Complications in Anorectal Malformation Repair

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why This Subspecialty Exists

Anorectal malformations (ARMs) represent a spectrum of congenital defects where the rectum fails to develop normally, often connecting to the urinary or genital tract through a fistula. Surgical correction — typically a posterior sagittal anorectoplasty (PSARP) or laparoscopic pull-through — creates a neoanal opening and positions the rectum within the sphincter complex. The technical repair is only the beginning. These children require years of structured follow-up to manage strictures, constipation, and functional outcomes. The subspecialty exists because getting the anatomy right at surgery means little if the postoperative care fails.

The Core Clinical Problem

The neoanal opening heals by secondary intention and will stricture without mechanical dilation. Simultaneously, these patients face constipation from dysmotility and must avoid fecal impaction, which can destroy a well-positioned repair. The challenge is balancing stricture prevention against the psychological burden of daily parental anal dilation in an infant. Geographic barriers compound this — families living hundreds of miles from the surgical center cannot return weekly, yet inadequate follow-up leads to preventable complications.

How Postoperative Management Works

Standard protocols involve seeing patients at 2 weeks to initiate dilation, then at 1, 3, and 6 months, with yearly follow-up thereafter for local patients 0:23. For remote families — one center covers 25% of U.S. land mass including Alaska and Montana — local providers handle interim care, with efforts to bring patients back at 3 and 6 months 0:46.

The traditional dilation approach starts at 2 weeks, teaching parents to use Hagar dilators at home, advancing to size 12 or 13 depending on patient size 1:06. First-year visits occur every 3 months with strict constipation protocols, advising parents not to let the child go more than 1.5–2 days without stool 1:35.

One discussant presents a minority approach: weekly in-clinic calibration for 6 weeks without parental home dilation. In a comparative study, this showed no difference in stricture rate, perforation rate, or enterocolitis rate compared to daily parental dilation 2:44. Approximately 10% of patients managed this way develop narrowing and require home dilation 3:01. The rationale is straightforward: "Daily dilatation by the parents is a psychological hardship for them, and I don't think it's necessary most of the time" [q4]. This approach requires families to remain near the surgical center for 3–4 weeks postoperatively 3:38. Interestingly, older children (ages 3–4) who missed early repair cannot be dilated by parents at home but do well with clinic dilation every 1–2 weeks 3:56. European centers are considering trial protocols starting with 6 weeks of dilations to potentially reduce current regimens 5:18.

Where Practice Remains Contested

The dilation debate is unresolved. One discussant states he would not have equipoise to randomize patients to daily dilation [q6], while others maintain traditional protocols. The evidence base is thin — one comparative study from a single center, not a randomized trial. Geographic realities force pragmatic compromises that may or may not affect outcomes.

Recognizing and Managing Complications

Retained vestibular fistulas occur when the original fistula is not excised during repair. If the neoanal opening is adequate, this is often inconsequential, but large fistulas extending behind the perineal body leave no structural support and require removal, particularly during revision procedures 6:41. The surgical goal in revision is positioning healthy rectum down, healthy vagina up, and creating a muscular perineal body structure between them 7:27. Postoperative management options include colostomy for diversion or keeping the patient NPO 7:49.

In cloacal repairs, the most common error is addressing only the rectum without managing the urogenital sinus 8:53. Misidentification of anatomy can lead to pulling through the bladder neck instead of the rectum if preoperative imaging is not carefully reviewed 9:33.

Rectal prolapse, a frequent complication, can be managed with staged hemi-anoplasty: half the circumference initially, the other half 3 months later as an ambulatory procedure 10:36. Half-circumferential repairs heal quickly and do not stricture, unlike full circumferential dissection 11:09. This eliminates dilation requirements.

Posterior urethral diverticulum represents retained distal rectum after inadequate distal dissection during laparoscopic pull-through for bulbar fistulas 12:00. When uncertain of anatomy during laparoscopic approach, the colon should be opened to identify the fistula from inside 12:25. This complication carries long-term risk: one case of colonic mucosa bathed in urine for 30 years developed into adenocarcinoma 12:50.

When to Involve This Team

Refer any child with ARM for initial surgical planning. For established patients, refer back if stricture develops despite dilation, if rectal prolapse occurs, if there is concern for retained fistula or mislocated anus, or if functional outcomes (continence, constipation management) are suboptimal. These are not problems for general pediatric surgery — they require surgeons who manage these patients in volume and understand the long-term functional trajectory.

