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Marc Levitt

1450 statements · 3 topics · summaries given as host listed separately

Colorectal / ARM & Hirschsprung · guest expert Etiologies (Gastroschisis/NEC/Atresia/Volvulus) · guest expert Intestinal Rehab · guest expert Motility / Pseudo-obstruction · guest expert Pediatric Robotic Surgery · episode host Single Ventricle / HLHS · guest expert

Featured statements

▶ Ep 95 · 9:11
I think the key to deciding whether to dive into a perineon posterior sagittally is where is the rectum? You want to know what structure you will find if you make a posterior sagittal or even a mini posterior sagittal incision. And there is no question in my mind that if I open posterior sagittally here, the first structure I would find would be rectum. Because the danger is that you go in posterior sagittally, you don't know where the rectum is, and you find something midline and white, like the urethra or the bladder neck or the bladder itself. And that's why we do colostomies. And that's why we do distal colostograms. So we know exactly where the rectum is, and we know whether we should approach it perineally or whether we should do it laparoscopically.
quote · Anorectal Malformation
▶ Ep 84 · 2:23
I had a fellow that said, why exactly are you keeping these patients NPO? And I said, well, because I don't want them to stool. Because if they stool, they're more likely to dehisc their perineal body. And the fellow said, you know, they still stool, even if they're NPO. And I said, yes, but not as much. And he said, this was Carlos Reck, who's now the premier colorectal surgeon in Austria. He's in Vienna. He said, I think it's about the same. And we studied it. And Carlos recorded stool output in two groups, NPO for seven days. And we gave them clear liquids. That was our test, clear liquids for seven days. And guess what? Same amount of poop.
quote · Anorectal Malformation
▶ Ep 10 · 9:50
I get asked all the time about the stimulator. It's the same electrical stimulator that anesthesia uses for their train of four. And then there's a connection that you can make that has little pins. Really, really inexpensive. And you just have to tell your anesthesiologist not to give skeletal muscle relaxant because it's a little bit weaker than the traditional stimulator, which was super expensive.
quote · Anorectal Malformations
▶ Ep 16 · 9:06
Richard Wood and I ran a randomized controlled trial of dilation and non-dilation for primary PSAP. Cloacass were excluded, and families knew that they were going to be randomized into one of two groups, and the backup plan, if a patient developed um a stricture was dilation, plus or minus a Heineke McCulitz anoplasty.
quote · Anorectal Malformations
▶ Ep 14 · 11:10
If you went in and grabbed this rectum and did a primary anoplasty. And did not know there was a fistula, and unfortunately, I have seen this done by some very good surgeons where they went in, did a beautiful anoplasty, but ignored the fistula, and the child down the road started peeing out their anus.
quote · Anorectal Malformations & Cloacal Reconstruction
▶ Ep 14 · 5:44
It's important that if this baby was born today, we're not rushing to do anything, because we need time to have this baby declare themselves to either be someone who's going to need a colostomy or someone who might be able to benefit from a primary repair.
quote · Anorectal Malformations & Cloacal Reconstruction

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How I Do It Levitt PSARP

▶ Ep 8 · 0:20
clinical A no-fistula anorectal malformation defect is managed very similarly to a bulbar urethral fistula. ↗
▶ Ep 8 · 0:45
quote Obviously the key to starting any such case is a good imaging study. ↗
▶ Ep 8 · 0:45
clinical The key to starting any anorectal malformation repair is a good imaging study. ↗
▶ Ep 8 · 1:05
clinical Fistula levels can be classified anatomically: bladder neck fistula is at the deltoid level (C), rectoprostatic fistula is at the triceps level (B), and rectobulbar fistula is at the elbow of the urethral curve or distal (A). ↗
▶ Ep 8 · 1:50
clinical It is important to mark the sphincter location before making the posterior sagittal incision because once the incision is made, it is hard to know exactly where the sphincter center is. ↗
▶ Ep 8 · 2:28
clinical The sphincters must be cut perfectly in the midline so that they can be easily reconstructed. ↗
▶ Ep 8 · 2:42
clinical Without a good distal colostogram, the midline whitish structure at the center of the dissection could be the urinary tract rather than the rectum. ↗
▶ Ep 8 · 2:46
quote If you don't have a good distal colostogram, this midline whitish structure could very easily be the urinary tract. ↗
▶ Ep 8 · 3:06
quote You don't want to hurt the urethra. ↗
▶ Ep 8 · 3:21
clinical Lateral dissection should be performed before turning attention anteriorly during rectal mobilization. ↗
▶ Ep 8 · 3:27
quote That is the critical moment. You want to separate the rectum from the urinary tract below without injuring the urinary tract. ↗
▶ Ep 8 · 3:35
clinical The initial anterior dissection to separate rectum from urinary tract is a submucosal dissection for the first few millimeters. ↗
▶ Ep 8 · 3:40
quote Imagine you are literally dropping down the urinary tract as the rectum is lifted up. ↗
▶ Ep 8 · 4:11
quote If you're not sure, go lateral. ↗
▶ Ep 8 · 4:14
clinical During lateral dissection, any fat seen means you can get closer to the rectum safely. ↗
▶ Ep 8 · 4:14
quote When you're lateral, any fat you see means you can get closer to the rectum. ↗
▶ Ep 8 · 4:23
clinical The lower the rectum is positioned, the longer is the common wall between rectum and urinary tract. ↗
▶ Ep 8 · 4:29
opinion A lower rectum is easier to repair in one sense but harder because there is a longer dissection adjacent to the urethra. ↗
▶ Ep 8 · 4:38
opinion A rectum at the bulbar level is too low to approach laparoscopically and is much safer to approach posterior sagittally. ↗
▶ Ep 8 · 4:41
quote That is way too low in my opinion to approach laparoscopically, much safer to approach such an operation posterior sagittally. ↗
▶ Ep 8 · 4:51
clinical Approaching a low rectum laparoscopically risks leaving behind distal rectum, a remnant of the urethral fistula, or a roof. ↗
▶ Ep 8 · 5:13
quote If you see fat, you can get closer. ↗
▶ Ep 8 · 5:16
clinical The rectum must be in the correct dissection plane or it will not mobilize properly. ↗
▶ Ep 8 · 5:16
quote You must be in the correct plane, otherwise the rectum does not mobilize. ↗
▶ Ep 8 · 5:44
clinical When closing the muscle complex, taking a bite of the rectum helps to avoid prolapse. ↗
▶ Ep 8 · 5:54
clinical The rectum should lie adjacent to, not constricted by, the muscle complex. ↗
▶ Ep 8 · 6:15
clinical As much rectum as possible should be preserved during the repair. ↗
▶ Ep 8 · 6:32
clinical The anoplasty is performed with 16 sutures under slight tension so that when stitches are cut, the rectum will gently retract and appear like a normal anus. ↗
▶ Ep 8 · 6:52
clinical Colostomy closure can take place 2 to 3 months after PSARP once the anus has reached its desired size. ↗
▶ Ep 8 · 6:52
clinical Dilations begin at 2 weeks postoperatively. ↗

Complications of Anorectal Malformations with Dr. Marc Levitt

▶ Ep 15 · 2:57
clinical Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period. ↗
▶ Ep 15 · 3:06
clinical Male babies with perineal fistula may pass meconium and have the malformation go unnoticed, typically presenting in the first year of life with severe constipation. ↗
▶ Ep 15 · 3:26
clinical In perineal fistula, the hole is too small and anterior to the center of the sphincters, causing the rectum and sigmoid to dilate as stool passes through a tiny fistulous orifice. ↗
▶ Ep 15 · 4:25
clinical The standard practice of checking temperature on the forehead or ear rather than rectally means the anus may not be examined, potentially missing malformations. ↗
▶ Ep 15 · 4:54
clinical Relocating a perineal fistula into the sphincters does not completely fix constipation, though it improves anatomy by making the hole adequately sized and lined by mucosa. ↗
▶ Ep 15 · 5:25
clinical Patients with uncorrected perineal fistula may have some continence with formed stool but will soil with loose stool or athletic activity because sphincter contraction cannot completely close the anteriorly located hole. ↗
▶ Ep 15 · 6:16
clinical A newborn anus should accept a size 12 Hagar dilator and a one-year-old should accept size 15. ↗
▶ Ep 15 · 6:42
clinical A bucket handle skin tag is consistent with perineal fistula; a probe can be passed underneath it even when the fistula itself is not visible. ↗
▶ Ep 15 · 7:33
opinion Diagnosing perineal fistula in females is probably the most confounding thing in pediatric colorectal surgery, with many patients either missed or overdiagnosed. ↗
▶ Ep 15 · 8:02
clinical Criteria for perineal fistula in females: hole too close to vagina (inadequate perineal body), inadequate hole size by Hagar dilators, and hole not centered in sphincter. ↗
▶ Ep 15 · 8:47
clinical If the hole is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, the patient does not need surgery; the perineal body will lengthen with growth. ↗
▶ Ep 15 · 9:51
clinical Examination under anesthesia with stimulation can confirm whether a questionable hole is properly centered within the sphincter. ↗
▶ Ep 15 · 11:06
quote You don't need to order those because you can take the anesthesia stimulator, which is $150 and then put these two nice little probes into the stimulator and connected to little needles and you get a beautiful sphincteric response. ↗
▶ Ep 15 · 11:06
clinical An anesthesia nerve stimulator costing $150 with appropriate needle probes works as well as commercial $15,000 sphincter stimulators. ↗
▶ Ep 15 · 12:18
clinical In rectourethral fistula, there is no anal opening and no hope for a hole; some babies pee meconium, making the diagnosis obvious. ↗
▶ Ep 15 · 12:45
clinical Rectourethral fistulas should not be approached primarily because the rectum location (bladder neck, prostatic, or bulbar level) is unknown; attempting posterior sagittal incision may find urinary tract structures instead of rectum. ↗
▶ Ep 15 · 13:20
clinical Rectourethral fistula patients should be managed with colostomy and distal colostogram, except in exceedingly rare cases where cross-table lateral at 20 hours shows very low rectum allowing safe primary posterior sagittal approach. ↗
▶ Ep 15 · 14:07
clinical Cloaca can be missed in the newborn period; a recent case presented at 6 months with constipation when someone finally noticed no anus. ↗
▶ Ep 15 · 15:54
clinical Ambiguous genitalia (clitoromegaly from endocrine stimulation) with urogenital sinus has a completely normal anus, distinguishing it from cloaca which has no anus. ↗
▶ Ep 15 · 16:24
clinical Cloaca patients have no endocrine problem and two completely normal ovaries, unlike urogenital sinus with virilization. ↗
▶ Ep 15 · 17:18
clinical The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through by the location of the colostomy or mucous fistula. ↗
▶ Ep 15 · 17:39
clinical Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections. ↗
▶ Ep 15 · 18:30
clinical Transverse colostomies can prolapse and, with large rectourethral fistula, the left colon absorbs urine causing acidosis; they also make distal colostogram difficult. ↗
▶ Ep 15 · 19:14
clinical Preferred technique is very proximal sigmoid colostomy leaving entire sigmoid for pull-through, with tiny flat mucous fistula separated from proximal stoma. ↗
▶ Ep 15 · 19:58
clinical Prolapse is related to colon mobility: mid-transverse colostomy both sides can prolapse, hepatic flexure only distal prolapses, proximal sigmoid only distal can prolapse because left colon is fixed to retroperitoneum. ↗
▶ Ep 15 · 20:37
clinical Ileostomies prolapse frequently because they are free-floating unless tacked to anterior abdominal wall. ↗
▶ Ep 15 · 21:30
clinical The anoplasty site should be marked before making the incision by drawing a circle around the pinkish ellipse where it stimulates on the skin surface, preventing confusion when anatomy is disrupted. ↗
▶ Ep 15 · 21:30
quote I actually make mark the anoplasty before I make the incision. I think you can get lost when you're looking at a bunch of jumping muscles from a stimulator. ↗
▶ Ep 15 · 22:04
clinical Without pre-marking, surgeons can choose the wrong place when seeing muscles jumping with stimulator after opening posterior sagittal incision, requiring re-operation despite good muscle potential. ↗
▶ Ep 15 · 23:04
quote Really, really good surgeons have put anuses in crazy places, and I think it's because they don't have a sense of what's the center because everything's disrupted once it's open. ↗
▶ Ep 15 · 23:29
clinical The distal colostogram is an absolutely vital study; many mistakes result from poorly done studies and misinterpretation. ↗
▶ Ep 15 · 23:55
clinical The colostogram must answer: where is the rectum, how low is it, is it reachable posterior sagittally or better laparoscopically, and what is its relationship to the urinary tract. ↗
▶ Ep 15 · 24:11
clinical Common colostogram error is insufficient contrast and pressure, giving false impression of high rectum and no fistula. ↗
▶ Ep 15 · 24:26
quote If you see that flattening of the rectum, you know the radiologist did not give enough of contrast, enough pressure, because you need to overcome the PC line because that's the sphincters. ↗
▶ Ep 15 · 24:26
clinical If the distal rectum shows a straight line corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure; more pressure will show bulging rectum and fistula. ↗
▶ Ep 15 · 25:23
quote I like to look at the urethra and think of it as a reverse C. Or let's say an elbow, and I think if the fistula is at the elbow or below, it's a bulbar fistula, and if the fistula is above the elbow, it's a prostatic fistula. ↗
▶ Ep 15 · 25:23
clinical Fistula classification using urethra as reverse C or elbow: fistula at or below elbow is bulbar, above elbow is prostatic, at bladder neck is bladder neck fistula. ↗
▶ Ep 15 · 25:55
clinical Bulbous rectum may be reachable posterior sagittally and hard laparoscopically due to girth; tapered rectum is better approached laparoscopically. ↗
▶ Ep 15 · 27:00
clinical Opening posterior sagittally without knowing rectum location will find a whitish shiny structure that may be bladder neck, not rectum. ↗
▶ Ep 15 · 28:42
clinical Adjunct techniques to locate rectum include balloon catheter in mucous fistula inflated with fluid or gastroscope to look for light, though the speaker has not used these. ↗
▶ Ep 15 · 29:28
clinical Never go to the operating room without knowing exactly what anatomy to expect from a proper distal colostogram; the key question is where is the rectum and is it the most posterior structure. ↗
▶ Ep 15 · 29:28
quote You should never go to the operating room without knowing exactly what anatomy you're going to expect to find. ↗
▶ Ep 15 · 30:09
clinical Bulbar or low prostatic rectum with bulge is more easily approached posterior sagittally; high prostatic tapered rectum is best served by laparoscopy; bladder neck fistulas are certainly best by laparoscopy. ↗
▶ Ep 15 · 30:43
clinical Laparoscopy for bulging rectum below peritoneal reflection at low prostatic or bulbar level requires unnecessary extra work and risks leaving remnant of original fistula (roof) if surgeon is timid. ↗
▶ Ep 15 · 31:16
clinical Posterior sagittal approach for high rectum is very difficult to mobilize and risks urinary tract injury. ↗
▶ Ep 15 · 31:48
quote I never look at it that way. I think that laparoscopy replaces laparotomy. It's an elegant dissection from above, but don't give away the advantages of the PSARP. ↗
▶ Ep 15 · 31:48
clinical Laparoscopy replaces laparotomy as elegant dissection from above but should not give away advantages of PSARP; a mini-PSARP during laparoscopy allows safe pelvic entry and rectal tacking to prevent prolapse. ↗
▶ Ep 15 · 32:44
opinion Preferred terminology is laparoscopic-assisted PSARP rather than laparoscopy versus PSARP. ↗
▶ Ep 15 · 32:44
quote I like to call mine a laparoscopic assisted PSARP. I think that's a better terminology. ↗
▶ Ep 15 · 33:04
clinical Prolapse prevention: proper levator closure, tacking rectum to posterior edge of muscle complex for 3-4 stitches, not dissecting rectum more than necessary, avoiding excessive trimming. ↗
▶ Ep 15 · 33:35
epidemiological Prolapse occurs in about 3% of cases, particularly in those without great muscles. ↗
▶ Ep 15 · 33:54
clinical Rectal prolapse causes bleeding, mucus, and can inhibit bowel control in patients with good muscle potential because they cannot close the opening with prolapsed tissue through it. ↗
▶ Ep 15 · 34:18
clinical Prolapse more than 3 millimeters should be treated; ideal time is when colostomy is still present. ↗
▶ Ep 15 · 34:48
clinical For circumferential prolapse, performing half the circumference in two different ambulatory settings is preferred by families over hospitalization and avoids need for dilation since half is untouched. ↗
▶ Ep 15 · 35:41
clinical Perineal body dehiscence prevention requires complete anterior rectal wall separation from posterior vaginal wall to reach areolar plane, avoiding tension on anoplasty. ↗
▶ Ep 15 · 36:03
clinical Perineal body dehiscence is the most common cause of reoperation in female ARM repairs. ↗
▶ Ep 15 · 36:35
clinical Traditional postoperative management is NPO for 7 days on 10% dextrose (hyperalimentation only if longer than 7 days); recently trialing clear liquids only for a week to avoid hard stool while allowing some oral intake. ↗
▶ Ep 15 · 37:32
clinical Daily perineal examination during the first week is critical; if dehiscence is detected on day 5-8, taking the patient back to OR to re-suture can salvage the repair, but by 3-4 weeks later nothing can be done. ↗
▶ Ep 15 · 37:48
quote If you see it's opening, I actually will take them back to the OR and re-suture the perineal body. You can actually save it by doing that. ↗
▶ Ep 15 · 38:36
clinical Laparoscopy causes trouble if dissecting a rectum that is too low, getting too close to urinary tract or being too timid and leaving remnant of original fistula (distal rectum). ↗
▶ Ep 15 · 39:20
clinical For high rectums, particularly bladder neck fistulas, dissection to make the rectum reach with good blood supply is challenging; the IMA must be preserved because prior colostomy may have disrupted left colic collaterals. ↗
▶ Ep 15 · 39:47
clinical The rectum has excellent intramural blood supply from the IMA; taking tiny distal vessels along the rectal wall preserves this, but taking IMA or branches too close to aorta will cause rectal necrosis. ↗
▶ Ep 15 · 40:18
clinical The biggest PSARP problem is exploring without knowing rectum location and finding bladder neck, urethra, seminal vesicles, vas deferens, or ectopic ureter instead of distal rectum. ↗
▶ Ep 15 · 41:02
quote There are some famous cases of pull through bladder neck made into beautiful anoplasties. And then post op, the patient was draining liquid out their anoplasty, and in fact it was the bladder neck. ↗
▶ Ep 15 · 41:02
clinical Famous cases exist of bladder neck being pulled through and made into beautiful anoplasties, with the patient postoperatively draining liquid (urine) from the anoplasty. ↗
▶ Ep 15 · 42:14
clinical To determine continence potential, assess three factors: original malformation type, sacral quality and calculated sacral ratio, and spine quality (ARM continence index). ↗
▶ Ep 15 · 42:57
clinical Three A's in continence index (malformation type, sacrum, spine) predicts continence; three C's predicts incontinence; intermediate grades are being quantified through data collection. ↗
▶ Ep 15 · 43:19
clinical Bulbar fistula with sacral ratio of 1 and normal spine should absolutely have bowel control; bladder neck fistula with sacral ratio 0.4 and tethered cord or myelomeningocele has no chance of good bowel control. ↗
▶ Ep 15 · 43:52
clinical For 4-year-old with soiling and continence potential, first step is mechanical cleaning with bowel management enemas to gain confidence, then when older try switching to laxatives for voluntary bowel movements. ↗
▶ Ep 15 · 44:25
clinical If patient cannot be weaned from enemas, consider antegrade option like Malone procedure. ↗
▶ Ep 15 · 44:39
clinical Indications for redo pull-through: any continence potential with imperfect anatomy including improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum). ↗
▶ Ep 15 · 45:08
clinical Redoing anoplasty to center rectum in sphincter can change a patient to have continence potential; success is very good when the right patient is selected. ↗
▶ Ep 15 · 46:25
quote I think one of the biggest problems with anorectal malformations is that if you don't get it right, you don't really know for a few years. Most things in surgery, if you don't do it right, you know right away. ↗
▶ Ep 15 · 46:25
opinion One of the biggest problems with anorectal malformations is that surgical errors do not become apparent for years, unlike most surgical complications which are evident immediately. ↗
▶ Ep 15 · 46:59
quote How are you supposed to as a surgeon, know what to fix about your technique if your problems are only becoming obvious years later? And I think that's why there is so much morbidity in colorectal. ↗

Posterior Sagittal Anorectaplasty in a Female: Pediatric Colorectal...