Takeaways from this story

Weekly in-clinic calibration may achieve equivalent outcomes to daily parental dilation while reducing family psychological burden.
Staged hemi-anoplasty for rectal prolapse eliminates stricture risk and dilation requirements compared to full circumferential repair.
Inadequate distal dissection during laparoscopic pull-through leaves retained rectum that can develop into adenocarcinoma decades later.
In cloacal repairs, the most common error is addressing only the rectum without managing the urogenital sinus.

Managing Suboptimal Outcomes After Anorectal Malformation Repair

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

The Dilatation Question

Weekly calibration may replace daily parental dilatation. One discussant challenges the standard practice of teaching parents to dilate their child's neo-anus daily at home, presenting data showing that weekly in-clinic calibration by the surgeon for six weeks produces equivalent outcomes—no difference in stricture rate, perforation rate, or enterocolitis rate compared to daily parental dilatation 2:16. Approximately 10% of patients managed this way develop narrowing and require home dilatation 3:01, but the remaining patients are spared what the discussant describes as "a psychological hardship" for families 3:10. The approach requires keeping patients near the surgical center for three to four weeks postoperatively 3:38, which may not be feasible for all families but represents a meaningful alternative when possible. Supporting this approach, children aged 3-4 years who missed the early anoplasty window cannot be dilated by parents at home but do well with clinic dilatation every one to two weeks 3:56.

Recognizing What Was Left Behind

The original vestibular fistula may persist after pull-through. When a retained vestibular fistula is small and the neo-anal opening is adequate, it is of no consequence 6:41. The problem arises when the fistula is large and extends behind the perineal body, leaving the perineal body without substance 6:41. These require removal, particularly during revision procedures. The surgical goal when repairing a dehisced perineal body—whether from ARM complications or obstetric injury—is to position healthy rectum down, healthy vagina up, and create a muscular perineal body structure between them 7:27.

Inadequate distal dissection creates a posterior urethral diverticulum. During laparoscopic pull-through for bulbar fistula, failing to dissect distally enough leaves the original distal rectum behind, forming a posterior urethral diverticulum 12:00. The prevention strategy is straightforward: if uncertain of anatomy during the procedure, open the colon and identify the fistula from inside 12:25. This complication is "happening a lot more" as one discussant notes, and carries long-term risk—one case of colonic mucosa bathed in urine for 30 years developed into adenocarcinoma in a 30-year-old patient 12:50.

When Anatomy Was Misidentified

The bladder neck can be mistaken for rectum during cloaca repair. The most common problem in cloacal repairs is addressing only the rectum without managing the urogenital sinus 8:53. A more catastrophic error occurs when the surgeon identifies "a beautiful, nice midline whitish structure" and pulls through the bladder neck instead of rectum 9:33. This error stems from not understanding the anatomy preoperatively—a reminder that cloaca repair is substantially more complex than Hirschsprung pull-through and requires honest assessment of one's skill set before proceeding laparoscopically.

The Staged Approach to Rectal Prolapse

Half-circumferential anoplasty eliminates stricture risk. For rectal prolapse after ARM repair, performing a staged hemi-anoplasty—half initially, the other half three months later as an ambulatory procedure—eliminates the need for dilatations 10:36. The key insight: half-circumferential anoplasty heals quickly and does not stricture, unlike full circumferential dissection which requires vigilant monitoring for stenosis 11:09. When families are offered this option versus a full circumferential repair with hospital stay and dilatation protocol, they consistently prefer the staged approach.

The thread connecting these teaching points is recognition—recognizing when standard protocols can be safely modified, recognizing what was left behind or misidentified at the initial operation, and recognizing which technical modifications prevent complications rather than simply managing them afterward.

Takeaways from this story

Weekly surgeon calibration for 6 weeks produces equivalent outcomes to daily parental dilatation, with approximately 10% requiring home dilatation
Retained vestibular fistula extending behind perineal body requires removal; small fistulas with adequate neo-anus are inconsequential
Posterior urethral diverticulum from inadequate distal dissection carries malignancy risk—one case developed adenocarcinoma after 30 years
Staged hemi-anoplasty for prolapse eliminates stricture risk and dilatation requirements; half-circumferential repairs heal without stenosis
When uncertain of anatomy during laparoscopic pull-through, open the colon to identify the fistula from inside rather than risk misidentification

Weekly Calibration Versus Daily Parental Dilatation After Anorectal Malformation Repair

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The Question

Should parents dilate their child's neoanal opening daily at home following anorectal malformation repair, or is weekly in-clinic calibration by the surgeon sufficient?