▶ Ep 27 · 1:17
quote This is a very good representation. I just have a very good question. I have a very good use. ↗
▶ Ep 27 · 1:17
quote This is a very good representation. I just have a very good question. I have a very good use. ↗
▶ Ep 27 · 3:21
clinical In babies this small, MRI has difficulty delineating uterine and ovarian structures ↗
▶ Ep 27 · 3:21
clinical In babies this small, MRI has difficulty delineating uterine and ovarian structures ↗
▶ Ep 27 · 7:47
clinical Train-of-four box from anesthesia machine is a less expensive alternative to dedicated nerve stimulator for muscle mapping ↗
▶ Ep 27 · 7:47
clinical Train-of-four box from anesthesia machine is a less expensive alternative to dedicated nerve stimulator for muscle mapping ↗
▶ Ep 27 · 9:59
quote I don't see a vagina. No, I don't see a vaginal opening at all. ↗
▶ Ep 27 · 9:59
quote I don't see a vagina. No, I don't see a vaginal opening at all. ↗
▶ Ep 27 · 15:16
clinical Lateral dissection defines the anterior plane in rectal mobilization - first step is to establish clean lateral plane ↗
▶ Ep 27 · 15:16
quote Lateral defines the anterior. First step, lateral. I want a nice, clean lateral plane. ↗
▶ Ep 27 · 15:16
quote Lateral defines the anterior. First step, lateral. I want a nice, clean lateral plane. ↗
▶ Ep 27 · 15:16
clinical Lateral dissection defines the anterior plane in rectal mobilization - first step is to establish clean lateral plane ↗
▶ Ep 27 · 19:47
clinical In absent vagina situations with recto-vestibular fistula, the urethra is characteristically enlarged ↗
▶ Ep 27 · 19:47
clinical In absent vagina situations with recto-vestibular fistula, the urethra is characteristically enlarged ↗
▶ Ep 27 · 20:28
clinical In this patient population, there is thick wall between rectum and urethra in absent vagina situations ↗
▶ Ep 27 · 20:28
clinical In this patient population, there is thick wall between rectum and urethra in absent vagina situations ↗
▶ Ep 27 · 27:20
opinion Surgeon would not perform independent examination under anesthesia in straightforward newborn primary anorectal malformation case, but would examine at time of repair ↗
▶ Ep 27 · 27:20
opinion Surgeon would not perform independent examination under anesthesia in straightforward newborn primary anorectal malformation case, but would examine at time of repair ↗
▶ Ep 27 · 35:07
clinical When fat is visible during rectal dissection, surgeon can safely dissect closer to the bowel wall ↗
▶ Ep 27 · 35:07
clinical When fat is visible during rectal dissection, surgeon can safely dissect closer to the bowel wall ↗
▶ Ep 27 · 48:12
opinion Best time to create neovagina is when rectum has been mobilized; waiting creates scarred perineum making later reconstruction more difficult ↗
▶ Ep 27 · 48:12
quote I think technically it's the ideal time to do the neovagina when the rectum has been mobilized. I think that would be a mistake. I think it would be a very scarred perineum to then put a neovagina through. ↗
▶ Ep 27 · 48:12
opinion Best time to create neovagina is when rectum has been mobilized; waiting creates scarred perineum making later reconstruction more difficult ↗
▶ Ep 27 · 48:12
quote I think technically it's the ideal time to do the neovagina when the rectum has been mobilized. I think that would be a mistake. I think it would be a very scarred perineum to then put a neovagina through. ↗
▶ Ep 27 · 49:17
opinion Staple lines should be removed from neovaginal segment rather than left in place ↗
▶ Ep 27 · 49:17
opinion Staple lines should be removed from neovaginal segment rather than left in place ↗
▶ Ep 27 · 59:42
opinion Surgeon prefers colon over small bowel for neovagina because small bowel mesentery is more tenuous and colon has more robust blood supply ↗
▶ Ep 27 · 59:42
opinion Surgeon prefers colon over small bowel for neovagina because small bowel mesentery is more tenuous and colon has more robust blood supply ↗
▶ Ep 27 · 1:05:08
clinical Standard neovaginal length in infant is 7-8 centimeters based on normal vaginal length in babies ↗
▶ Ep 27 · 1:05:08
clinical Standard neovaginal length in infant is 7-8 centimeters based on normal vaginal length in babies ↗
▶ Ep 27 · 1:07:53
quote I don't know what's going to happen with our technology and our ability to think with uteruses. I mean, who would have thought a year ago that there would be such a thing as a uterine transplantation? ↗
▶ Ep 27 · 1:07:53
quote I don't know what's going to happen with our technology and our ability to think with uteruses. I mean, who would have thought a year ago that there would be such a thing as a uterine transplantation? ↗
▶ Ep 27 · 1:08:53
clinical Neovagina should be tacked to pelvic fascia or posterior bladder to prevent prolapse and ensure it grows with the patient ↗
▶ Ep 27 · 1:08:53
clinical Neovagina should be tacked to pelvic fascia or posterior bladder to prevent prolapse and ensure it grows with the patient ↗
▶ Ep 27 · 1:09:37
clinical Six months after breast budding is appropriate timing for pelvic ultrasound and vaginoscopy to assess Müllerian structures and menstrual patency ↗
▶ Ep 27 · 1:09:37
opinion Surgeon does not dilate neovaginas post-operatively, anticipating some patients will need minor revision but avoiding torture of vaginal dilations ↗
▶ Ep 27 · 1:09:37
clinical Six months after breast budding is appropriate timing for pelvic ultrasound and vaginoscopy to assess Müllerian structures and menstrual patency ↗
▶ Ep 27 · 1:09:37
opinion Surgeon does not dilate neovaginas post-operatively, anticipating some patients will need minor revision but avoiding torture of vaginal dilations ↗
▶ Ep 27 · 1:09:37
quote I think it's a lot of torture to make them go through vasomal dilations. ↗
▶ Ep 27 · 1:09:37
quote I think it's a lot of torture to make them go through vasomal dilations. ↗
▶ Ep 27 · 1:22:15
clinical MRI has limited ability to determine presence of vaginal lumen in very young patients unless there is clear hematocolpos or hydrocolpos ↗
▶ Ep 27 · 1:26:40
quote I don't think I would have changed a thing. I don't think we would have changed the preoperative workup. I wouldn't do an independent EUA. I would examine the patient at the time of the PSAR. ↗
▶ Ep 27 · 1:26:40
quote I don't think I would have changed a thing. I don't think we would have changed the preoperative workup. I wouldn't do an independent EUA. I would examine the patient at the time of the PSAR. ↗

Posterior Sagittal Anorectaplasty-Female Part III: Pediatric Colorectal...

▶ Ep 24 · 2:12
clinical Colon is preferred over small bowel for neovagina construction because small bowel mesentery is more tenuous and colon has more robust blood supply. ↗
▶ Ep 24 · 2:12
quote I don't think that's the case. I find the small bowel mesentery a bit tenuous. So I prefer, I think the colon is a little bit more robust. From a blood supply point of view. ↗
▶ Ep 24 · 2:12
clinical Colon is preferred over small bowel for neovagina construction because small bowel mesentery is more tenuous and colon has more robust blood supply. ↗
▶ Ep 24 · 2:12
quote I don't think that's the case. I find the small bowel mesentery a bit tenuous. So I prefer, I think the colon is a little bit more robust. From a blood supply point of view. ↗
▶ Ep 24 · 7:56
clinical 7-8 centimeters is used for neovaginal conduit length based on normal vaginal length in an infant, though there is no science behind this measurement. ↗
▶ Ep 24 · 7:56
quote I just normally in a baby do about 78 centimeters because that's what a normal vaginal length looks like in a. I think there's no science behind that at all. ↗
▶ Ep 24 · 7:56
quote I just normally in a baby do about 78 centimeters because that's what a normal vaginal length looks like in a. I think there's no science behind that at all. ↗
▶ Ep 24 · 7:56
clinical 7-8 centimeters is used for neovaginal conduit length based on normal vaginal length in an infant, though there is no science behind this measurement. ↗
▶ Ep 24 · 10:09
clinical The family agreed to preserve structures that did not need removal, acknowledging uncertainty about future technology and outcomes. ↗
▶ Ep 24 · 10:09
clinical The family agreed to preserve structures that did not need removal, acknowledging uncertainty about future technology and outcomes. ↗
▶ Ep 24 · 10:27
quote I mean, who would have thought a year ago that there would be such a thing as a uterine transplantation. The successful. ↗
▶ Ep 24 · 10:27
quote I mean, who would have thought a year ago that there would be such a thing as a uterine transplantation. The successful. ↗
▶ Ep 24 · 10:27
clinical Uterine transplantation has become successful within the past year, representing advancement in reproductive technology. ↗
▶ Ep 24 · 10:27
clinical Uterine transplantation has become successful within the past year, representing advancement in reproductive technology. ↗
▶ Ep 24 · 11:10
clinical Neovagina should be tacked to pelvic fascia or posterior bladder to prevent prolapse and allow it to grow and lengthen into the pelvis. ↗
▶ Ep 24 · 11:10
clinical Neovagina should be tacked to pelvic fascia or posterior bladder to prevent prolapse and allow it to grow and lengthen into the pelvis. ↗
▶ Ep 24 · 11:58
quote Well, I, I don't dilate the, I don't dilate these vaginas. And I anticipate that a certain percentage of them will need a little bit of an internalplasty later, but I think it's a lot of torture to make them go through vaginal dilations. ↗
▶ Ep 24 · 11:58
quote Well, I, I don't dilate the, I don't dilate these vaginas. And I anticipate that a certain percentage of them will need a little bit of an internalplasty later, but I think it's a lot of torture to make them go through vaginal dilations. ↗
▶ Ep 24 · 11:58
clinical Vaginal dilation is not performed post-operatively; a certain percentage will need introitoplasty later, but dilation is considered torture for patients. ↗
▶ Ep 24 · 11:58
clinical Vaginal dilation is not performed post-operatively; a certain percentage will need introitoplasty later, but dilation is considered torture for patients. ↗
▶ Ep 24 · 12:13
clinical Six months after breast budding, Müllerian structures must be monitored for dilation and menstrual function assessed. ↗
▶ Ep 24 · 12:13
clinical Six months after breast budding, Müllerian structures must be monitored for dilation and menstrual function assessed. ↗
▶ Ep 24 · 12:29
clinical Vaginoscopy should be performed after breast budding to determine if a cervix is present and if structures are larger. ↗
▶ Ep 24 · 12:29
clinical Vaginoscopy should be performed after breast budding to determine if a cervix is present and if structures are larger. ↗
▶ Ep 24 · 13:55
clinical If no cervix is found on vaginoscopy, there is a difficult decision between empirical removal of Müllerian structures or waiting for complications. ↗
▶ Ep 24 · 13:55
clinical If no cervix is found on vaginoscopy, there is a difficult decision between empirical removal of Müllerian structures or waiting for complications. ↗
▶ Ep 24 · 14:17
clinical In patients without a cervix, some develop pelvic inflammatory disease episodes requiring removal, while others remain asymptomatic. ↗
▶ Ep 24 · 14:17
clinical In patients without a cervix, some develop pelvic inflammatory disease episodes requiring removal, while others remain asymptomatic. ↗
▶ Ep 24 · 19:58
clinical Anal transitional epithelium (dentate line) should be preserved during anoplasty rather than excised. ↗
▶ Ep 24 · 19:58
clinical Anal transitional epithelium (dentate line) should be preserved during anoplasty rather than excised. ↗
▶ Ep 24 · 24:51
clinical Pelvic MRI in infants struggles to identify vaginal lumen unless there is clearly hematocolpos or hydrocolpos; it is less helpful than desired. ↗
▶ Ep 24 · 24:51
clinical Pelvic MRI in infants struggles to identify vaginal lumen unless there is clearly hematocolpos or hydrocolpos; it is less helpful than desired. ↗
▶ Ep 24 · 25:20
quote It's always promises to be much better than it is, and. The very young patient ↗
▶ Ep 24 · 25:20
quote It's always promises to be much better than it is, and. The very young patient ↗
▶ Ep 24 · 25:32
clinical MRI can frequently identify fallopian tubes, ovaries, and uterine anatomy, but determining the presence and characteristics of the vaginal lumen is very challenging with low confidence. ↗
▶ Ep 24 · 25:32
clinical MRI can frequently identify fallopian tubes, ovaries, and uterine anatomy, but determining the presence and characteristics of the vaginal lumen is very challenging with low confidence. ↗
▶ Ep 24 · 26:14
clinical Keeping fluid in the vagina during MRI imaging is difficult once the patient is in the magnet. ↗
▶ Ep 24 · 26:14
clinical Keeping fluid in the vagina during MRI imaging is difficult once the patient is in the magnet. ↗
▶ Ep 24 · 27:31
opinion No preoperative workup including independent examination under anesthesia, MRI, or better scoping would have changed the surgical approach in this case. ↗
▶ Ep 24 · 27:31
quote So I don't think I would have changed a thing. I don't think we would have changed the preoperative workup. I wouldn't do an independent EUA. I would examine the patient at the time of the PSA. ↗
▶ Ep 24 · 27:31
quote So I don't think I would have changed a thing. I don't think we would have changed the preoperative workup. I wouldn't do an independent EUA. I would examine the patient at the time of the PSA. ↗
▶ Ep 24 · 27:31
opinion No preoperative workup including independent examination under anesthesia, MRI, or better scoping would have changed the surgical approach in this case. ↗
▶ Ep 24 · 28:15
clinical None of the imaging or office examination hinted at the Müllerian anatomy found intraoperatively; the office exam looked amazingly normal from a gynecologic point of view. ↗
▶ Ep 24 · 28:15
clinical None of the imaging or office examination hinted at the Müllerian anatomy found intraoperatively; the office exam looked amazingly normal from a gynecologic point of view. ↗
▶ Ep 24 · 28:15
quote None of the imaging hinted at this, and even the office exam looked amazingly normal from a, a gynecologic point of view. ↗
▶ Ep 24 · 28:15
quote None of the imaging hinted at this, and even the office exam looked amazingly normal from a, a gynecologic point of view. ↗
▶ Ep 24 · 29:20
clinical When the neovagina is connected to the patient's native vagina, it is already tethered into the abdomen and does not require additional tacking to the bladder. ↗
▶ Ep 24 · 29:20
clinical When the neovagina is connected to the patient's native vagina, it is already tethered into the abdomen and does not require additional tacking to the bladder. ↗