The Case for Daily Parental Dilatation

One approach teaches parents to dilate at home with Hagar dilators, starting at two weeks postoperatively 1:06. The protocol advances to size 12 or 13 depending on patient size, with the surgeon examining the child approximately two months after dilatations begin to confirm the anastomosis remains supple 1:06. First-year follow-up occurs every three months, with strict attention to constipation management — parents are instructed not to let the child go more than 1.5 to 2 days without a bowel movement 1:35. This approach assumes that consistent mechanical dilatation prevents stricture formation and that parental involvement ensures daily adherence to the protocol.

The Case for Weekly In-Clinic Calibration

The alternative position holds that "daily dilatation by the parents is a psychological hardship for them, and I don't think it's necessary most of the time" [q4]. This approach involves weekly in-clinic calibration for six weeks without any parental home dilatation 2:16. The surgeon calibrates the anastomosis in clinic, and parents are spared the daily intervention. When outcomes were compared between this approach and daily parental dilatation, there was no difference in stricture rate, perforation rate, or enterocolitis rate 2:16. A minority of patients managed with weekly calibration develop narrowing and require home dilatation, but most avoid it entirely 3:01.

This position gains additional support from clinical observation: children aged 3-4 years who missed the early anoplasty window cannot be dilated by parents at home, yet "they do fine" with clinic dilatation every 1-2 weeks 3:56[q5]. If older children tolerate less frequent dilatation without adverse outcomes, the argument follows that younger children may not require daily intervention either.

The psychological dimension carries weight here. One discussant stated explicitly: "I would not be willing to randomize my children to daily dilatation" [q6], reflecting the view that asking parents to perform daily dilatation on their infant constitutes an avoidable burden when evidence suggests weekly calibration produces equivalent results.

Where They Agree

Both approaches share fundamental principles. Both involve close postoperative surveillance with regular assessment of the anastomosis. Both recognize that some patients will develop narrowing requiring intervention — the disagreement is about whether prophylactic daily dilatation prevents this or simply subjects most families to an unnecessary burden. Both emphasize constipation management as critical to outcomes. Both acknowledge that geographic distance and family circumstances sometimes force modifications to the ideal protocol 0:46 3:38. Neither position disputes that when stricture develops, dilatation becomes necessary.

What Would Resolve It

One discussant proposed a randomized trial, though immediately acknowledged lacking equipoise: "I would not be willing to randomize my children to daily dilatation" [q6]. The existing comparative data come from a single-center retrospective review comparing one surgeon's weekly calibration approach against colleagues using daily parental dilatation 2:16. A multi-center randomized trial with adequate power to detect differences in stricture rate, perforation, enterocolitis, and family-reported psychological burden would provide definitive evidence.

European centers are considering a trial protocol starting with six weeks of dilatations to potentially reduce current protocols 5:18, suggesting the question has international relevance and that movement toward less intensive protocols is under active consideration.

The evidence required is straightforward: stricture rates, complication rates, and validated measures of family psychological burden across randomized groups. Until such evidence exists, the disagreement persists — one side viewing daily dilatation as necessary prophylaxis, the other viewing it as an unproven intervention that imposes measurable harm on families for uncertain benefit.

Takeaways from this story

Weekly in-clinic calibration for 6 weeks shows no difference in stricture, perforation, or enterocolitis rates vs daily parental dilatation
A minority of patients managed with weekly calibration develop narrowing requiring home dilatation
Children aged 3-4 who cannot be dilated at home do fine with clinic dilatation every 1-2 weeks
European centers are considering trial protocols starting with 6 weeks of dilatations to reduce current protocols

Keywords

anorectal malformation vestibular fistula rectal prolapse constipation stricture enterocolitis posterior urethral diverticulum adenocarcinoma cloaca bulbar fistula urethral stricture ARM repair dilatation calibration anoplasty

Hashtags

#ARMRepair #PediatricSurgery #Hirschsprungs #SurgicalProtocol #PostOpCare #FistulaManagement #ColorectalSurgery #DilationTechnique #ConstipationAwareness #AnastomosisCare #ProlapseManagement #SurgicalOutcomes #PatientFollowUp #SurgicalComplications #PediatricHealth #ColorectalHealth #SurgicalEducation #ClinicalGuidelines #PatientCare #SurgicalInnovation #AnorectalMalformation