Complications of Anorectal Malformations with Dr. Marc Levitt

▶ Ep 34 · 2:57
clinical Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period. ↗
▶ Ep 34 · 3:06
clinical Male babies with perineal fistula may pass meconium and no one notices anything wrong with their anorectal anatomy, typically presenting in the first year of life with severe constipation. ↗
▶ Ep 34 · 4:25
opinion The standard practice of checking temperature on forehead or ear rather than rectally makes it easier to miss anorectal malformations in newborns. ↗
▶ Ep 34 · 4:54
clinical Relocating a perineal fistula into the sphincters improves anatomy but does not completely fix constipation; patients will inherently have some constipation requiring aggressive treatment. ↗
▶ Ep 34 · 5:38
clinical If a perineal fistula is not centered in the sphincter, patients with loose stool will soil, and athletic activity will cause soiling because sphincter squeeze cannot completely close the hole. ↗
▶ Ep 34 · 6:13
clinical A newborn anus should accept a size 12 Hagar dilator and a 1-year-old should accept a size 15. ↗
▶ Ep 34 · 8:02
clinical In females, diagnostic criteria for perineal fistula are: hole too close to vagina (inadequate perineal body), inadequate hole size by Hagar dilators, and hole not centered in sphincter. ↗
▶ Ep 34 · 8:47
clinical If a female's anal opening is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, no surgery is needed; the perineal body will lengthen with growth. ↗
▶ Ep 34 · 11:06
quote You don't need to order those because you can take the anesthesia stimulator, which is $150 and then put these two nice little probes into the stimulator and connected to little needles and you get a beautiful sphincteric response. ↗
▶ Ep 34 · 11:06
clinical An anesthesia nerve stimulator costing $150 with appropriate needle probes works as well as commercial $15,000 stimulators for identifying sphincter muscles. ↗
▶ Ep 34 · 17:00
quote I think that operation of a colostomy needs to be taken very seriously, and every pediatric surgeon who deals with newborns, which is the art of our specialty, needs to be really, really good at this because there's a lot of morbidity that's conveyed to a patient with an improperly done colostomy. ↗
▶ Ep 34 · 17:18
clinical The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through by the location of the colostomy or mucous fistula. ↗
▶ Ep 34 · 17:45
clinical Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections. ↗
▶ Ep 34 · 18:38
clinical With transverse colostomy and large rectourethral fistula, the left colon absorbs urine which doesn't exit the mucous fistula, potentially causing acidosis from urine absorption. ↗
▶ Ep 34 · 19:58
clinical Prolapse risk depends on colostomy location: mid-transverse allows bilateral prolapse, hepatic flexure allows only distal prolapse, proximal sigmoid allows only distal prolapse because left colon is fixed to retroperitoneum. ↗
▶ Ep 34 · 21:30
quote I actually make mark the anoplasty before I make the incision. I think you can get lost when you're looking at a bunch of jumping muscles from a stimulator. ↗
▶ Ep 34 · 21:30
clinical Marking the sphincter ellipse on skin surface before making any incision prevents confusion from muscle stimulation after dissection is open, avoiding misplaced anoplasty. ↗
▶ Ep 34 · 24:26
clinical A distal colostogram showing flattening of the rectum corresponding to the pubococcygeal line indicates insufficient contrast or pressure; more pressure is needed to overcome the sphincters and reveal the true rectal position and fistula. ↗
▶ Ep 34 · 24:26
quote If you see that flattening of the rectum, you know the radiologist did not give enough of contrast, enough pressure, because you need to overcome the PC line because that's the sphincters, that's where the sphincters are compressing the distal rectum. ↗
▶ Ep 34 · 25:23
clinical Fistula level is determined by viewing the urethra as a reverse C or elbow: fistula at or below the elbow is bulbar, above the elbow is prostatic, at bladder neck is bladder neck fistula. ↗
▶ Ep 34 · 25:55
clinical Bulbous rectum on colostogram may be reachable posterior sagittally and difficult laparoscopically; tapered rectum is better approached laparoscopically. ↗
▶ Ep 34 · 27:00
clinical Opening posterior sagittally without knowing exact rectal location risks finding and potentially mobilizing bladder neck instead of rectum. ↗
▶ Ep 34 · 29:28
quote You should never go to the operating room without knowing exactly what anatomy you're going to expect to find. ↗
▶ Ep 34 · 30:09
clinical Bulbar and low prostatic fistulas with bulbous rectum are best approached posterior sagittally; high prostatic with tapered rectum and bladder neck fistulas are best approached laparoscopically. ↗
▶ Ep 34 · 30:43
clinical Attempting laparoscopy for bulging rectum below peritoneal reflection at low prostatic or bulbar level risks leaving behind a remnant of the original fistula (roof) if the surgeon is timid. ↗
▶ Ep 34 · 31:48
opinion Laparoscopy replaces laparotomy, not PSARP; a mini-PSARP during laparoscopy allows safe entry through peritoneal reflection and tacking rectum to posterior muscle complex to prevent prolapse. ↗
▶ Ep 34 · 31:48
quote I think that laparoscopy replaces laparotomy. It's an elegant dissection from above, but don't give away the advantages of the PSARP. ↗
▶ Ep 34 · 33:35
epidemiological Rectal prolapse occurs in about 3% of cases, particularly in patients without great muscles. ↗
▶ Ep 34 · 34:14
clinical Rectal prolapse more than 3 millimeters should be treated because it causes bleeding, mucus, and can inhibit bowel control in patients with good muscle potential. ↗
▶ Ep 34 · 34:48
clinical Circumferential prolapse can be trimmed in two separate ambulatory sessions (half circumference each), avoiding hospitalization and eliminating need for dilation since half the circumference remains untouched. ↗
▶ Ep 34 · 35:41
clinical Complete anterior rectal wall mobilization to the areolar plane between rectum and vagina is essential to avoid tension on the anoplasty that can lead to perineal body dehiscence. ↗
▶ Ep 34 · 36:03
clinical Perineal body dehiscence is the most common cause of reoperation in female ARM repairs. ↗
▶ Ep 34 · 36:45
clinical Clear liquids only for one week postoperatively prevents hard stool formation while allowing more stool volume, showing good perineal body healing results without traditional 7-day NPO period. ↗
▶ Ep 34 · 37:48
clinical If perineal body dehiscence is recognized on days 5-8, taking the patient back to OR to re-suture can salvage the repair; by 3-4 weeks the entire perineal body is dehisced and unsalvageable. ↗
▶ Ep 34 · 39:33
clinical During laparoscopic approach for high rectums, the IMA must be preserved because prior colostomy may have disrupted collaterals down the left colic, making the rectum completely dependent on IMA blood supply. ↗
▶ Ep 34 · 42:14
clinical Continence potential in ARM patients is predicted by three factors: original malformation type, sacral ratio, and spine quality (ARM continence index). Three A's predicts continence, three C's predicts incontinence. ↗
▶ Ep 34 · 43:19
clinical A bulbar fistula with sacral ratio of 1 and normal spine should have bowel control; a bladder neck fistula with sacral ratio of 0.4 and tethered cord or myelomeningocele has no chance of good bowel control. ↗
▶ Ep 34 · 43:52
clinical Initial management of soiling 4-year-old with continence potential is bowel management with enemas to achieve cleanliness, then trial of laxatives when older and more mature to attempt voluntary bowel movements. ↗
▶ Ep 34 · 44:39
clinical Indications for redo pull-through include any patient with continence potential who has improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum). ↗
▶ Ep 34 · 46:25
quote If you don't do it right, you don't really know for a few years. Most things in surgery, if you don't do it right, you know right away. ↗
▶ Ep 34 · 46:25
opinion The major problem with anorectal malformations is that surgical errors may not become apparent for years; an improperly placed anus appears successful initially but presents with soiling at age 4. ↗
▶ Ep 34 · 46:59
quote How are you supposed to as a surgeon, know what to fix about your technique if your problems are only becoming obvious years later? And I think that's why there is so much morbidity in colorectal. ↗

The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula

▶ Ep 35 · 3:01
guideline Anorectal malformation patients require screening for VACTERL association: vertebral abnormalities (plain X-ray), cardiac defects (exam and echo), esophageal atresia (NG tube pass), renal abnormalities (kidney ultrasound), and limb abnormalities (physical exam). ↗
▶ Ep 35 · 3:34
quote We want to make sure we've checked for any cardiac defect, both on exam and on echo. ↗
▶ Ep 35 · 3:55
clinical Sacral ratio measurement should wait until the child is 3 months of age for true measurements, though early imaging gives a feel for pelvic development. ↗
▶ Ep 35 · 4:22
clinical Spinal ultrasound in anorectal malformation patients should include evaluation of the presacral space to screen for presacral masses. ↗
▶ Ep 35 · 4:33
epidemiological Presacral masses are rare in typical imperforate anus but occur in almost half of anal stenosis or rectal atresia cases, which require MRI evaluation. ↗
▶ Ep 35 · 7:11
quote The sacrum looks quite normal. I bet this kid is gonna have a pretty normal sacral ratio, certainly greater than 0.7. Which connotes a very good prognosis for bowel control and really peace of mind for the family. ↗
▶ Ep 35 · 7:20
clinical A sacral ratio greater than 0.7 connotes very good prognosis for bowel control and provides peace of mind for families regarding potty training and school readiness at 4 years of age. ↗
▶ Ep 35 · 7:31
quote They want to know what's going to happen to this baby in 4 years when they need to potty train and go to school. ↗
▶ Ep 35 · 9:06
clinical The key to deciding whether to perform primary posterior sagittal anorectoplasty is knowing where the rectum is located; the danger is finding midline white structures like urethra, bladder neck, or bladder instead of rectum. ↗
▶ Ep 35 · 9:06
quote I think the key to deciding whether to dive into a perineum and posterior sagittal is, where is the rectum? ↗
▶ Ep 35 · 9:25
quote The danger is that you go in posterior sagittal, you don't know where the rectum is, and you find something midline and white, like the urethra, the bladder neck or the bladder itself. ↗
▶ Ep 35 · 9:42
clinical Colostomies and distal colostograms are performed to know exactly where the rectum is and whether to approach it perineally or laparoscopically. ↗
▶ Ep 35 · 10:18
quote I will tell you that the surgeon who sent me this case, they did not do that. They felt more comfortable doing a colostomy, and I wanna tell you, that was the safe thing to do. Bravo to them. That was the right choice. ↗
▶ Ep 35 · 10:24
clinical Colostomy is the safe choice for anorectal malformation repair, though it carries risks of complications from both the colostomy creation and the subsequent closure. ↗
▶ Ep 35 · 10:34
quote We are giving the child a colostomy. And whatever complications can happen from that, and we are giving the child a colostomy closure, and whatever complications can happen from that. ↗
▶ Ep 35 · 11:10
quote This is sort of scary, because if you went in and grabbed this rectum and did a primary anoplasty. And did not know there was a fistula, and unfortunately, I have seen this done by some very good surgeons where they went in, did a beautiful anoplasty, but ignored the fistula, and the child down the road started peeing out their anus. ↗
▶ Ep 35 · 11:10
clinical Surgeons have performed primary anorectoplasty on low anorectal malformations without knowing about a fistula, resulting in children later urinating out of the anus. ↗
▶ Ep 35 · 12:09
quote When I do that, I open up the posterior wall of the rectum and I inspect the anterior wall of the rectum. ↗
▶ Ep 35 · 12:09
clinical During primary posterior sagittal anorectoplasty, the surgeon should open the posterior wall of the rectum and inspect the anterior wall to rule out a fistula. ↗
▶ Ep 35 · 13:44
epidemiological 95% of Down syndrome patients with imperforate anus have no fistula, but 5% do have a fistula, so distal colostogram is still indicated. ↗
▶ Ep 35 · 13:48
quote 95% of Down's patients have no fistula, but 5% do. So I would still do a distal colostogram, and some of them might have a fistula. ↗

Colorectal Quiz Episode 2: When to redo a PSARP

▶ Ep 36 · 4:30
clinical The original malformation in Case 1 was a prostatic fistula. ↗
▶ Ep 36 · 4:40
clinical The patient in Case 1 has a tethered cord and a sacral ratio of 0.66. ↗
▶ Ep 36 · 7:29
clinical Visual cues for identifying correct sphincter location include the anal dimple, a midline raised area where the sphincters are, the ellipse, color change, indentation or raised area, and appropriate perineal body length. ↗
▶ Ep 36 · 8:40
clinical Case 2 patient was born with a vestibular fistula, has a normal spine and an excellent sacrum, indicating a much better prognosis for bowel control. ↗
▶ Ep 36 · 9:50
quote I get asked all the time about the stimulator. It's the same electrical stimulator that anesthesia uses for their train of four. And then there's a connection that you can make that has little pins. Really, really inexpensive. And you just have to tell your anesthesiologist not to give skeletal muscle relaxant because it's a little bit weaker than the traditional stimulator, which was super expensive. ↗
▶ Ep 36 · 9:50
clinical The electrical stimulator used is the same one that anesthesia uses for their train of four, with an inexpensive connection with little pins. ↗
▶ Ep 36 · 10:10
clinical You have to tell your anesthesiologist not to give skeletal muscle relaxant because the stimulator is a little bit weaker than the traditional stimulator. ↗
▶ Ep 36 · 13:28
opinion If you know the anatomy is off, you should do the redo, and there's an advantage to getting the anatomy right the younger the child is. ↗
▶ Ep 36 · 13:50
opinion For a two-year-old with a mislocated anus or bad prolapse, offer a redo and let them live in diapers for a year or two with better anatomy, then see if they can successfully potty train. ↗
▶ Ep 36 · 14:20
clinical Many patients present after the age of potty training because they're incontinent, and evaluation reveals the reason is they don't have the best operation—their anus isn't in the right place. ↗
▶ Ep 36 · 14:30
opinion For patients presenting with incontinence after potty training age, do the redo and usually add a Malone at the same time so they can learn how to get control with their new anatomy before attempting voluntary bowel movements. ↗
▶ Ep 36 · 14:35
clinical The process of learning control with new anatomy after redo and Malone may take 6 to 12 months. ↗
▶ Ep 36 · 15:03
opinion For a patient with a mislocated anus that's 50% within the sphincter complex, three and a half years old and fecally incontinent, one approach is to redo them, do a Malone, get them perfectly clean mechanically, then see if they can develop bowel control. ↗
▶ Ep 36 · 15:45
opinion If patients haven't declared their continence yet because they're not old enough to do so from a behavioral point of view, give them a chance—they may succeed. ↗

Colorectal Quiz Episode 13: Newborn ARM Part 2

▶ Ep 39 · 2:34
quote You must achieve a hole in the center of the sphincter with an adequate peroneal body. And those are the indications for surgery. ↗
▶ Ep 39 · 2:34
clinical Indications for surgery in female ARM include: hole too small, hole not in center of sphincter, and inadequate perineal body ↗
▶ Ep 39 · 7:14
clinical If anal opening is adequately sized, surrounded by sphincter, and has a perineal body (albeit short), no surgery is indicated ↗
▶ Ep 39 · 8:01
clinical Short perineal body will grow over time and there is nothing to do about it surgically ↗
▶ Ep 39 · 8:01
quote One of our professors like to say, and we trained at the same place, Jason and I, the great Mount Sinai in New York, it's very hard to improve on an asymptomatic patient. ↗
▶ Ep 39 · 8:39
quote I think that if you don't have a sphincter on the anterior aspect of the analplasty, they will leak stool because they won't be able to close the hole. ↗
▶ Ep 39 · 8:39
clinical If half the fistula is within sphincter complex and half outside, patient will leak stool because they cannot close the hole, making surgery worthy ↗
▶ Ep 39 · 11:25
clinical Cloaca presents with single perineal orifice and hypertrophied area around clitoral hood is typical, not ambiguous genitalia ↗
▶ Ep 39 · 11:25
quote That little hypertrophied area around the clitoral hood on the right photo is fairly typical, and it is not, and I repeat, not ambiguous genitalia. ↗
▶ Ep 39 · 11:25
quote This patient has no endocrine problem, does not need steroids, does not need an endocrinologic workup. This is a cloaca. There's no question of their gender assignment. It's a female. ↗
▶ Ep 39 · 11:25
clinical Cloaca patients are still being misdiagnosed as ambiguous genitalia, with some babies not having proper gender assignment for one to two weeks ↗
▶ Ep 39 · 11:25
clinical Cloaca patients do not need endocrine workup or steroids and there is no question of gender assignment - they are female ↗
▶ Ep 39 · 13:26
quote You really want to push down and flatten the perineal body. That is the key. You want to see if the perineal body is normal or not. ↗
▶ Ep 39 · 13:26
clinical Key to perineal exam is to push down and flatten the perineal body to assess if it is normal ↗
▶ Ep 39 · 13:47
clinical Normal anus is centered within sphincter, of adequate size, and perineal body is of normal length properly distanced from vestibule ↗

The Colorectal Quiz Episode 23: Hirschsprung Disease - The Soiling Patient...

▶ Ep 41 · 1:17
quote Let's talk dentate line, shall we? ↗
▶ Ep 41 · 1:23
clinical The three components of continence are quality of sphincters, quality of dentate line, and motility. ↗
▶ Ep 41 · 1:23
quote Remember, the three components of continence are quality of sphincters, quality of dentate line, and motility. ↗
▶ Ep 41 · 1:30
clinical In Hirschsprung disease, two sphincters are of concern: the external sphincter (under voluntary control) and the internal sphincter (which tends not to relax due to absent rectoanal inhibitory reflex). ↗
▶ Ep 41 · 1:45
clinical If both internal and external sphincters have been overstretched, both become problematic. ↗
▶ Ep 41 · 1:57
clinical A patient who has voluntary bowel movements during the day but soils at night indicates working external sphincters but non-functioning internal sphincters; when sleeping, they relax the external sphincter and lose control. ↗
▶ Ep 41 · 1:57
quote One very typical scenario that we see, let me ask you, what do you think it means if you have a patient that has voluntary bowel movements during the day and has accidents when they go to sleep. ↗
▶ Ep 41 · 2:08
quote So at night, they poop, but during the day, they have control. What does that mean to you here? What, what is working and what is not working? ↗
▶ Ep 41 · 2:35
clinical Loss of dentate line can occur with overstretching and some preservation of external sphincter, resulting in daytime control but nighttime soiling. ↗
▶ Ep 41 · 4:53
quote I'm, I'm, I'm gonna sign off and you guys just, ↗
▶ Ep 41 · 4:58
clinical The rectum (not the anal canal) has proprioception capacity to detect stretch, which is the signal that stool is accumulating and it's time to hold stool and find a bathroom. ↗
▶ Ep 41 · 4:58
quote I actually, if I may add one more thing, I also think that there is a proprioception concept, the stretch. ↗
▶ Ep 41 · 5:07
clinical In anorectal malformation patients, the rectum should be preserved because rectal stretch provides proprioception. ↗
▶ Ep 41 · 5:22
quote That's called proprioception, and that's your signal. Uh oh, stool is accumulating. It's time to exert some authority over my external sphincter, hold the stool in and find a bathroom. ↗
▶ Ep 41 · 5:36
clinical When the internal sphincter is functioning properly, it relaxes at the time of rectal stretch. ↗
▶ Ep 41 · 5:43
quote This is why in ARM patients, in erectal malformation patients, giving them a stool softener is so problematic, because basically, they never feel the stretch. They just have loose stool flowing. ↗
▶ Ep 41 · 5:43
clinical Giving anorectal malformation patients stool softeners is problematic because they never feel the stretch; loose stool just flows and they will never have control of that. ↗
▶ Ep 41 · 5:58
clinical ARM patients are much better off with bulk (kicked out by a laxative) than a stool softener that slowly oozes out. ↗
▶ Ep 41 · 5:58
quote So they are much better off with bulk, which is then kicked out by a laxative, than a stool softener that just slowly oozes out, they'll never have control of that. ↗
▶ Ep 41 · 7:41
quote And they said, well, I'm not yet farting with confidence. ↗
▶ Ep 41 · 7:47
clinical Loose stool is the enemy if you have borderline continence or even completely normal continence, because you don't know for sure that it's there. ↗
▶ Ep 41 · 7:47
quote And what that says is so important because loose stool. Is your enemy if you have borderline continence. It's your enemy if you have completely normal continents. Right? Loose stool is hard to deal with, because you don't know for sure that it's there. ↗
▶ Ep 41 · 8:07
quote We are very dependent on the stretch, on the bulk of the stool in the rectum, and then that's when the external sphincter goes into motion, and the internal sphincter relaxes. ↗
▶ Ep 41 · 8:07
clinical We are very dependent on the stretch and bulk of stool in the rectum; that's when the external sphincter goes into motion and the internal sphincter relaxes. ↗
▶ Ep 41 · 8:19
clinical Hirschsprung patients with absolutely intact sphincters are dependent on that stretch; they don't have a rectum (it's been removed) and their sigmoid has taken over that job. ↗
▶ Ep 41 · 8:19
quote Patients with Hirschprung's disease, with absolutely intact sphincters. Are dependent on that stretch, remember, they don't have a rectum, it's been removed. Their sigmoid has now taken over that job. ↗
▶ Ep 41 · 8:32
quote If they have injured sphincters, they're particularly in trouble. ↗
▶ Ep 41 · 8:32
clinical Hirschsprung patients with injured sphincters are particularly in trouble regarding dependence on stool bulk and stretch. ↗
▶ Ep 41 · 9:00
quote This is a trick question because this patient's never had any surgery. This patient is about to get a biopsy to rule out Hirschrung's disease, and I took this picture of a absolutely totally normal, never touched dentate line. ↗
▶ Ep 41 · 10:44
quote I do think it's a myth to say that this patient cannot have bowel control. I think this patient can develop bowel control, provided their sphincters are working. ↗
▶ Ep 41 · 10:44
clinical A patient with missing dentate line can develop bowel control provided their sphincters are working, but they will be very sensitive to loose stool. ↗
▶ Ep 41 · 10:55
quote They will be very sensitive to loose stool. They won't be good at detecting that something is there unless they have bulk, but if they have the right diet and the right stool consistency, And sphincters that are intact, we can get this patient through, but it's really challenging if they have a missing dentate. ↗
▶ Ep 41 · 11:00
clinical Patients with missing dentate line won't be good at detecting that something is there unless they have bulk, but with the right diet, right stool consistency, and intact sphincters, they can achieve control. ↗
▶ Ep 41 · 11:38
quote So here you're about to go train in a wonderful children's hospital. If I asked you which side of this anoplasty did the fellow do, and which side did the faculty member do, what, what would your, what would your answer be? ↗
▶ Ep 41 · 11:58
quote Very good. You are ready for your fellowship. ↗
▶ Ep 41 · 12:35
quote I mean, this is just absolutely the worst. These patients, there are two of them here, show a horrific diaper rash, perineal excoriation related to no dentate line, no intact sphincters. ↗
▶ Ep 41 · 12:35
clinical Patients with horrific diaper rash and perineal excoriation related to no dentate line and no intact sphincters need temporary stomas; some may need permanent stomas. ↗
▶ Ep 41 · 12:48
quote These patients needed temporary stomas, and I think the one on the right needed a permanent stoma. ↗
▶ Ep 41 · 15:09
clinical In a soiling Hirschsprung patient with no obstruction, no distention, no enterocolitis, and 3 stools a day, that's a patient who needs management of a slow-moving colon. ↗
▶ Ep 41 · 19:10
quote I mean, the bottom line is we have solved the obstruction. The Hirschprung's is an obstruction problem. Now the tough part is getting them clean. Two separate and independent challenges. ↗
▶ Ep 41 · 19:10
clinical Hirschsprung disease is an obstruction problem; once that's solved, the tough part is getting patients clean—two separate and independent challenges. ↗
▶ Ep 41 · 19:22
clinical The vast majority of Hirschsprung patients get clean on their own and have great success stories. ↗
▶ Ep 41 · 19:22
quote Most of them get clean on their own. That's why Hirshprung's vast majority of patients have a great, great success stories. ↗
▶ Ep 41 · 19:30
clinical Clinicians need to determine if Hirschsprung patients are too slow or too fast, how to manipulate their motility, and understand if they have the mechanisms needed for continence (sphincters and dentate line). ↗
▶ Ep 41 · 19:30
quote But then we need to know, are they too slow or are they too fast? How do we manipulate their motility, and we need to understand inherently, do they have the mechanisms needed for continence, i.e., their sphincters and their dentate line. ↗
▶ Ep 41 · 20:00
clinical For hypermotile patients, skin care is vitally important; a cyanoacrylate-based barrier is very helpful. ↗
▶ Ep 41 · 20:12
clinical Wound care improvements for perineums in Hirschsprung or any hypermotile patient have dramatically improved over the last 4-5 years. ↗
▶ Ep 41 · 20:27
clinical Proton pump inhibitors are helpful to reduce the acidity of stool in hypermotile patients. ↗
▶ Ep 41 · 20:37
clinical Some antacid products can be taken orally as liquid and put on the skin to reduce acidity and help excoriation. ↗
▶ Ep 41 · 20:47
clinical Small volume enemas are a very helpful maneuver for hypermotile patients. ↗
▶ Ep 41 · 20:52
clinical Water-soluble fiber (not water-insoluble) produces bulky stool and is helpful for hypermotile patients. ↗
▶ Ep 41 · 21:05
clinical Loperamide is very helpful medicine for hypermotile patients; the maximum dose is 0.5 to 0.8 mg per kilogram divided daily based on patient weight. ↗
▶ Ep 41 · 21:24
clinical Cholestyramine is the next level of treatment after loperamide for hypermotile patients. ↗
▶ Ep 41 · 21:27
clinical Hyoscyamine (Levsin) 0.125 mg tablet every six hours has been used for hypermotile patients. ↗
▶ Ep 41 · 21:40
clinical Diphenoxylate-atropine (Lomotil) is almost never used because it has cardiac side effects. ↗
▶ Ep 41 · 21:55
clinical Tincture of opium is useful for slowing stool but is a controlled substance and difficult to get prescribed. ↗
▶ Ep 41 · 22:06
clinical If everything checks out with the pull-through and patients are still not emptying, Botox may be needed to help patients train and control their non-relaxing sphincters rather than being withholders. ↗
▶ Ep 41 · 24:49
quote But I will say, the hardest group of patients of all the soilers that we take care of. Which include anorectal malformation, Hirschsprung's, functional constipation, and spinal. The worst group, the hardest group is definitely Hirschprung's, without question, because the sphincters are so troublesome. ↗
▶ Ep 41 · 24:49
opinion Of all soiling patients (anorectal malformation, Hirschsprung, functional constipation, spinal), the hardest group is definitely Hirschsprung without question, because the sphincters are so troublesome. ↗
▶ Ep 41 · 25:09
quote Um, but of that group, the hypermodal are much harder than the hypomodal. ↗
▶ Ep 41 · 25:09
opinion Of Hirschsprung patients, the hypermotile are much harder to manage than the hypomotile. ↗
▶ Ep 41 · 25:14
quote But with strategies, you can really get a lot of these patients clean that were told they could never be clean. Um, if you sort of have your methodology, you know if they have potential for bowel control. And then you manipulate the motility as we've, as we've discussed. ↗
▶ Ep 41 · 25:14
opinion With systematic strategies—knowing if patients have potential for bowel control and manipulating motility accordingly—many Hirschsprung patients who were told they could never be clean can achieve cleanliness. ↗

Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula

▶ Ep 42 · 2:25
opinion Conversations about female perineal fistula management are more time-consuming than those about cloaca, and patients seek multiple opinions for this relatively benign malformation. ↗
▶ Ep 42 · 2:25
quote the conversations that go around a female, the perineal fistula are more time-consuming than the conversations that need to happen about a cloaca. ↗
▶ Ep 42 · 3:12
clinical If the hole is in the center of the sphincter with adequate lumen and a perineal body is present, the patient does not need surgery. ↗
▶ Ep 42 · 3:12
quote if the hole is in the center of the sphincter or it's in somewhat of the sphincter, and if the hole is enough of a lumen, and if there's a perineal body, that patient does not need to be touched. ↗
▶ Ep 42 · 3:24
clinical If the hole is too small or outside of the sphincter, surgery is required. ↗
▶ Ep 42 · 4:20
clinical There are five valid management options for perineal fistula: colostomy then repair, primary repair, dilation then repair, simultaneous colostomy and repair, and dilation alone. ↗
▶ Ep 42 · 5:23
quote diverting with a colostomy doesn't necessarily stop that from happening and You have the morbidity of a colostomy and of the colostomy closure, which is nothing to sneeze at. ↗
▶ Ep 42 · 5:23
clinical Diverting with a colostomy does not necessarily prevent perineal body dehiscence, and colostomy carries significant morbidity including closure complications. ↗
▶ Ep 42 · 5:46
quote this is not an emergency. They are passing stool, so the diversion of stool is not the reason for the colostomy, unless it's a very, very tiny fistula, and they can't pass stool, but that can be managed by, by dilation. ↗
▶ Ep 42 · 6:07
clinical Dilation alone is potentially acceptable but could be problematic if the fistulous distal end will not grow, leading to proximal distension. ↗
▶ Ep 42 · 7:38
clinical Anal stenosis (position 5 on the classification) requires screening for Currarino syndrome. ↗
▶ Ep 42 · 9:14
quote this vestibular fistula is not a vaginal fistula because the vaginal wall, the posterior vaginal wall is intact. There's no fistula to it. ↗
▶ Ep 42 · 9:14
clinical A vestibular fistula is not a vaginal fistula because the posterior vaginal wall is intact with no fistula to it. ↗
▶ Ep 42 · 9:34
epidemiological True vaginal fistulas are exceedingly rare in anorectal malformations. ↗
▶ Ep 42 · 10:50
clinical Some perineal fistulas (position 4 on the classification) can be managed with posterior wall mobilization without touching the anterior wall. ↗
▶ Ep 42 · 14:09
clinical Surgeons performing vaginoscopy should look for single versus duplicated cervix, distal vaginal atresia, and vaginal septum. ↗
▶ Ep 42 · 14:21
quote Incidence of vaginal atresia is quite rare, and vaginal septums are a little bit more common, somewhere around 3 to 5% of vestibulars. ↗
▶ Ep 42 · 14:21
epidemiological The incidence of distal vaginal atresia is quite rare in anorectal malformations. ↗
▶ Ep 42 · 14:28
epidemiological Vaginal septums occur in approximately 3 to 5% of vestibular fistulas. ↗
▶ Ep 42 · 14:36
clinical Perineal fistulas can be associated with distal vaginal atresia, though less commonly than vestibular fistulas. ↗
▶ Ep 42 · 16:36
clinical For patients with anorectal malformations and ureteral abnormalities, differential renal function assessment (such as DMSA scan) is important to determine whether to reimplant the ureter or remove a non-functional kidney. ↗
▶ Ep 42 · 17:20
clinical Absent kidneys in anorectal malformation patients are usually not truly absent but rather non-functional, often multicystic and dysplastic. ↗
▶ Ep 42 · 17:20
quote absent kidney, quote unquote. And it's usually not absent, it's more non-functional and it's often multicystic and dysplastic, not absent ↗
▶ Ep 42 · 17:44
quote every surgeon takes care of an interectal malformation, ought to know the type of malformation, the status of the spine, i.e., tethered cord or myelomeningocele, or in most cases, luckily normal, and the status of the sacrum ↗
▶ Ep 42 · 17:44
guideline Every surgeon caring for anorectal malformations should know the malformation type, spinal status (tethered cord, myelomeningocele, or normal), and sacral anatomy including sacral ratio. ↗
▶ Ep 42 · 18:15
quote this is an interesting patient with a very low type of malformation, however, with an associated spinal problem, and therefore their prognosis is not the same as a perineal fistula patient with a normal spine ↗
▶ Ep 42 · 18:15
clinical Sacral ratio calculation is valuable for informing family conversations about potential for bowel control in anorectal malformation patients. ↗
▶ Ep 42 · 18:15
clinical A patient with a low-type anorectal malformation (such as perineal fistula) but with associated spinal pathology has a different prognosis for bowel control than the same malformation with a normal spine. ↗

Colorectal Quiz Episode 29: Female ARM-Post Op Management

▶ Ep 43 · 1:17
quote So are you trying to say that I am a conservative surgeon because I may have a different protocol? ↗
▶ Ep 43 · 1:37
clinical Alberto Pena's original protocol mandated 7 days NPO with central line and hyperalimentation after ARM repair, feeding only on day 7 if healed. ↗
▶ Ep 43 · 2:42
quote I had a fellow that said, why exactly are you keeping these patients NPO? And I said, well, because I don't want them to stool, because if they stool, they're more likely to hiss their perineal body. And the fellow said, you know, they still stool. Even if they're NPO. And I said yes, but not as much. ↗
▶ Ep 43 · 2:42
quote And I had a fellow that said, why exactly are you keeping these patients NPO? ↗
▶ Ep 43 · 3:04
clinical A study by Carlos Reck (now in Vienna, Austria) compared NPO for 7 days versus clear liquids for 7 days and found the same amount of stool output in both groups. ↗
▶ Ep 43 · 3:29
quote Same amount of poop. ↗
▶ Ep 43 · 3:30
quote So then I came to the conclusion that it's not the pooping that's the problem, it's the hard pooping that's the problem. ↗
▶ Ep 43 · 3:30
clinical The problem is not stool passage itself but hard stool passage that can disrupt the perineal body anastomosis. ↗
▶ Ep 43 · 3:37
clinical Dr. Levitt's current protocol is regular IV (no PICC line), clear liquids or breast milk for 5 days, with very low dehiscence rate. Day 5 provides better healing than day 1-2. ↗
▶ Ep 43 · 3:58
opinion There is no published article showing post-op day 1 regular diet (not breast milk, but actual food or formula) with a very low dehiscence rate. ↗
▶ Ep 43 · 5:45
clinical Perineal body dehiscence usually leads to no perineal body over several months, requiring redo surgery because the anterior anoplasty has no sphincter around it (it's split). ↗
▶ Ep 43 · 5:45
quote And invariably, a perineal body dehiscence usually leads to no perineal body over several months, and needing for a redo because the anterior anoplasty has no sphincter around it, it's split. ↗
▶ Ep 43 · 5:59
quote And every single one of those that I see nearly, I ask them what was the feeding protocol, and in invariably they were fed right away and discharged to home. ↗
▶ Ep 43 · 5:59
clinical Nearly every redo case Dr. Levitt sees for perineal body dehiscence involved patients who were fed right away and discharged home. ↗
▶ Ep 43 · 7:43
quote All right, my friend, give them clear liquids. You're gonna make a lot happier families and kids. We tested it. We have a nice paper about clear liquids. ↗
▶ Ep 43 · 9:06
quote Richard Wood and I ran a randomized controlled trial of dilation and non-dilation for primary PSAP. Cloacass were excluded, and families knew that they were going to be randomized into one of two groups, and the backup plan, if a patient developed um a stricture was dilation, plus or minus a Heineke McCulitz anoplasty. ↗
▶ Ep 43 · 9:06
clinical A randomized controlled trial by Richard Wood and Dr. Levitt compared dilation versus non-dilation for primary PSARP (cloacas excluded). Families were randomized and knew the backup plan for stricture was dilation ± Heineke-Mikulicz anoplasty. ↗
▶ Ep 43 · 9:33
clinical In the dilation trial, both groups (dilation and non-dilation) had stricture rates somewhere between 10 and 20%. ↗
▶ Ep 43 · 10:25
clinical Many patients' anoplasties look absolutely fine 8 weeks later at colostomy closure if they were never touched with a dilator, provided the anoplasty was healthy with no tension and good blood supply. ↗
▶ Ep 43 · 10:45
clinical The dilation study was prompted by asking families their biggest concern about ARM care, and by far number one was dilations. This was family-driven research, not doctor-driven problem-solving. ↗
▶ Ep 43 · 10:50
quote And what prompted the paper was, and this was Richard's idea, was to ask the families, what is their biggest concern relative to care of patients with an anorectal malformation, and by far, number one was dilations. ↗
▶ Ep 43 · 11:21
quote This was a real family-driven research. ↗
▶ Ep 43 · 11:25
clinical The non-dilation protocol offers families a choice: dilate twice daily for 4 months, or accept a 10-15% risk of stricture requiring Heineke-Mikulicz anoplasty, with the child already going under anesthesia in 8 weeks for colostomy closure. ↗
▶ Ep 43 · 13:45
clinical Jack Langer's protocol is to see patients weekly in clinic and pass a dilator himself rather than having families do it at home. ↗
▶ Ep 43 · 15:35
quote We don't know the answer to that question. That's a more longer term follow up. ↗
▶ Ep 43 · 15:58
quote Have you negatively affected their continence 3 years hence? And I don't know the answer to that question. ↗
▶ Ep 43 · 16:38
clinical Full continence can be restored with a redo operation for stricture, and data is available showing this. One indication for redo is stricture. ↗
▶ Ep 43 · 16:56
quote I personally have come to the conclusion that the amount of morbidity that we're putting families through by dilating them, and the minimal risk to them of even needing an intervention. And then if they do need an intervention, it's relatively minor, and the vast majority of those, they're already undergoing surgery for their colostomy closure. ↗
▶ Ep 43 · 17:12
clinical The vast majority of patients needing intervention for stricture in the non-dilation protocol are already undergoing surgery for colostomy closure, making the intervention relatively minor. ↗
▶ Ep 43 · 17:21
quote I can tell you, I have yet to, I have yet to meet a family that has chosen dilation. ↗
▶ Ep 43 · 17:21
clinical Dr. Levitt has yet to meet a family that has chosen dilation when presented with the non-dilation option and its risks/benefits. ↗
▶ Ep 43 · 18:31
quote I think the good news is that there's no right answer, we just have to all work together and suffer together on these difficult problems and try to, uh, improve lives as best we can. ↗
▶ Ep 43 · 19:37
clinical In Ghana, a colleague makes anoplasties slightly bigger knowing patients won't return for follow-up, anticipating some contraction will occur. ↗
▶ Ep 43 · 20:18
clinical For redo ARM cases, Dr. Levitt makes the anoplasty a little bigger knowing there will be contraction. Redos are not dilated at all, but are examined under anesthesia at one month to check for early stricture. ↗
▶ Ep 43 · 20:26
quote We don't dilate the redos, period. We EUA them at a month just to make sure no early stricture is developing. ↗
▶ Ep 43 · 20:33
quote In the primaries, I basically make the lumen what the rectum needs, what the maximal rectal lumen can be. And whatever that is, that fills the sphincter, that's how I make the anoplasty. ↗
▶ Ep 43 · 20:33
clinical For primary repairs, Dr. Levitt makes the lumen match what the maximal rectal lumen can be. With good mobilization (not overdoing it, throwing away as little rectum as possible), the anoplasty is usually a good size, about Hegar 13 or 14 at the end. ↗

Is Multi-disciplinary care the future of medicine?