Transcript

Analysts what their standard protocol is for follow up. Dilations, um, and examination after an ARM repair in a female, which is, which is where these slides are gonna take us. So Jeff, would you mind getting started on that? What is, how do you follow these kids routinely? Discharged from the hospital? So they get discharged. I'll see them back usually at 2 weeks' time, uh, to start dilations, and then, you know, we, we cover, you know, our hospitals, uh, located in an area that covers 25% of the US land mass. So some of our patients live in Alaska and Montana, so follow up becomes very challenging. If I can, I'll see them back. If they live locally, I'll see them back in 1 month, then 3 months, and then 6 months, and then usually like in a year. And then follow them at least yearly thereafter, um, if they live like in Montana or Alaska, we'll make sure that there's a local follow up, um, just to keep an eye on the perineum, but I'll make an effort to have them come back in at least 3 months and, and 6 months if possible. I see them back at 2 weeks, start the dilatation process. I dilate them a week later and teach the parents how to dilate them and then send them home with the Hagar dilators, dilate them up to 12 or 13 depending on the size of the patient. Um, then I examine them and if it's supple, which it usually is by then, then, uh, I see them back about 2 months later to make sure it's not, uh, stricturing. And after that I follow them the first year every 3 months. Um, we have a pretty strict protocol in terms of some of these patients have a tendency toward constipation. I warn the parents about that. Tell them not to let the child go more than a day and a half or 2 days without a stool, and um. Most parents are pretty religious about it. If I suspect that the patient's not going to follow through, then I see the patient more frequently. So I take a minority opinion on this one. I, I don't, um, I don't think that daily dilatation by the parents is necessary most of the time, so I see them. Between 1 week and 2 weeks after, and this is true for all of the ARMs and my Hirschmann's patients, I calibrate, uh, the anastomosis, and if it's open, then I see them on a weekly basis, usually for about 6 weeks, and I do the calibration in the clinic. I don't have the parents dilating at home, um, when we, uh, when we looked at our experience because I'm on, I'm the only one in our group who does that, so we had a control group that had parental dilatations and. When we compared the outcomes, there was no difference in stricture rate, perforation rate, uh, or or enterocolitis rate in the Hirschmann's patients, um, but the parents, uh, most of them did not have to dilate their children, which is psychologically a very difficult thing for them to do. Uh, about 10% of them ended up narrowing down during this process, and those ones I taught them how to dilate, and they dilated at home. But I, I continue to believe that this daily dilatation by the parents is a psychological hardship for them, and I don't think it's necessary most of the time. So can I ask you a question? What you do about your kids who are coming from far away, or, I mean, and obviously Canada as well, but there's a lot of, you know, a lot of people have trouble getting to hospital appointments and time off work and all those lost opportunities. I mean, uh, well, so I, I do make, uh, allowances for that, so. You know, we, I do like to keep them around Toronto for at least 3 or 4 weeks afterwards. I mean, that's, I, I ask them to make that commitment to their child, um, the ones that absolutely can't, then I teach those parents how to do it and I, I try and find somebody in their community who can, uh, keep an eye on them. I, I gotta, uh, I, I do dilate, but I gotta say sometimes you have a 3 or 4 year old that missed a window of, of getting their annoplasty early, and you can't dilate those children. The parents certainly can't at home, and I don't see a difference in how they do. And you know, you will every week or two they'll come to clinic and I'll do a dilatation, but um, they do fine. It's interesting. That's a topic worth studying randomized. I'd be very cool. You know, I, I wouldn't, I wouldn't have, uh, equipoise on that. Uh, I would not be willing to randomize my children to daily dilatation. Some might feel the opposite way. Ivo, so sorry, uh, what about the European representative on the panel? Sorry, the program is a little bit delayed. We have, we have the discussion on the calibration of dinotations in Europe as well, particularly with the, the, the parent organizations about the post-op dilatations we were talking about. Of what structure? The anastomosis after anus anus, OK, because we had just been talking about vaginal, no, not, not the anus. They particularly want to reduce it, so we're thinking of making a kind of a first step protocol to try some kind of trial to start off with at least 6 weeks of dilatations, see what the effect is, and then maybe reduce it, but most of us are still a bit scared because in a way we don't want to. Um, yeah, we don't want to rule out, uh, uh, the things we do right at this moment which are kind of successful, but Like you say, I've, I've read your manuscript as well, and it seems to be OK. Not mine. So I, we have a whole very lovely session on uh problems post ARM pull-through that I was excited about, and I'm sorry we delayed the program. There was a case going on, I guess, but, um, but uh there's gonna be a bus at 5. I may invade that a little bit, be about 5, 10 minutes if that's OK. Just so we can show a couple of these pictures. Is that, would that be all right? Maybe 5, 10 minutes