▶ Ep 52 · 2:07
quote Thank you, Sophie. Hi everybody, nice to see you in this uh venue, um, we. Love spending time with you. We are very dependent upon you, uh, for this collaboration ↗
▶ Ep 52 · 2:30
quote What I put together today has two parts. One is what is our colorectal center all about, what we're trying to achieve here at Children's National. Um, and the second part is very specific to what are the colorectal anesthesia collaborations ↗
▶ Ep 52 · 3:50
quote This is a physiologic process that everyone deals with and honestly everyone pretty much takes for granted ↗
▶ Ep 52 · 4:00
clinical Most families who have a baby born with an anorectal malformation have never heard that such a condition could happen and experience psychological shock ↗
▶ Ep 52 · 4:10
quote many families, in fact, most families who have a baby that's born with an anorectal malformation, never heard that that was ever something that could happen ↗
▶ Ep 52 · 5:30
clinical The Babylonian Talmud from 2000 years ago describes that if an infant whose anus is not visible is born, they should be rubbed with oil and stood in the sun, and where it shows transparent should be torn crosswise with a barley grain, representing an early description of anoplasty ↗
▶ Ep 52 · 6:20
clinical The first PSARP (posterior sagittal anorectoplasty) was performed in 1980, making modern functional colorectal reconstruction techniques much more recent than other congenital surgeries like esophageal atresia and diaphragmatic hernia repairs from the 1950s ↗
▶ Ep 52 · 6:20
quote Really the modern techniques of how to actually do a reconstruction that not just conveys survival, but also conveys function. It's very recent in the world of pediatric surgery. The first PSARP was in 1980 ↗
▶ Ep 52 · 6:40
clinical Before modern techniques, anorectal malformation patients survived but suffered from constipation and fecal incontinence due to poor surgical outcomes that rescued the anus but did not create function ↗
▶ Ep 52 · 7:20
quote Our goal is not only to do a good anatomic reconstruction, but it's also to create a functional anus that the patient can go to normal school and have wear normal underwear and all of those things that everyone else takes for granted ↗
▶ Ep 52 · 7:20
clinical The goal of colorectal reconstruction is not only anatomic repair but creating a functional anus that allows the patient to attend normal school and wear normal underwear ↗
▶ Ep 52 · 8:10
quote if you think about something parallel in our lives like a cloacal reconstruction. Most of the world doesn't function in the way these individuals function to plan this bridge ↗
▶ Ep 52 · 8:35
quote what happens is maybe the pediatric surgeon deals with the rectum and doesn't think too much about the urologic system. Doesn't even consider that there might be gynecologic implications of what they're doing ↗
▶ Ep 52 · 9:00
clinical Alberto Pena, the father of pediatric colorectal surgery who performed the first PSARP in 1980, initially provided all aspects of care alone including colorectal surgery, urology, gynecology, psychology, and social work ↗
▶ Ep 52 · 9:30
quote I watched what he was doing. And in those days, he had, um, uh, written about the PSAC. It was only 12 years old at that point. And still, he was already quite well known and patients were coming from all over, but he was a lone wolf in the care of these patients ↗
▶ Ep 52 · 10:00
opinion Dr. Levitt trained with Alberto Pena as a medical student in 1992 and recognized he could never provide that level of complex care alone, which led to conceiving the collaborative care model ↗
▶ Ep 52 · 10:10
quote he used to joke that if someone would call the office and say, can I speak to the colorectal surgeon, he would say, you got him. That's me. All right, can you patch me through now to the urologist? He would say I do the urology as well. Do you have a gynecologist on your staff? I got that covered. Psychology, social work, I handle it all ↗
▶ Ep 52 · 10:50
quote I watched this as a medical student and I was actually quite intimidated by the possibility that there's no way I could possibly provide that level of complexity of care, particularly with the way medicine was moving ↗
▶ Ep 52 · 13:00
clinical Babies with anorectal malformations are almost always full-term and healthy with no prenatal expectation of the condition ↗
▶ Ep 52 · 13:30
clinical When families learn their baby has an anorectal malformation, their primary question is whether their child will be normal at age 4 during potty training, not about surgical technique elegance ↗
▶ Ep 52 · 13:40
quote As soon as they figure out that there's a problem with the anus, I can assure you also, they don't care much about how elegant is our technique to perform an anoplasty. Their question is, will my child be normal when they're age 4 and are supposed to be potty training ↗
▶ Ep 52 · 14:10
opinion The mission of colorectal surgery is achieving good functional results, not just anatomic reconstruction, as anatomic correction without function is inadequate (analogous to correcting scoliosis but leaving the child unable to walk) ↗
▶ Ep 52 · 14:20
quote our job. Is to do an anatomic reconstruction with a good functional result. Because a good anatomic reconstruction without a good functional result. Think about any of the surgeries you do. It's all about correcting the anatomy or getting a good functional result ↗
▶ Ep 52 · 15:20
clinical The bladder, gynecologic system, and rectum all fill the pelvis with intertwined anatomy, making collaboration between colorectal, urology, and gynecology essential ↗
▶ Ep 52 · 15:40
quote How could colorectal urology and gynecology not collaborate? It makes very little sense for us not to work closely together ↗
▶ Ep 52 · 16:00
clinical Children's National is the World Center for Cloacal Care, having performed 32 cloacal reconstructions in the last 4 years, while most centers see one cloaca every 5 years ↗
▶ Ep 52 · 16:10
quote this is the World Center for Cloacal Care. I think today's is the 32nd Cloaca in the last 4 years. Most centers see one Cloaca every 5 years ↗
▶ Ep 52 · 17:30
clinical Cloacal malformations may be prenatally diagnosed through identification of large pelvic mass, hydronephrosis, or missing kidney on ultrasound ↗
▶ Ep 52 · 18:00
clinical Hydrocolpos (vagina filled with urine) in newborns with cloaca can depress respiration, cause kidney failure, and cause hydronephrosis, requiring immediate management ↗
▶ Ep 52 · 19:00
clinical Patients with anorectal malformations often have associated neurologic problems, may have a single kidney or chronic kidney disease, and may have abnormal gynecologic anatomy including duplicated Mullerian systems ↗
▶ Ep 52 · 19:40
clinical Sacrum and spine quality are used to predict continence outcomes and allow confident prognostic discussions with families on the first day of life ↗
▶ Ep 52 · 20:20
clinical A patient with a favorable malformation, good quality sacrum, and normal spine will have continence in 4 years after reconstruction ↗
▶ Ep 52 · 20:20
quote if a patient has a favorable malformation, a good quality sacrum and a normal spine, I can tell the family very confidently your child will have continence in 4 years after the reconstruction ↗
▶ Ep 52 · 20:50
clinical A patient born with myelomeningocele will not be continent in 4 years, but bowel management programs can achieve functional outcomes ↗
▶ Ep 52 · 20:50
quote If they are born with a myelomeningocele, I will tell them they will not be continent in 4 years, but we will have bowel management programs ↗
▶ Ep 52 · 21:20
quote our mission is not just the anatomic reconstruction, but to get them to be functionally doing what all other kids are doing ↗
▶ Ep 52 · 22:20
clinical In a cloaca, the rectum, vagina, and bladder all form one confluence with a single exit, and the surgical goal is to create three separate openings ↗
▶ Ep 52 · 22:40
quote cloaca actually is from the French word. We have some French speakers here, I believe, which means sewer ↗
▶ Ep 52 · 22:40
clinical The term 'cloaca' comes from the French word meaning sewer, and birds have cloacas that combine fecal and urinary output ↗
▶ Ep 52 · 23:00
quote for those of you who ever had a bird poop on your car, you would know that they combine the poop and the pee together because they all have cloacas ↗
▶ Ep 52 · 24:00
clinical The Malone procedure involves taking the appendix, connecting it to the belly button, and using it as a conduit to flush the colon once daily, resulting in no bowel movements for 24 hours and allowing a clean child who can wear normal underwear without requiring continence or sphincters ↗
▶ Ep 52 · 24:20
quote we take the appendix, connect it to the belly button, and through the appendix, the patient can be flushed. Their colon can be flushed once a day. They don't poop for the next 24 hours. Very reliable system ↗
▶ Ep 52 · 24:20
clinical The center performs approximately 100 Malone procedures per year ↗
▶ Ep 52 · 24:50
clinical Fifteen years ago there was one collaborative colorectal center in Cincinnati, and now such centers have spread throughout the world ↗
▶ Ep 52 · 24:50
clinical The colorectal program provides care from 20-week fetal diagnosis through adulthood, including a new transition program with Erin Tel in collaboration with MedStar for adult care ↗
▶ Ep 52 · 24:50
clinical In the UK, biliary atresia and bladder exstrophy are specifically concentrated at certain centers and cannot be operated on at other centers due to recognized expertise benefits of the collaborative model ↗
▶ Ep 52 · 24:50
opinion Low surgical volume is one reason for poor outcomes and the need for reoperations in anorectal malformation surgery, supporting the case for regional centers of expertise ↗
▶ Ep 52 · 24:50
quote I believe this is one of the reasons why we see so many redos, which is why I've been a big advocate for regional centers ↗
▶ Ep 52 · 24:50
clinical An appendix can be split to create both a Malone channel (for colon flushing) and a Mitrofanoff channel (for bladder catheterization) from a single appendix ↗
▶ Ep 52 · 24:50
epidemiological There are 600 newborns with anorectal malformations born per year in the United States ↗
▶ Ep 52 · 24:50
quote There are 600 newborns with ARM per year born in the United States. There are pediatric surgery fellows. We have those training right here. They do about 14 cases in 2 years, and a pediatric surgeon does about one case per year. How are they possibly supposed to have enough experience and expertise to get it right? ↗
▶ Ep 52 · 24:50
quote I just want you to think about the fact that I was at a bowling alley. Having a conversation about a cloaca. With the gentleman who was asked to drill only one hole ↗
▶ Ep 52 · 24:50
epidemiological Pediatric surgery fellows perform about 14 anorectal malformation cases in 2 years of training, and a general pediatric surgeon does about one case per year ↗
▶ Ep 52 · 24:50
quote In, for example, in the UK, biliary atresia and bladder atrophy are specifically focused at certain centers. They are not able to be operated on in other centers because the country recognized the expertise that was available by having the collaborative model in one or two locations ↗
▶ Ep 52 · 24:50
clinical In patients with myelomeningocele requiring both urinary and fecal management, bladder augmentation can be performed using a segment of colon, which simultaneously makes the bladder bigger and the colon shorter and easier to empty, solving both problems in one operation ↗
▶ Ep 52 · 25:00
quote You don't need continence. You don't need sphincters. As long as the poop comes out at a specific time and no poop comes anymore for the next 24 hours, you have a clean child that can wear normal underwear ↗
▶ Ep 52 · 25:40
clinical If a patient does not have an appendix, one can be surgically created for the Malone procedure ↗
▶ Ep 52 · 25:50
quote if the patient doesn't have an appendix, we can actually make one ↗

Colorectal Quiz Episode 38: Transitional Care in Colorectal Surgery

▶ Ep 55 · 3:37
quote I encourage you to do examinations under anesthesia. This is a very valuable maneuver for ARM patients who have had a previous surgery. ↗
▶ Ep 55 · 3:37
clinical Examination under anesthesia is a valuable maneuver for ARM patients with previous surgery, allowing assessment of anoplasty prolapse, stricture, and proper location via electrical stimulation. ↗
▶ Ep 55 · 4:15
clinical In males, cystoscopy is added to evaluation to rule out remnant fistula and assess bladder mucosa and emptying; in females, cystoscopy can identify inappropriate fistulas. ↗
▶ Ep 55 · 5:28
quote I was just going to say from a very functional point of view, what what's missing here is sphincters anterior to the anoplasty. ↗
▶ Ep 55 · 5:28
clinical The functional problem is absence of sphincter anterior to the anoplasty: when the patient squeezes, the sphincter cannot close the anterior aspect and stool slips out, whereas proper concentric sphincter placement would successfully close the hole. ↗
▶ Ep 55 · 5:36
quote So when the patient with very good sphincters tries to squeeze those sphincters, they simply cannot close the anterior aspect of the anus, and stool can slip out of there, whereas if the anoplasty was properly located and the sphincter was concentric. They would successfully close the hole, and that's the incontinence problem ↗
▶ Ep 55 · 5:54
clinical The most common problem in females requiring redo surgery is absence of a circular sphincter (an O), either from improper initial placement or dehiscence of the perineal body leaving a C-shaped sphincter; the surgical goal is to get muscle in front of the anus. ↗
▶ Ep 55 · 5:54
quote it's the most common problem in females that Jason and I have done redos for, uh, because there simply is no circle ↗
▶ Ep 55 · 9:52
clinical The strategy of non-diversion with postoperative clear liquids (not NPO/TPN) produces soft watery stool that does not harm the perineal repair, whereas real food produces harder stool that can disrupt the repair; patients and families are much happier avoiding PICC lines and TPN. ↗
▶ Ep 55 · 10:22
quote my impression is that if you give someone real food. They make harder stool which can then blow through your perineal repair, whereas if you give the patient clear liquids, the stools that they produce are very soft and very watery, which don't do anything really to the wound care ↗
▶ Ep 55 · 10:55
clinical At 5 days, if perineal healing looks good, diet is advanced with laxatives to keep stool liquidy; the problem is hard stool going through the repair, not stool itself, as long as the wound is kept clean. ↗
▶ Ep 55 · 11:12
quote I think the problem is hard stool going through your repair, not stool. As long as you're keeping the wound clean, we have not had a problem, and I have not, uh, needed to divert, uh, such a patient. ↗
▶ Ep 55 · 16:03
opinion The ideal transition model begins psychologic discussion in early teenage years, engages friendly adult colleagues, and involves joint clinic visits and collaborative operating; most pediatric surgeons understand this because they have received calls from adult surgeons encountering unfamiliar pediatric conditions like malrotation. ↗
▶ Ep 55 · 17:16
opinion Not all pediatric colorectal surgeons need to physically operate in the adult setting if there are interested adult colleagues; in Jason Frischer's model, he has privileges at the adult hospital but functions primarily as an assistant while the adult surgeon (Ian Piquette) provides adult care expertise. ↗
▶ Ep 55 · 18:00
clinical In the United States, the age line for pediatric vs. adult care is very blurry, which is problematic; patients over age 21 (or possibly 18) at children's hospitals face credentialing issues where pediatric nurse practitioners cannot write orders due to licensing restrictions. ↗
▶ Ep 55 · 18:46
clinical If a 40-year-old at a children's hospital needs ICU care, the intensivists are pediatric-trained, not adult-trained, creating a safety concern. ↗
▶ Ep 55 · 20:11
opinion Bowel management expertise needs to be passed not just doctor-to-doctor but also nurse-to-nurse and advanced practice provider (NP/PA) to advanced practice provider. ↗
▶ Ep 55 · 20:23
opinion Adult colleagues should be introduced to the Malone appendicostomy (which many have never heard of) and the use of Peristeen for self-controlled enemas in adults; these are tricks learned in the pediatric population. ↗
▶ Ep 55 · 20:46
opinion In the United States, financial pressures favor operations, but many ARM patients do not require operations—they just need medical management that can change their life positively; one week of bowel management can achieve continence in a patient who has been soiling for decades. ↗
▶ Ep 55 · 21:11
opinion The presented case converted a patient with 27 years of fecal incontinence to normal bowel control by changing anatomy, but this is not always an option; medical management is important, and transition will require devoted colleagues not solely motivated by procedures. ↗
▶ Ep 55 · 23:25
opinion A patient-held 'passport' template documenting all previous surgical procedures, dates, and medical history should be created and distributed to parent organizations so each family is responsible for maintaining their own record to hand to any new care provider. ↗
▶ Ep 55 · 24:07
clinical Transitional care is being done well in several places worldwide, including Paris where pediatric and adult surgeons join each other's clinics for the first couple of visits. ↗

Colorectal Quiz: Episode 49 – Collaborating for Kids: Colorectal & Pelvic Solutions (with a Little Help from AI)

▶ Ep 65 · 2:41
quote I was expecting lots of errors and a very computer sounding experience, and it wasn't that at all. ↗
▶ Ep 65 · 3:00
quote The computer read, and I put that in quotes, the article fully and then knew what was coming later in the article to get us as the listener excited about it. ↗
▶ Ep 65 · 6:39
clinical A urologist produced a review article outline in minutes using Notebook LM with 30 articles, a task that previously took two weeks. ↗
▶ Ep 65 · 7:08
clinical AI can identify gaps in knowledge across a set of uploaded research articles. ↗

Colorectal Quiz: Episode 49 – Collaborating for Kids: Colorectal & Pelvic Care (with Help from AI)

▶ Ep 82 · 0:48
quote We did something crazy. I uploaded an article that Jason Fisher and I wrote together about the collaborative model in colorectal care, published in seminars in pediatric surgery and loaded that article using AI into a podcast format. ↗
▶ Ep 82 · 2:41
opinion The AI-generated podcast voices were human-sounding, accurate, and foreshadowed content from later in the article ↗
▶ Ep 82 · 2:41
quote I was expecting lots of errors and a very computer sounding experience, and it wasn't that at all. It was a lovely two human sounding voices that were chatting about the article that Jason and I wrote. ↗
▶ Ep 82 · 3:00
quote The computer read, and I put that in quotes, the article fully and then knew what was coming later in the article to get us as the listener excited about it. ↗
▶ Ep 82 · 6:39
clinical A neurology review article that took 2 weeks to write 5 years ago can now be produced in minutes using Notebook LM with the same 30 source articles ↗
▶ Ep 82 · 6:52
quote They just did the same exercise with Notebook LM and they put the same 30 articles in. And of course it produced a very elegant outline in minutes, basically something that took 2 weeks to do only 5 years ago. ↗
▶ Ep 82 · 7:08
clinical Notebook LM can identify gaps in knowledge from a set of articles and recognize when new articles fill those gaps ↗

Colorectal Quiz Episode 1 - Low Bulbar Fistua

▶ Ep 83 · 3:01
guideline Patients with anorectal malformations require evaluation for associated VACTERL anomalies: vertebral abnormalities (plain X-ray), cardiac defects (exam and echo), esophageal atresia (NG tube passage), renal abnormalities (kidney ultrasound), and limb abnormalities (physical exam). ↗
▶ Ep 83 · 3:34
quote We want to make sure we've checked for any cardiac defect both on exam and on echo. ↗
▶ Ep 83 · 3:55
clinical Sacral ratio measurements should wait until the child is 3 months of age for true accuracy, though early imaging gives a preliminary sense of pelvic development. ↗
▶ Ep 83 · 4:33
epidemiological Presacral masses are rare in typical imperforate anus but occur in almost half of patients with anal stenosis or rectal atresia defects, requiring MRI evaluation. ↗
▶ Ep 83 · 5:44
clinical The 24-hour waiting period allows the baby to declare whether they need a colostomy or might benefit from primary repair if a perineal fistula develops. ↗
▶ Ep 83 · 5:44
quote It's important that if this baby was born today, we're not rushing to do anything, because we need time to have this baby declare themselves to either be someone who's going to need a colostomy or someone who might be able to benefit from a primary repair. ↗
▶ Ep 83 · 7:01
quote The air column has really risen very nicely, and boy is that thing close to the perineal skin. It's right there, isn't it? ↗
▶ Ep 83 · 7:20
quote I bet this kid is gonna have a pretty normal acle ratio, certainly greater than 0.7. Which connotes a very good prognosis for bowel control and really peace of mind for the family. ↗
▶ Ep 83 · 7:20
clinical A sacral ratio greater than 0.7 connotes very good prognosis for bowel control and provides peace of mind for families regarding potty training and school readiness at age 4 years. ↗
▶ Ep 83 · 9:06
clinical The key to deciding whether to perform primary posterior sagittal anorectoplasty is knowing where the rectum is located—the first structure encountered should be rectum, not urethra, bladder neck, or bladder. ↗
▶ Ep 83 · 9:06
quote The key to deciding whether to dive into a perineum and posterior sagiti is where is the rectum. You wanna know that the what structure you will find if you make a posterior sagittal or even a mini posterior sagittal incision. ↗
▶ Ep 83 · 9:25
quote The danger is that you go in posterior sagitary, you don't know where the rectum is, and you find something midline and white, like the urethra, the bladder neck or the bladder itself. ↗
▶ Ep 83 · 9:42
clinical Colostomies and distal colostograms are performed to know exactly where the rectum is and whether to approach it perineally or laparoscopically. ↗
▶ Ep 83 · 10:18
quote I will tell you that the surgeon who sent me this case, they did not do that. They felt more comfortable doing a colostomy, and I wanna tell you, that was the safe thing to do. Bravo to them. That was the right choice. ↗
▶ Ep 83 · 10:24
opinion Performing a colostomy is the safe choice and was the right decision in this case, though it subjects the child to colostomy-related complications and later colostomy closure with its own complications. ↗
▶ Ep 83 · 10:34
quote We are giving the child a colostomy. And whatever complications can happen from that, and we are giving the child a colostomy closure, and whatever complications can happen from that. So everything in medicine is a balance, but there is no question that the anal part has been made safer by having a colostomy. ↗
▶ Ep 83 · 10:48
opinion Colostomy makes the definitive anoplasty safer, representing a balance of risks in medical decision-making. ↗
▶ Ep 83 · 11:10
quote If you went in and grabbed this rectum and did a primary anoplasty. And did not know there was a fistula, and unfortunately, I have seen this done by some very good surgeons where they went in, did a beautiful anoplasty, but ignored the fistula, and the child down the road started peeing out their anus. ↗
▶ Ep 83 · 11:20
clinical Very good surgeons have performed primary anorectoplasty on low defects without knowing about a fistula, resulting in children who later urinate through the anus. ↗
▶ Ep 83 · 12:09
quote When I do that, I open up the posterior wall of the rectum and I inspect the anterior wall of the rectum. ↗
▶ Ep 83 · 12:09
clinical During primary posterior sagittal repair, the surgeon should open the posterior wall of the rectum and inspect the anterior wall to rule out a fistula. ↗
▶ Ep 83 · 13:44
epidemiological 95% of patients with Down syndrome and imperforate anus have no fistula, but 5% do have a fistula, so distal colostogram is still indicated. ↗
▶ Ep 83 · 13:48
quote 95% of Down's patients have no fistula, but 5% do. So I would still do a distal colostogram, and some of them might have a fistula. ↗

Episode 19 - Interview with Dr Marc Levitt, Chief of Colorectal & Pelvic Reconstruction, Children‘s

▶ Ep 84 · 4:29
clinical The first dedicated colorectal center was launched at Cincinnati Children's Hospital in 2005, 16 years before this interview. ↗
▶ Ep 84 · 6:50
opinion Training surgeons provides exponentially greater impact than treating individual patients because trained surgeons can help hundreds or thousands more patients in their own cities. ↗
▶ Ep 84 · 8:40
clinical The bowel management program is a major advance in ARM care, involving focused nursing attention for 4-5 days with good long-term follow-up to achieve continence. ↗
▶ Ep 84 · 9:12
clinical Integration of urology and bladder management has revolutionized ARM care; kidney transplant was previously not uncommon but is now exceedingly rare due to better urologic care. ↗
▶ Ep 84 · 9:41
clinical Gynecologic collaboration has eliminated nervousness about menstruation problems at puberty because anatomy is now well understood through multidisciplinary care. ↗
▶ Ep 84 · 11:06
opinion Transition care for ARM patients into adult services is the most deficient aspect of the field, lagging behind congenital heart disease and cystic fibrosis programs. ↗
▶ Ep 84 · 12:12
clinical Only three surgeons worldwide are trained in both pediatric and adult colorectal surgery: Ali Gisher in Columbus Ohio, Erin Teeple in Wilmington Delaware, and Mark [last name not recalled] in Munich Germany. ↗
▶ Ep 84 · 13:16
clinical Paris at Necker Children's Hospital has an exemplary transition model where teenagers meet pediatric and adult providers together, then subsequent visits occur at the adult facility. ↗
▶ Ep 84 · 15:21
epidemiological At dedicated colorectal centers, at least half of the surgical work is reoperative surgery for patients with anatomic issues causing soiling problems. ↗
▶ Ep 84 · 17:48
clinical ARM surgery differs fundamentally from typical surgery because it requires years of tinkering and medical management rather than immediate anatomic cure. ↗
▶ Ep 84 · 18:14
quote If this field was easy, everyone would do it. ↗
▶ Ep 84 · 19:27
quote The complex colorectal operation takes about 4 hours, but to deliver a good result, you need 96 more hours of tinkering. Almost all of that is nursing care. ↗
▶ Ep 84 · 19:27
clinical A complex colorectal operation takes about 4 hours, but delivering a good functional result requires 96 more hours of tinkering, almost all of which is nursing care. ↗
▶ Ep 84 · 20:01
opinion Most families would agree they would rather change a colostomy bag than a diaper if the colostomy is properly constructed. ↗
▶ Ep 84 · 20:44
clinical The delayed feedback problem in ARM surgery: if the anus is misaligned with sphincters at 6 months, the surgical error may not be discovered until potty training fails at age 4 years. ↗
▶ Ep 84 · 21:13
quote How is the surgeon supposed to fix their technique if they're only discovering their problem 4 years later? ↗
▶ Ep 84 · 22:30
epidemiological In typical US pediatric surgery training programs, fellows see approximately 12 ARM cases over two years of training. ↗
▶ Ep 84 · 22:57
epidemiological The average practicing pediatric surgeon performs approximately one ARM case per year after completing training. ↗
▶ Ep 84 · 24:29
clinical Pull-through surgery should be performed and colostomy closed in virtually all ARM patients; with proper bowel management and nursing care, patients can achieve continence mechanically. ↗
▶ Ep 84 · 24:29
quote I don't want any kid to have a colostomy. I want everyone, I want those kids typical, normal, just like all the other kids. ↗
▶ Ep 84 · 25:03
clinical Patients without innate sphincter anatomy can still be cleaned mechanically by emptying the colon once daily through bowel management programs. ↗
▶ Ep 84 · 25:29
clinical Permanent colostomy may be more practical for rare patients who do not ambulate, but the vast majority can be clean with stool flowing through the normal anal route. ↗
▶ Ep 84 · 25:54
quote You would be amazed how many patients actually develop bowel control even if they were predicted that they would never achieve bowel control, again with proper nursing care and tinkering with their medical regimen. ↗
▶ Ep 84 · 25:54
clinical Many patients develop bowel control even when predicted they would never achieve it, with proper nursing care and medical regimen tinkering. ↗
▶ Ep 84 · 30:05
epidemiological Approximately 25 countries currently have specialized colorectal centers, but there are over 110 countries in the world requiring such programs. ↗
▶ Ep 84 · 31:10
epidemiological Family surveys identified the dilation process as the most stressful part of colorectal care for ARM patients. ↗
▶ Ep 84 · 32:07
clinical A randomized controlled trial comparing standard dilation protocol versus no dilation found similar stricture rates of approximately 15% in both groups. ↗
▶ Ep 84 · 32:49
clinical Strictures can be treated with a minor Heineke-Mikulicz anoplasty at the time of colostomy closure, making the downside of the no-dilation approach acceptable. ↗
▶ Ep 84 · 33:29
clinical Based on the randomized trial, Levitt's centers no longer perform routine post-operative dilations, and families universally choose to avoid them when offered the choice. ↗
▶ Ep 84 · 35:09
clinical Skin irritation and frequent stools after colostomy closure typically last about 2 weeks as the distal colon segment learns to absorb water and thicken stool. ↗
▶ Ep 84 · 35:56
clinical The problem switches to constipation at approximately 3 weeks post-closure; surgeons who don't aggressively manage this allow colon dilation that makes later potty training harder. ↗
▶ Ep 84 · 36:36
clinical Almost all ARM patients should be on laxatives about 3-4 weeks after colostomy closure to maintain stool flow and prevent colon dilation. ↗
▶ Ep 84 · 36:58
clinical The goal by age 2-3 years is establishing a pattern of one to two well-formed stools per day using diet with bulk fiber and senna-based laxatives. ↗
▶ Ep 84 · 37:33
clinical Stool softeners make ARM patients worse, not better, because loose stool prevents the rectal stretch sensation needed to develop bowel control in patients with surgically created anal canals. ↗
▶ Ep 84 · 37:56
clinical ARM patients lack typical anal canal sensation and may have inadequate sphincters, making them dependent on rectal stretch from bulky stool to feel the urge to defecate. ↗
▶ Ep 84 · 39:09
clinical Bowel management with enemas should be introduced when the child should be in normal underwear according to family circumstances, typically age 3-5 years, certainly by age 5. ↗
▶ Ep 84 · 40:11
clinical Bowel management programs are nurse practitioner-led and begin with anatomic assessment, as any anatomic issues should be corrected first, though bowel management can proceed even with imperfect anatomy. ↗
▶ Ep 84 · 41:17
clinical Bowel management involves mechanical colon emptying with saline plus additives that provoke stool emptying, with the goal of 24-hour cleanliness between flushes. ↗
▶ Ep 84 · 42:24
clinical Initial bowel management programs last approximately 4-5 days with X-ray monitoring, but success must be measured at one year, not one week. ↗
▶ Ep 84 · 43:16
clinical Published research showed bowel management success rates well over 80% at one year for ARM patients, with Hirschsprung's disease being the hardest group due to sphincter dysfunction. ↗
▶ Ep 84 · 44:31
epidemiological Approximately 75% of ARM patients should develop their own voluntary bowel control based on good operation, good sacrum quality, and good spine quality. ↗
▶ Ep 84 · 44:47
epidemiological Approximately 25% of ARM patients will not achieve voluntary bowel control even with perfect surgery due to inadequate sphincters or spinal issues and will require bowel management. ↗
▶ Ep 84 · 45:04
quote I can tell you many patients will choose the route for the enema to not be the rectum, but to be the appendix connected to the umbilicus. ↗
▶ Ep 84 · 45:31
clinical Levitt performs over 100 Malone appendicostomies per year laparoscopically as one-hour procedures with one-night hospital stays. ↗
▶ Ep 84 · 45:54
clinical The Malone appendicostomy route through the umbilicus makes it easier for older children to administer enemas independently without parental help. ↗
▶ Ep 84 · 46:30
clinical A full-fledged colorectal center requires an integrated psychologist who meets every patient proactively rather than being called only when problems arise. ↗
▶ Ep 84 · 48:22
clinical Fecal incontinence is a physiologic problem, not a psychologic problem; many patients receiving extensive psychological help actually need anatomic re-operation and good bowel management first. ↗
▶ Ep 84 · 48:39
quote There are many patients that get emotional help, psychologic help that actually what they needed was a re-operation and good bowel management. And then all the psychological and emotional problems go away because the kid's now clean and in normal underwear. ↗
▶ Ep 84 · 51:16
epidemiological Greg Ryan went 52 years before meeting another ARM patient, illustrating the historical isolation that modern patient networks have eliminated. ↗
▶ Ep 84 · 52:56
clinical Modern ARM care originated in Melbourne Australia with Dr. Kelly, who taught Dr. Stevens, who taught Dr. Pena, who revised and launched the PSARP operation in 1980. ↗

2019 Chandler Lecture: Dr. Marc Levitt

▶ Ep 85 · 0:40
quote How do you think this project started? Just think about how this got built, and I predict that a group of people got in a room. And designed this and said, what do you want it to look like and how tall does it need to be and what's the order of events and when do we pour the cement and when do we put the steel and Architects and engineers and all of these people got organized and then said, OK, what date are we starting? And that sounds extremely logical for this project, but I can tell you in medicine it's rarely done this way. ↗
▶ Ep 85 · 1:18
opinion In medicine, care is often uncoordinated: a colorectal surgeon may repair a colorectal problem without addressing a bladder issue, and six months later a urologist discovers the need for intervention after the patient has already had a laparotomy. ↗
▶ Ep 85 · 6:15
guideline In the UK, biliary atresia and bladder exstrophy can only be treated at certain designated medical centers because experience improves outcomes. ↗
▶ Ep 85 · 7:09
clinical Walmart sends employees anywhere in the United States to Cleveland Clinic for coronary surgery because they have designated it their go-to place for open heart surgery. ↗
▶ Ep 85 · 8:05
epidemiological There are approximately 600 newborns with anorectal malformations born per year in the United States. ↗
▶ Ep 85 · 8:05
epidemiological A pediatric surgery fellow does about 14 anorectal malformation cases in 2 years, and a graduate does about 1 case per year. ↗
▶ Ep 85 · 8:20
clinical Complications of anorectal malformation surgery include fecal incontinence, urinary incontinence, renal dysfunction requiring renal transplant, sexual dysfunction, and infertility. ↗
▶ Ep 85 · 8:47
clinical If a surgeon misplaces the anus outside the sphincters during surgery on a 6-month-old, the error will not be apparent until the child is 4 years old and attempting to potty train. ↗
▶ Ep 85 · 10:27
quote Did you notice how long it took surgeon 2 to admit that he was wrong? Did you see that? Like, no, it couldn't possibly, it couldn't possibly be the case. ↗
▶ Ep 85 · 10:38
opinion Surgeons are slow to admit they could have a complication until it happens to them personally. ↗
▶ Ep 85 · 10:46
quote We as surgeons never really admit that we could possibly have that complication until it happens to us personally. ↗
▶ Ep 85 · 11:13
clinical Approximately 60% of Levitt's practice is reoperative surgery for anorectal malformations. ↗
▶ Ep 85 · 12:35
quote You need actually a clinician, a surgeon, who can actually do the complex cases and has the capacity to develop a reputation that the patients seek and the fellow clinicians seek that individual out. ↗
▶ Ep 85 · 13:16
quote One can make the argument that because of the creation of the program and the collaborative model, the spinal surgery was facilitated by the fact that a program existed. ↗
▶ Ep 85 · 15:26
quote If I And I have the capacity to do a cystoscopy, but if I invite a urologist to do that cystoscopy, that should be good for the program. I should be encouraged to have the urologist present for that cystoscopy while I'm examining the rectum at the same time because the patient gets comprehensive care. In the traditional model, that would be a bad thing. For me, because I do less surgery, because I could have done the cystoscopy, but I give the RVUs to someone else, you need an administrative model that says no, no, no, that's a good thing because you get credit for the collaborative approach. ↗
▶ Ep 85 · 16:38
quote You can't just do rectal cancer surgery wherever you want because the colorectal surgeons made the argument that you need radiation therapy and oncology. You need a whole list of things in order to provide best outcomes. ↗
▶ Ep 85 · 18:07
quote Punctuation saves lives. ↗
▶ Ep 85 · 19:02
quote If you did, if I do a 10 hour operation that requires urology and gynecologic collaboration, who gets credit for the 10 hours of work? Do I get all the RVUs? Do they get some RVUs? What if gynecology is only needed for 2 hours? Do they look like a slacker that they only work 2 hours that day, because it's not like they can do a lot of other things. They need to basically wait around until they're part of this 10 hour operation comes together. ↗
▶ Ep 85 · 19:02
opinion In a collaborative 10-hour operation requiring urology and gynecology, traditional siloed RVU models fail because they do not account for the fact that all participants are essential and cannot do other work during the case. ↗
▶ Ep 85 · 19:42
quote I can't do the operation by myself. Why should I get the credit? Urology and gynecology are vital to the care of that child. ↗
▶ Ep 85 · 22:04
quote You don't want to have a pediatric surgeon managing. A child with a colorectal problem and then 5 years later discovering that the patient has a neurologic problem that no one ever knew about because at that point they may have renal damage. ↗
▶ Ep 85 · 22:31
quote We have to share the credit. That's not easy for surgeons, but it's obviously much better for the patient's care. ↗
▶ Ep 85 · 22:37
clinical Patients with anorectal malformations often have associated Mullerian anomalies (e.g., hemisystems) that, if not identified and addressed during initial abdominal surgery at 6 months, will present as pelvic pain at age 13 due to obstructed menstrual blood. ↗
▶ Ep 85 · 22:52
quote This is something you want to know about when they're 6 months old, when you're in their abdomen doing their cloacal reconstruction. And if you don't collaborate at that point or think about gynecology at that point, you're setting yourself up for a very difficult problem 13 years down the road. ↗
▶ Ep 85 · 23:07
clinical Knowledge of associated sacral and spinal problems allows prediction of continence in the neonatal period, enabling clinicians to tell families either that the child will likely be continent with proper management or that continence is unlikely but the child can be kept clean with bowel management. ↗
▶ Ep 85 · 23:41
quote Imagine the conversation that you're having with a 1 week old, the, the parents of a 1 week old baby. We couldn't do that before. It was sort of like roll the dice, see you in a few years. We don't have to do that anymore because of the collaborative model. ↗
▶ Ep 85 · 24:02
quote I was on a mission to find the ideal elbow because what I saw was that. Right, that's what I saw, because what surgeons were not doing is properly defining the rectourethral anatomy of children born with congenital colorectal problems. ↗
▶ Ep 85 · 24:11
clinical Rectourethral fistulas are classified as bladder neck (at the deltoid level), prostatic (at the tricep level), or bulbar (at the elbow level), and each has a different surgical approach and potential outcome. ↗
▶ Ep 85 · 25:09
clinical Common technical errors in anorectal malformation surgery include placing the anus too far posterior (outside the sphincter center), creating a stricture, leaving a remnant of the original fistula, and causing rectal prolapse. ↗
▶ Ep 85 · 25:55
clinical Reoperative surgery for misplaced anus and other technical errors can convert a significant number of patients to continence and improve quality of life. ↗
▶ Ep 85 · 26:43
clinical The baseline surgical site infection rate after colostomy and ileostomy closure was 22.4%, which is standard in the literature. ↗
▶ Ep 85 · 27:11
clinical Implementing a GI bundle (most importantly, changing instruments and gloves before closing the fascia) reduced the surgical site infection rate to 7.9%. ↗
▶ Ep 85 · 27:22
clinical Organisms growing in surgical site infections after colostomy closure were resistant to the preoperative antibiotic (cefoxitin) given within an hour of incision. ↗
▶ Ep 85 · 27:53
clinical Switching the preoperative antibiotic from cefoxitin to Unasyn (based on wound culture data and infectious disease consultation) reduced the surgical site infection rate to 2.2%. ↗
▶ Ep 85 · 29:45
clinical In cloacal malformations, if the residual urethra after reconstruction will be shorter than 1.5 cm, the patient will be urinary incontinent ('wet'); leaving adequate urethral length preserves continence. ↗
▶ Ep 85 · 30:12
quote You need to know what's going to happen in 4 years. You need to plan your surgery accordingly. If you're not tracking your data, you have no idea that you've caused any sort of morbidity. ↗
▶ Ep 85 · 32:09
clinical In a coordinated operation for a child with myelomeningocele and urinary and fecal incontinence, the sigmoid colon can be resected to improve bowel care but preserved on its mesentery and used for bladder augmentation, and the appendix can be divided to create both a Malone antegrade enema channel (proximal) and a Mitrofanoff catheterizable channel (distal). ↗
▶ Ep 85 · 32:53
quote I don't use the appendix for a Malone. Anti grade enema option unless I know that the urologist doesn't need it for their metrofenoff. ↗
▶ Ep 85 · 33:19
quote The ultimate in collaborative care. This is not easy because obviously the surgeon's there, the clinic patient is there, and you want to just book the case. No, now you've got to wait. You've got to call urology. You've got to get them to do their workup. You've got to make sure that they're OK with you doing the operation. ↗
▶ Ep 85 · 36:02
clinical The Pediatric Colorectal and Pelvic Learning Consortium has collected data on 22,200 patients across 15 centers over three years, allowing real-time queries such as the incidence of enterocolitis in Hirschsprung disease. ↗
▶ Ep 85 · 36:30
opinion The Sir Dennis Browne medal from the British Association of Paediatric Surgeons states that 'the aim of pediatric surgery is to set a standard, not to seek a monopoly.' ↗
▶ Ep 85 · 38:05
quote I can tell you, and I'm about to get on a United Airlines flight in a number of hours, if there are delays out of SFO today, then tomorrow someone knows how many flights were over the 15 minute mark. Tomorrow someone knows that fact. In most departments of surgery, you have no clue. About that wound infection. Death, Lyme infection, all of those things you don't know. You think you're doing well unless you're tracking it. You don't know. ↗
▶ Ep 85 · 38:45
opinion In most departments of surgery, clinicians do not know their wound infection, death, or line infection rates in real time, unlike industries such as airlines, which track delay statistics daily. ↗
▶ Ep 85 · 39:30
opinion Tissue engineering (e.g., engineered vaginal tissue) will revolutionize cloacal reconstruction by eliminating the need to use bowel. ↗
▶ Ep 85 · 40:36
quote A lot of complex medicine all comes down to the moment of truth when you're in the room, in that clinic room. There's no insurers in the room. There's no administrators in the room. It's just you and the patient, and they're asking for help, and you have to deliver that help. And then the question is, did you deliver what they asked for? ↗