of this. Um, we talked a little bit about this problematic female. This is a patient who had a previous pull-through, and what do you see is the problem? What did the original surgeon not do? Does everyone see what is looking, what is this? Yeah, so that's the original vestibular fistula that was never removed. Now, the reality is if this anus is OK, this is really of no consequence, but sometimes this is quite large and actually it goes behind the perineal body and then the perineal body has no substance to it at all. So I have removed these, particularly when the anus needs to be redone. And this is a, um, this is an interesting colorectal problem, not related to ARM. This is an adult who had a, a episiotomy that didn't heal. But it looks exactly like a mislocated anus situation after a dehisted perineal body after a PSAP. Looks the same. Essentially, there's no perineal body in the. The goal for the surgical repair is to get healthy rectum down, healthy vagina up, and make a muscular structure of the perineal body in between. You live in Austin. You see all, all sorts of things with, with this. Yes. Well, I think you can choose. You can either do a colostomy to divert or keep the patient NPO. Those are always your choices. Um, uh, uh, on, on, uh, D10, 7 days, etc. like we talked about before. Here is, here is the vestibular fistula that is actually still connected to the perineum. So, obviously, this needs a redo with a full remobilization of the rectum. Um, this is a video, but actually, I don't need to show you the video. Can everyone see where this anus ought to be? Oh, look, oh, the video's working. See that? Anuses should have been there, right? It's too a little bit too posterior. So in this patient who has good potential for bowel control, good sacrum, good spine, I'm going to offer this child a redo and move the anus to here, where it will be concentrically closed by the sphincters. Saw that. This is the most common um problem in, in, uh, uh cloacas, where the surgeon only dealt with the rectum and didn't do anything to the urogenital sinus, needs a redo. All right. So mislocation, posterior mislocation. Nice. And that's what this looks like. This is actually one of those cases. This is a, the rectum was done quite nicely, but the patient was left with a fistula. They missed it. Bulbar fistula not touched. All right, what do you think this is? Shamael just fluttered his eyes like. This is unbelievable, really, but I can tell you this uh surgeon was moving along and said, there's a beautiful, nice midline whitish structure, let's go get that. And it's the bladder neck. They pull through the bladder neck, and there's the urethra. This is not hard to do. Unless, if you don't know the anatomy before going in, you can do this. Brent still here? No, so this is a, uh, you may have shown some of these mislocated, uh, pull through on MRI. I've never prolapse. Prolapse. I, I caught this fish. I caught this fish. There are 4 fishermen in the boat. I brought this fish in. Can you believe it? So I did a quick anoplasty and got him back in the water. All right, so that's a, a nice repair. Uh, I can tell you I've, I, I have started to do this. I'm sure, I'm curious to know what you all think. I'll do half only. And then do the other half 3 months later. And it heals very quickly. I do that as an ambulatory procedure and then no dilations are necessary. Anyone have an opinion about how they manage prolapse? This is something we all are confounded by, Jack. Well, I'm actually surprised at how often the only half is prolapsing in many of them. Well, when it's just half, then it's nice. You can just do the other. But I do it as an ambulatory procedure. I, I do, and I don't, and I don't dilate them. I just calibrate them the way I suggested. So me too. I think if you do a circumferential dissection, you've got to watch for a stricture. Where if you only do half, there's no way it's going to stricture. So I've started to do half as an ambulatory and half as an ambulatory 3 months later, and when that's offered to the family, they would love that rather than, you know, a circumferential worry about dilations, etc. and have to stay in the hospital. All right, so the same. There's, there's your half. So which is the faculty half and which is the fellow half? All right. So now, this is a post laparoscopic pull through for a bulbar. Does anyone know what that is? And the answer is not two bladders. So that you would call a posterior urethral diverticulum, which is the old original rectum. And Keith, how do you avoid that? I think I mentioned, I think I mentioned that this morning. First of all, I think you should not overestimate your skill set and make sure that you're comfortable doing this is a much more complex operation than, uh, the Hirschprung's operation. But um and then the other thing is if you don't know where you are, open the colon and find the fistula from inside. Yeah, so this is a complication that is happening a lot more because people are not dissecting distally enough or just don't doing it properly. And here is a patient who's this has been left behind. And this is a patient with a similar problem, but this developed into an adenocarcinoma. This is the original distal rectum and an adenocarcinoma of the pelvis in a 30-year-old, so that posterior urethral diverticulum, which is clonic mucosa bathed by urine for 30 years, is a, is a cancer risk at least in one, in one case. Clearly though, I don't think that was done laparoscopically. It, it was not. It was not. And here's a pretty impressive had to defend my turf. Urethral stricture, and I, I think that's.

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