Time for some patient driven change | Marc Levitt | TEDxColumbus

▶ Ep 86 · 0:22
opinion In medicine, complex problems are often approached in a disorganized manner analogous to building a bridge by having cement layers start on Monday, steel workers arrive Tuesday without knowing what to do, architect on Wednesday, and engineers on Thursday. ↗
▶ Ep 86 · 1:32
clinical Some children are born without an opening for stool (anorectal malformation), a condition most families have never heard could go wrong. ↗
▶ Ep 86 · 1:54
clinical A cloacal malformation is demonstrated on fetal MRI at 20 weeks gestation, showing bladder, gynecologic system, and colon system all converging as one opening. ↗
▶ Ep 86 · 2:20
clinical A cloacal malformation with all urinary, gynecologic, and colonic structures coming together as one opening is not compatible with life and once surgically solved has unique implications on the child's quality of life. ↗
▶ Ep 86 · 2:39
clinical In cloacal malformations, all anatomic structures (urinary, gynecologic, colonic) are right next to each other, each handled by a different type of doctor, requiring collaborative work to manage the patient. ↗
▶ Ep 86 · 2:53
opinion Twenty-five years ago, the speaker's mentor attempted to function as colorectal surgeon, urologist, and gynecologist for these patients, but as medicine became more complicated, the speaker felt incapable of solving all problems without a unified team approach. ↗
▶ Ep 86 · 3:01
quote if the phone rang and someone said, can I speak to the colorectal surgeon, he would say, Speaking. Well, actually, I'd like now to speak to the urologist, and he would say, you got him. And the gynecologist, that's me ↗
▶ Ep 86 · 3:50
opinion A multidisciplinary team for complex colorectal patients should include GI motility specialists, medical colorectal specialists, colorectal surgeons, gynecologic surgeons, and urologic surgeons working together. ↗
▶ Ep 86 · 5:47
opinion Surgeons, particularly, like to be in charge and do not like to share patients or be told they cannot go first in an operation when another team needs to go first for the patient's benefit. ↗
▶ Ep 86 · 6:03
opinion Surgeons must park their egos at the door when sharing patients in a collaborative model. ↗
▶ Ep 86 · 6:12
opinion Hospital barriers to collaborative care include questions about billing, clinic scheduling with all doctors in the same place on the same day (not efficient), and productivity concerns when a specialist is needed for only 2 hours of a 10-hour operation. ↗
▶ Ep 86 · 6:33
clinical A specialist cannot leave during a long operation to do other work because when needed, they must be immediately available while the patient is under anesthesia. ↗
▶ Ep 86 · 6:41
opinion From the patient perspective, gathering multiple specialists together is difficult, especially when experts are in different cities, requiring families to schedule multiple appointments at different times and dates, possibly requiring air travel and sibling care arrangements. ↗
▶ Ep 86 · 7:06
clinical There are clinical circumstances where a child benefits from one operation where tissues can be shared between surgical teams. ↗
▶ Ep 86 · 7:20
clinical In a patient (Rebecca) with both a non-functioning colon segment and a bladder that was too small, a section of colon can be removed from the fecal stream and added to the bladder to make it bigger, performed simultaneously in one operation. ↗
▶ Ep 86 · 7:46
clinical Normally, bladder augmentation would be performed and six months later someone would do the colon work, rather than coordinating both procedures in advance in one operation. ↗
▶ Ep 86 · 8:00
opinion A collaborative care model requires deep infrastructure including coordinators, administrative assistants, schedulers, and multiple types of nurses (floor, OR, clinic) with different areas of expertise. ↗
▶ Ep 86 · 8:11
opinion An institution must commit significant infrastructure to make collaborative care work, with the expectation that done correctly, more patients can be helped. ↗
▶ Ep 86 · 8:36
opinion Nationwide Children's Hospital successfully implemented the collaborative care model after the speaker had tried at other institutions where no one bought into the collaborative process. ↗
▶ Ep 86 · 8:46
opinion The siloed approach was the traditional way of medicine, requiring convincing to change. ↗
▶ Ep 86 · 8:55
opinion In the collaborative model, one plus one can equal three and the sum is greater than the individual parts. ↗
▶ Ep 86 · 9:06
opinion The collaborative care model could spread to other hospital areas, such as a limb program requiring orthopedic surgery, rehabilitation medicine, and other specialties meeting together before the patient arrives and seeing the patient on the same day. ↗
▶ Ep 86 · 9:33
opinion A patient (Rebecca) would have benefited much more from the collaborative process available today than when the speaker first met her 25 years ago. ↗
▶ Ep 86 · 9:50
clinical An 8-year-old patient (Michael) with daily fecal soiling was being teased at school so badly his parents pulled him out of school. ↗
▶ Ep 86 · 10:07
clinical The speaker promised an 8-year-old with daily soiling that in one week he would be clean and in normal underwear, and one week later the patient achieved this outcome. ↗
▶ Ep 86 · 10:07
quote In one week, you will be clean and in normal underwear. ↗
▶ Ep 86 · 10:34
opinion Because of the collaborative process, the team is able to make promises to patients and keep them. ↗

cincinnati children's hospital medical team in Korle Bu

▶ Ep 87 · 1:24
opinion Ghana was selected as an ideal location to create a West African center for colorectal problems because it already had very good expertise and infrastructure to handle complex cases ↗
▶ Ep 87 · 1:24
quote We sought out Ghana because we thought Ghana would be an ideal location to create a West African center for colorectal problems. ↗
▶ Ep 87 · 1:34
quote We felt that they had already a very good expertise and an infrastructure that they could handle complex cases. ↗
▶ Ep 87 · 1:43
opinion The goal is to create in Ghana a center where children from all of Africa could come for colorectal problems ↗
▶ Ep 87 · 1:46
quote And I had the dream of creating in Ghana a center where children from all of Africa could come for colorectal problems. ↗

Colorectal Quiz: Episode 49 - Collaborating for Kids: Colorectal & Pelvic Solutions (with a Little Help from AI)

▶ Ep 88 · 0:00
quote we did something crazy i uploaded an article that jason frischer and i wrote together about the collaborative model in colorectal care published in seminars in pediatric surgery and loaded that article using ai into a podcast format ↗
▶ Ep 88 · 2:30
quote i was expecting lots of errors and a very computer sounding experience and it wasn't that at all it was a lovely two human sounding voices that were chatting about the article that jason and i wrote ↗
▶ Ep 88 · 2:30
quote it foreshadowed things the computer read and i put that in quotes the article fully and then knew what was coming later in the article to get us as the listener excited about it ↗
▶ Ep 88 · 5:47
clinical NotebookLM creates an expert from only the provided document, not pulling information from external sources like other chatbots. ↗

Colorectal Quiz: Episode 43

▶ Ep 79 · 3:53
quote It's very important to know the type of malformation, the quality of the sacrum, and the quality of the spine and give the patient's family some estimate of the likelihood that they will or not be continent. ↗
▶ Ep 79 · 8:09
quote I mean, I have to say, I'm sort of speechless that we're talking about physics with Jason Frischer. ↗
▶ Ep 79 · 13:14
epidemiological Small bowel volvulus around the appendix can occur but is rare, seen in only two or three cases. ↗
▶ Ep 79 · 14:31
clinical When doing a neo-Malone, try to orient the channel so the catheter enters into the right colon rather than refluxing into the ileum. ↗
▶ Ep 79 · 15:17
clinical When doing plication, pass the tube after each stitch to ensure it passes in the desired direction. ↗
▶ Ep 79 · 19:33
clinical Lone Star ring and pins can be placed in the umbilicus to get excellent exposure to visualize a tiny Malone hole. ↗
▶ Ep 79 · 20:31
clinical Ultrasound can be used to find the appendix around the umbilicus and needle localize the lumen for access rescue. ↗
▶ Ep 79 · 20:55
clinical Appendicitis in a Malone is impossible unless the hole closes, because there is no obstruction in pathophysiology. ↗
▶ Ep 79 · 20:59
quote It's impossible. Well, unless the hole closes. Unless the hole closes. ↗
▶ Ep 79 · 21:26
clinical In South Africa, appendix is never removed as part of laparoscopic appendectomy for appendicitis; it is a United States practice. ↗
▶ Ep 79 · 21:26
quote No one is obligating you to take out the appendix. And I will tell you, in South Africa, they never take out the appendix as part of a lads. It's just not done. It's a United States thing. ↗
▶ Ep 79 · 21:26
clinical Do not take out the appendix in a first Crohn's or ARM patient or a kid with spine issues or absent sacrum or spina bifida, as they may need it for future Malone or Mitrofanoff. ↗
▶ Ep 79 · 22:01
clinical Appendix tips should be sent to pathology because neuroendocrine tumors (carcinoids) can be found; one was discovered three months after pathology insisted on receiving specimens. ↗

Colorectal Quiz: Episode 43

▶ Ep 78 · 8:09
quote Frankly, what I learned from physics, you got to write it out every single step, prove to yourself that you can do it. And I think that's very appropriate for surgeons who are training. You've got to put yourself in the position. You got to say, can I do this by myself? Would I need help? And you got to get to that point. So I learned that life lesson the hard way in physics. ↗
▶ Ep 78 · 8:09
quote I have to say, I'm sort of speechless that we're talking about physics with Jason Frischer. ↗
▶ Ep 78 · 11:41
clinical When mesentery parallels the appendix, wrap cecum around appendix like a fundoplication; when mesentery is fenestrated, make one window at the bottom and plicate through that window to avoid crunching the mesentery. ↗
▶ Ep 78 · 13:21
epidemiological Small bowel volvulus around the appendix has been seen in two or three cases. ↗
▶ Ep 78 · 13:21
clinical Cecum should be positioned underneath the umbilicus without leaving a long-stemmed appendix hanging to reduce volvulus risk. ↗
▶ Ep 78 · 14:16
clinical When doing a neo-Malone, orient the channel so the catheter will enter into the right colon rather than refluxing into the ileum. ↗
▶ Ep 78 · 15:17
clinical During plication, pass the tube after every stitch to ensure it passes in the desired direction. ↗
▶ Ep 78 · 19:33
clinical Lone Star ring and pins can be placed in umbilicus to get exposure and visualize the Malone hole for catheterization. ↗
▶ Ep 78 · 20:31
clinical Ultrasound can be used to find the appendix around the umbilicus, then needle-localize the lumen ultrasound-guided to rescue malones. ↗
▶ Ep 78 · 20:55
clinical Appendicitis in a Malone is impossible unless the hole closes, because there is no obstruction in the pathophysiology. ↗
▶ Ep 78 · 20:59
quote It's impossible. Well, unless the hole closes. Unless the hole closes. ↗
▶ Ep 78 · 21:26
epidemiological In South Africa, appendix is never taken out as part of laparoscopic appendectomy; it is a United States practice. ↗
▶ Ep 78 · 21:26
clinical Appendix should not be removed in first Crohn's or ARM patients, kids with spine issues, absent sacrum, or spina bifida because they may need it for future Malone or Mitrofanoff. ↗
▶ Ep 78 · 22:01
clinical Appendix tissue should always be sent to pathology during Malone creation; one case had a carcinoid (neuroendocrine tumor) discovered three months later. ↗

Colorectal Quiz: Episode 40

▶ Ep 90 · 1:39
epidemiological Anorectal malformation occurs more commonly in females and has a prevalence of about one in 5,000 births. ↗
▶ Ep 90 · 2:21
clinical When you look in laparoscopically and see an end of the colon with nothing else visible, you do not have to do a divided colostomy—you can bring out that distal end as your stoma rather than interfering with the blood supply for the distal segment. ↗
▶ Ep 90 · 2:21
quote When you look in and you see an end of the colon and that's all you see, you do not have to do a divided colostomy. That can be the end. That can be your colostomy. ↗
▶ Ep 90 · 2:21
quote We've talked about this before on some of these rare circumstances. ↗
▶ Ep 90 · 2:59
opinion The only potential benefit of doing a divided colostomy when encountering blind-ending colon is protecting the ultimate rectal repair, but this risks the blood supply to the distal rectum. ↗
▶ Ep 90 · 2:59
quote I think the smartest thing to do in this very rare case is make a true end colostomy. ↗
▶ Ep 90 · 5:32
clinical Meyer-Rokitansky-Küster-Hauser syndrome can present with anorectal malformation, creating Meyer-Rokitansky-like anatomy where ovaries and remnant tubes are present but no midline Müllerian structures. ↗
▶ Ep 90 · 6:37
clinical The more common scenario of anorectal malformation with absent vagina is a recto-vestibular fistula with completely normal urethra but no vagina in between—this is called recto-vestibular fistula with distal vaginal atresia, where the rectum ends as a fistula in the vestibule. ↗
▶ Ep 90 · 7:08
clinical In this case, the rectum ended blind and quite high in the pelvis, making it unreachable through a posterior sagittal incision. ↗
▶ Ep 90 · 7:18
clinical The foreshortened sacrum in this case suggests caudal regression, where everything below that level forgot to develop. ↗
▶ Ep 90 · 10:12
clinical Not diverting after limited posterior sagittal anorectoplasty is safe when you have a colocolonic anastomosis at the colostomy closure site and only an anoplasty with a couple of posterior sutures. ↗
▶ Ep 90 · 11:04
clinical In the past, vaginal replacement would have been done at the same time as rectal repair in these patients, but time and research have shown that colonic neovaginas are not great for patients 20 years down the road, and surgeons should try very hard to avoid them. ↗
▶ Ep 90 · 11:04
quote In the past, a vaginal replacement would have been done at the same time as the rectal repair in these patients. However, time and research have shown that colonic neovaginas are not great for patients 20 years down the road. And we should try very hard to avoid them. ↗
▶ Ep 90 · 11:35
quote I can tell you in most cloacas, you should be able to get the native vagina to reach. ↗
▶ Ep 90 · 11:35
clinical In most cloacas, you should be able to get the native vagina to reach without needing vaginal replacement. ↗
▶ Ep 90 · 14:50
clinical Vascular anomalies associated with anorectal malformation have not been much written about in the literature. ↗
▶ Ep 90 · 15:11
quote I vividly remember a case where we encountered an aberrant external iliac artery that looped up and actually was within the abdominal wall and looked very much like the obliterated umbilical artery and in fact was a blood supply to one of the extremities. ↗
▶ Ep 90 · 15:11
clinical An aberrant external iliac artery can loop up within the abdominal wall, looking very much like the obliterated umbilical artery, while actually being a blood supply to one of the extremities. ↗

Colorectal Quiz: Episode 40

▶ Ep 80 · 1:39
epidemiological Anorectal malformation occurs more commonly in females and has a prevalence of about one in 5,000 births. ↗
▶ Ep 80 · 2:21
clinical When laparoscopy reveals a blind-ending colon with no distal segment visible, an end colostomy is preferable to a divided colostomy to avoid interfering with blood supply to the distal rectum. ↗
▶ Ep 80 · 2:21
quote When you look in and you see an end of the colon and that's all you see, you do not have to do a divided colostomy. That can be the end. That can be your colostomy. ↗
▶ Ep 80 · 2:59
opinion The only potential benefit of a divided colostomy when a blind-ending colon is seen is protecting the ultimate rectal repair, but this risks the blood supply to the distal rectum. ↗
▶ Ep 80 · 5:32
clinical Meyer-Rokitansky-Küster-Hauser syndrome can occur with an anorectal malformation, though it is extremely rare. ↗
▶ Ep 80 · 5:35
quote It is Meyer-Rotakansky-like in that there are ovaries, there are scrawny little tubes, probably remnants, and then nothing else. No midline structure at all. ↗
▶ Ep 80 · 6:37
clinical The more common scenario is a recto-vestibular fistula with a completely normal urethra but no vagina in between (distal vaginal atresia), where the rectum ends as a fistula in the vestibule. ↗
▶ Ep 80 · 7:08
clinical In this case, the rectum ends blind and quite high in the pelvis, unreachable through a posterior sagittal incision. ↗
▶ Ep 80 · 7:18
clinical The sacrum appears foreshortened on imaging, suggesting caudal regression where everything below a certain level forgot to develop. ↗
▶ Ep 80 · 8:31
quote You couldn't safely dig through all those pulsating vessels with laparoscopes, right? ↗
▶ Ep 80 · 10:12
clinical Not diverting was considered safe because there was a colocolonic anastomosis at the colostomy closure site and only an analplasty with a couple of posterior sutures, unlike Hirschsprung's disease where distal obstruction from non-relaxing sphincters could blow out the anastomosis. ↗
▶ Ep 80 · 11:14
clinical In the past, vaginal replacement would have been done at the same time as rectal repair, but time and research have shown that colonic neovaginas are not great for patients 20 years down the road and should be avoided. ↗
▶ Ep 80 · 11:14
quote In the past, a vaginal replacement would have been done at the same time as the rectal repair in these patients. However, time and research have shown that colonic neovaginas are not great for patients 20 years down the road. ↗
▶ Ep 80 · 11:35
clinical In most cloacas, the native vagina should be able to reach and vaginal replacement should be avoided. ↗
▶ Ep 80 · 11:56
quote I think in 20 years or perhaps even shorter, we're going to have tissue engineering options. ↗
▶ Ep 80 · 11:56
clinical A buccal graft could be laid into the opened introitus area as an alternative to dilation. ↗
▶ Ep 80 · 12:34
opinion One can completely avoid vaginal replacement in these cases in the current era. ↗
▶ Ep 80 · 12:34
quote I think really in these, these days, one can completely avoid a vaginal replacement. ↗
▶ Ep 80 · 12:46
clinical Gynecologist Alison May proposed providing a neovagina as a temporary bridge so the patient can menstruate, with potential removal 20 years later when tissue engineering becomes available. ↗
▶ Ep 80 · 13:21
clinical Using the remaining colon in this patient for vaginal replacement would be very risky due to compromised blood supply from the prior divided stoma. ↗
▶ Ep 80 · 14:09
quote There's going to be a real estate problem. ↗
▶ Ep 80 · 15:11
clinical Mark Levitt recalls a case with an aberrant external iliac artery that looped up within the abdominal wall, resembling the obliterated umbilical artery but actually supplying blood to an extremity. ↗
▶ Ep 80 · 15:11
quote I vividly remember a case where we encountered an aberrant external iliac artery that looped up and actually was within the abdominal wall and looked very much like the obliterated umbilical artery and in fact was a blood supply to one of the extremities. ↗
▶ Ep 80 · 15:11
clinical Vascular anomalies associated with anorectal malformations have not been much written about in the literature. ↗
▶ Ep 80 · 17:13
opinion The odds of continence for this child are concerning given the anatomy. ↗
▶ Ep 80 · 17:13
quote The odds of continence for this child are concerning. ↗
▶ Ep 80 · 17:39
clinical The patient is not leaking urine all the time, which is a positive finding for future continence. ↗

Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies

▶ Ep 91 · 4:06
quote there is an anal dimple. That means... A raised area and a good change in color. Which means there's probably a good sphincter ↗
▶ Ep 91 · 4:06
clinical An anal dimple with raised area and good color change indicates there is probably a good sphincter. ↗
▶ Ep 91 · 4:41
quote I don't stand in the way when the NICU gets an echo. I routinely get them all ↗
▶ Ep 91 · 6:03
opinion Dilation and sending baby home is a suboptimal choice in a baby with no cardiac defect, but might be a good choice in a baby you don't want to take to the OR. ↗
▶ Ep 91 · 6:32
opinion If you could dilate a perineal fistula patient, you don't need to go to the OR at all and can let them deal with the heart. ↗
▶ Ep 91 · 6:32
clinical In a male perineal fistula, the hole isn't always easy to see and dilation is more dangerous because it's near the urethra, but with care and Hagar dilators you can get egressive stool and never go to the OR. ↗
▶ Ep 91 · 6:32
quote There's no rush on a vestibular. There's no rush on a perineal ↗
▶ Ep 91 · 6:32
clinical There is no rush on a vestibular fistula in a female patient or a perineal fistula, allowing time to address cardiac issues first. ↗
▶ Ep 91 · 8:13
quote I actually don't think there's a need to do a colostomy in a baby like this. You can dilate and then do the repair primarily later ↗
▶ Ep 91 · 8:13
opinion There is no need to do a colostomy in a baby with perineal fistula and cardiac disease; you can dilate and then do the repair primarily later. ↗
▶ Ep 91 · 8:13
opinion Colostomy is not any more or less risky than a one-hour mini-PSARP for perineal fistula. ↗
▶ Ep 91 · 9:43
clinical A turnable loop ostomy with 95-5 percentage behaves like an end colostomy, and no one knows except the surgeon that there's another side where you can do a contrast study. ↗
▶ Ep 91 · 9:43
quote Sort of a 95-5 percentage loop. It behaves like an end. And no one knows except for you that there's another side there you can do a contrast ↗
▶ Ep 91 · 11:00
clinical If the baby has an umbilical line, consider going into Palmer's Point instead of accessing through the umbilicus, using a Hasson technique. ↗
▶ Ep 91 · 12:33
clinical A baby with a low ARM lesion (closely approximated perineal fistula to anal muscular complex) should do really well with continence. ↗
▶ Ep 91 · 12:33
clinical Important factors for continence include sensation in the anal canal, absence of the dentate line, quality of the spine, type of anorectal malformation, and sacral anatomy. ↗
▶ Ep 91 · 12:33
quote This baby has a low lesion. So, basically, just had a closely approximated perineal fistula to the anal muscular complex. So, should do really well ↗
▶ Ep 91 · 12:33
clinical Sacral ratio measurement should wait until 3 months of age. ↗
▶ Ep 91 · 14:10
clinical The perineal fistula tract is only one millimeter deep; do not dive in to find it as it will disappear with good anoplasty and anterior rectal wall mobilization. ↗
▶ Ep 91 · 14:10
quote It's one millimeter deep. Do not dive in and try to find that fistula's tract. It will disappear, provided you have a good anoplasty with a good anterior rectal wall mobilization ↗
▶ Ep 91 · 14:57
clinical If the fistula is completely outside of the sphincteric ellipse, then full mobilization is required. ↗

Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies

▶ Ep 82 · 4:06
clinical An anal dimple with raised area and good color change means there's probably a good sphincter. ↗
▶ Ep 82 · 6:03
quote I think it's important to know how to do that because it might be a good choice in a baby who you don't want to take to the OR. ↗
▶ Ep 82 · 6:32
clinical In males, the perineal hole isn't always easy to see and dilation is more dangerous because it's near the urethra, but with care and Hagar dilators you can achieve egressive stool. ↗
▶ Ep 82 · 6:32
quote In a male, the perineal hole isn't always so easy to see. And the dilation is a little bit more dangerous because it's near the urethra. But with care and Hagar dilators, you can definitely get egressive stool and never go to the OR. ↗
▶ Ep 82 · 6:32
clinical For female patients with vestibular or perineal fistulas, there's no rush to operate; dilation can allow egressive stool without going to the OR. ↗
▶ Ep 82 · 8:13
opinion There's no need to do a colostomy in a baby with perineal fistula and cardiac disease; you can dilate and then do the repair primarily later, and colostomy is not more or less risky than a one-hour PSARP. ↗
▶ Ep 82 · 9:43
quote Sort of a 95-5 percentage loop. It behaves like an end. And no one knows except for you that there's another side there you can do a contrast. ↗
▶ Ep 82 · 9:43
clinical A turnable loop ostomy behaves like an end ostomy in a 95-5 percentage configuration, and no one knows except the surgeon that there's another side where you can do a contrast study. ↗
▶ Ep 82 · 11:08
clinical When accessing the umbilicus for laparoscopy, dissect in with a mosquito, make sure you're in without touching any vessel before insufflating, and clear the line of air. ↗
▶ Ep 82 · 14:02
clinical The raphe beads should be scraped off at one millimeter depth; do not dive in to find the fistula tract as it will disappear with good anoplasty and anterior rectal wall mobilization. ↗
▶ Ep 82 · 14:02
quote you've got to scrape that off. It's one millimeter deep. Do not dive in and try to find that fistula's tract. It will disappear, provided you have a good anoplasty with a good anterior rectal wall mobilization. ↗
▶ Ep 82 · 14:23
clinical For a 50-50 fistula (half within muscle complex, half anterior), leave the anterior wall as it's the danger zone, mobilize posteriorly to fill the anal sphincter, creating an 80-20 reconstruction; if the fistula is completely outside the sphincteric ellipse, full mobilization is required. ↗

Colorectal Quiz Episode 29: Female ARM

▶ Ep 92 · 1:13
clinical The problem is not pooping itself but hard pooping that can disrupt the perineal body repair. ↗
▶ Ep 92 · 1:13
clinical Alberto Pena's historical protocol kept patients mandatory NPO for seven days with central line and hyperalimentation, feeding on day seven if healed. ↗
▶ Ep 92 · 1:13
clinical Dr. Levitt's current protocol is regular IV (no PICC line) and clear liquids or breast milk for five days, based on better healing by day five compared to day one or two. ↗
▶ Ep 92 · 1:13
clinical A study by Carlos Reck comparing NPO for seven days versus clear liquids for seven days found the same amount of stool output in both groups. ↗
▶ Ep 92 · 5:23
clinical In redo cases seen by Dr. Levitt, patients were invariably fed right away and discharged home. ↗
▶ Ep 92 · 5:23
quote I think the key to this will be as minimal amount of perineal body injury by surgery as possible. ↗
▶ Ep 92 · 5:23
clinical Perineal body dehiscence usually leads to no perineal body over several months and requires redo surgery because the anterior anoplasty has no sphincter around it. ↗
▶ Ep 92 · 8:05
clinical A paper by Dr. Levitt found that clear liquids were no different than NPO in terms of stool output, but both groups still produced very thin, liquidy stool that would not disrupt the anastomosis. ↗
▶ Ep 92 · 9:05
clinical A randomized controlled trial by Richard Wood and Dr. Levitt compared dilation versus non-dilation for primary PSARP (cloacas excluded), with backup plan of dilation plus or minus Heineke-Mikulicz anoplasty for strictures. ↗
▶ Ep 92 · 9:05
clinical Many anoplasties that were never touched with a dilator look absolutely fine eight weeks later at colostomy closure if the repair was healthy with no tension and good blood supply. ↗
▶ Ep 92 · 9:05
clinical The dilation RCT was prompted by families identifying dilations as their biggest concern in caring for patients with anorectal malformation. ↗
▶ Ep 92 · 9:05
clinical The dilation RCT found that both dilated and non-dilated groups developed strictures somewhere between 10 and 20% of the time. ↗
▶ Ep 92 · 13:48
clinical Jack Langer's routine is to see patients every week in clinic and pass a dilator without having families do it at home. ↗
▶ Ep 92 · 14:04
clinical In the dilation RCT, four patients required redo operations for stricture: two in the dilation arm (both chose not to do dilations) and two in the non-dilation arm. ↗
▶ Ep 92 · 16:30
clinical There is existing data showing that full continence can be restored with a redo operation, including for stricture as an indication. ↗
▶ Ep 92 · 16:30
clinical Dr. Levitt has yet to meet a family that has chosen dilation when presented with the option of non-dilation with selective intervention. ↗
▶ Ep 92 · 18:31
quote I think the good news is that there's no right answer. We just have to all work together and suffer together on these difficult problems and try to improve lives as best we can. ↗
▶ Ep 92 · 19:37
clinical In redo cases, Dr. Levitt makes the anoplasty a little bigger knowing there will be contraction, and does not dilate redos but performs EUA at one month to check for early stricture. ↗
▶ Ep 92 · 19:37
clinical In primary repairs, Dr. Levitt makes the lumen match what the maximal rectal lumen can be, filling the sphincter, which is usually about a 13 or 14 Hegar size at the end. ↗
▶ Ep 92 · 19:37
clinical A surgeon in Ghana taught Dr. Levitt to make anoplasties a little bigger in cases where patients will not return for follow-up, knowing there will be some contraction. ↗

Colorectal Quiz Episode 29: Female ARM

▶ Ep 84 · 1:13
clinical Alberto Pena's historical protocol mandated 7 days NPO with central line and hyperalimentation, feeding on day 7 if healed. ↗
▶ Ep 84 · 2:23
quote I had a fellow that said, why exactly are you keeping these patients NPO? And I said, well, because I don't want them to stool. Because if they stool, they're more likely to dehisc their perineal body. And the fellow said, you know, they still stool, even if they're NPO. And I said, yes, but not as much. And he said, this was Carlos Reck, who's now the premier colorectal surgeon in Austria. He's in Vienna. He said, I think it's about the same. And we studied it. And Carlos recorded stool output in two groups, NPO for seven days. And we gave them clear liquids. That was our test, clear liquids for seven days. And guess what? Same amount of poop. ↗
▶ Ep 84 · 2:23
clinical Carlos Reck (Vienna) studied stool output in NPO versus clear-liquid groups for 7 days and found the same amount of stool in both groups. ↗
▶ Ep 84 · 3:30
quote I remain very concerned about passage of hard stool. And I believe that one way to keep people from, kids from passing hard stool is to keep them on clear liquids. ↗
▶ Ep 84 · 3:30
clinical Levitt's current protocol is IV fluids (no PICC line) with clear liquids or breast milk for 5 days, based on conclusion that hard stool passage (not stool volume) causes dehiscence. ↗
▶ Ep 84 · 5:23
clinical Perineal body dehiscence usually leads to loss of perineal body over several months, requiring redo surgery because the anterior anoplasty has no sphincter around it. ↗
▶ Ep 84 · 5:23
clinical In Levitt's redo cases for perineal body dehiscence, patients were invariably fed right away and discharged home. ↗
▶ Ep 84 · 9:05
clinical Wood-Levitt randomized controlled trial compared dilation versus non-dilation for primary PSARP (cloacas excluded), with backup plan of dilation under anesthesia plus/minus Heineke-Mikulicz anoplasty for strictures. ↗
▶ Ep 84 · 10:28
clinical In the dilation RCT, stricture rate was 10-20% in both dilation and non-dilation groups. ↗
▶ Ep 84 · 10:56
quote What prompted the paper was, and this was Richard's idea, was to ask the families what is their biggest concern relative to care of patients with an anorectal malformation. And by far, number one was dilations. ↗
▶ Ep 84 · 10:56
clinical Family surveys identified dilations as the number one concern for families of patients with anorectal malformations, prompting the dilation RCT. ↗
▶ Ep 84 · 10:56
clinical Many patients' anoplasties look absolutely fine 8 weeks later at colostomy closure if never touched with a dilator, assuming good technique (healthy tissue, no tension, good blood supply). ↗
▶ Ep 84 · 13:48
clinical Jack Langer's protocol involves seeing patients weekly in clinic and passing a dilator in office rather than having families dilate at home. ↗
▶ Ep 84 · 14:04
clinical In the dilation RCT, four patients required redo operations for stricture: two in the dilation arm (both chose not to dilate) and two in the non-dilation arm. ↗
▶ Ep 84 · 16:56
clinical Levitt has yet to meet a family that chose dilation when presented with the option of non-dilation with 10-15% stricture risk and Heineke-Mikulicz backup. ↗
▶ Ep 84 · 16:56
quote I can tell you, I have yet to meet a family that has chosen dilation. ↗
▶ Ep 84 · 19:37
clinical For primary anoplasties, Levitt makes the lumen match the maximal rectal lumen that fills the sphincter, typically resulting in Hegar size 13-14. ↗
▶ Ep 84 · 19:37
clinical In Ghana, surgeons make anoplasties slightly larger knowing patients will not return for follow-up, accounting for expected contraction. ↗
▶ Ep 84 · 19:37
clinical For redo anoplasties, Levitt makes the opening larger knowing there will be contraction; redo patients are not dilated but undergo EUA at one month to check for early stricture. ↗

Dr. Marc Levitt on building global pediatric colorectal surgery programs

▶ Ep 93 · 3:24
clinical Alberto Pena performed gynecologic, urologic, and surgical procedures himself on complex colorectal patients, demonstrating the need for a collaborative multidisciplinary approach. ↗
▶ Ep 93 · 3:57
quote at that moment, the idea was born that we must have a collaborative approach with lots of disciplines represented to help a complicated patient. ↗
▶ Ep 93 · 4:29
clinical The first dedicated colorectal center was established at Cincinnati Children's Hospital in 2005. ↗
▶ Ep 93 · 6:50
opinion Training surgeons provides exponentially greater impact than treating individual patients because trained surgeons can help hundreds or thousands more patients in their own cities. ↗
▶ Ep 93 · 8:40
clinical The bowel management program is a major advance, involving focused attention for 4-5 days with good long-term follow-up to achieve fecal continence, primarily through nursing expertise. ↗
▶ Ep 93 · 9:13
clinical Integration of urology and bladder management has revolutionized ARM care, with renal disease and kidney transplant now exceedingly rare compared to previously being not uncommon. ↗
▶ Ep 93 · 9:41
clinical Better gynecologic care has eliminated nervousness about menstruation problems at puberty because of improved understanding of anatomy through collaboration. ↗
▶ Ep 93 · 10:14
clinical The PSARP incision has gotten smaller and understanding of anatomy has improved since the procedure's introduction. ↗
▶ Ep 93 · 10:29
clinical Laparoscopy has been added to many types of ARM cases as a surgical innovation. ↗
▶ Ep 93 · 11:07
opinion Transition to adult care is probably the most inefficient process in ARM care, with the field being most behind in getting teenagers and young adults cared for by adult providers. ↗
▶ Ep 93 · 11:33
epidemiological Cystic fibrosis patients now commonly survive to age 70, compared to not surviving past their 30s when Levitt was young, due to integrated care and transition programs. ↗
▶ Ep 93 · 12:12
clinical There are only three surgeons in the entire world trained in both pediatric and adult colorectal surgery: Ali Gisher (Columbus, Ohio), Erin Teeple (Wilmington, Delaware), and a surgeon named Mark in Munich, Germany. ↗
▶ Ep 93 · 13:16
clinical Paris's Necker Children's Hospital has an exemplary transition model where teenagers meet pediatric and adult providers together, then continue care at the adult facility. ↗
▶ Ep 93 · 15:21
clinical At devoted colorectal centers, at least half of the surgical work is reoperative surgery for patients with anatomic issues causing soiling problems. ↗
▶ Ep 93 · 15:51
clinical No parent has ever known anything about ARM when their baby is born, creating significant shock when the diagnosis is announced. ↗
▶ Ep 93 · 16:41
clinical Many ARM patients require three surgeries within the first year of life: newborn colostomy, reconstructive operation, and colostomy closure. ↗
▶ Ep 93 · 17:51
opinion ARM surgery requires months to years of tinkering and minute changes to achieve good functional results, unlike typical surgery where anatomic reconstruction immediately solves the problem. ↗
▶ Ep 93 · 18:20
quote if this field was easy, everyone would do it. ↗
▶ Ep 93 · 18:25
opinion Parents care more about functional results than anatomic reconstruction, but surgeons are often very proud of their anatomic creations and want to be done after the surgery. ↗
▶ Ep 93 · 19:27
clinical A complex colorectal operation takes about 4 hours, but delivering a good result requires 96 more hours of tinkering, almost all of which is nursing care. ↗
▶ Ep 93 · 19:27
quote the complex colorectal operation takes about 4 hours, but to deliver a good result, you need 96 more hours of tinkering. Almost all of that is nursing care. ↗
▶ Ep 93 · 20:01
opinion Most families would rather change a colostomy bag than a diaper if the colostomy is properly made. ↗
▶ Ep 93 · 20:44
clinical If the anus is misaligned with sphincters due to surgical error, the problem is not discovered until potty training at age 4, making it very difficult for surgeons to improve their technique when feedback is delayed 4 years. ↗
▶ Ep 93 · 21:13
quote How is the surgeon supposed to fix their technique? If they're only discovering their problem 4 years later. ↗
▶ Ep 93 · 22:30
epidemiological In a typical US pediatric surgical training program, trainees do approximately 12 ARM cases over two years, and finished surgeons average 1 case per year. ↗
▶ Ep 93 · 23:05
opinion Regionalization of care and devoted teams are necessary to build sufficient experience in ARM surgery. ↗
▶ Ep 93 · 24:29
opinion Levitt does not want any child to have a permanent colostomy and wants all children to be typical and normal. ↗
▶ Ep 93 · 24:29
quote I don't want any kid to have a colostomy. I want everyone, I want those kids. Typical, normal, just like all the other kids. ↗
▶ Ep 93 · 24:40
clinical With proper bowel management and good nursing care, patients can be kept clean mechanically even without innate sphincter anatomy or capacity for voluntary bowel movements. ↗
▶ Ep 93 · 25:31
clinical The vast majority of patients can be perfectly clean with stool flowing through the normal anal route, even if mechanically managed. ↗
▶ Ep 93 · 25:54
quote you would be amazed how many patients actually develop bowel control. Even if they were predicted that they would never achieve bowel control ↗
▶ Ep 93 · 25:54
clinical Surgeons should not give up on pull-through surgery at 6 months of age because many patients develop bowel control even when predicted they would never achieve it, with proper nursing care and medical regimen tinkering. ↗
▶ Ep 93 · 31:12
clinical Families surveyed identified the dilation process as the most stressful part of their entire colorectal care. ↗
▶ Ep 93 · 32:00
clinical A randomized controlled trial comparing routine post-PSARP dilations versus no dilations found similar stricture rates of approximately 15% in both groups. ↗
▶ Ep 93 · 32:42
clinical Strictures can be treated with a straightforward minor Heineke-Mikulicz anoplasty to enlarge the stricture, which can be done at the time of colostomy closure. ↗
▶ Ep 93 · 33:29
clinical All families offered the choice between routine dilations or accepting a 10-15% stricture risk have chosen to avoid routine dilations. ↗
▶ Ep 93 · 35:09
clinical Skin irritation after colostomy closure is a short-term problem lasting about 2 weeks, occurring because the skin has never seen stool and the distal segment needs to adapt to absorb water and thicken stool. ↗
▶ Ep 93 · 35:56
clinical At 3 weeks post-closure, the problem switches to constipation, which many surgeons fail to manage aggressively, leading to colonic dilation and difficulty with potty training at age 4. ↗
▶ Ep 93 · 36:36
clinical Almost all patients should be on laxatives about 3-4 weeks after colostomy closure to keep them flowing. ↗
▶ Ep 93 · 36:58
clinical A good bowel movement pattern is one or two well-formed stools per day, achieved with diet providing bulk, water-soluble fiber, and laxatives containing senna or bisacodyl (not stool softeners). ↗
▶ Ep 93 · 37:33
clinical Stool softeners make ARM patients worse because they prevent the bulky stool needed to feel rectal stretch, which is essential for developing bowel control in patients with surgically created anal canals and impaired sensation. ↗
▶ Ep 93 · 37:56
clinical ARM patients are dependent on rectal stretch sensation because they lack typical anal canal sensation and have compromised sphincters. ↗
▶ Ep 93 · 39:09
clinical Bowel management should be started at whatever age the family chooses for the child to be in normal underwear, typically age 3-5, with all children in normal underwear by age 4-5. ↗
▶ Ep 93 · 40:11
clinical The bowel management program is nurse practitioner-run and involves assessing anatomy first, then developing an enema regimen with saline plus an additive to provoke stool emptying. ↗
▶ Ep 93 · 41:31
clinical The goal of bowel management is to mechanically empty the colon with a flush, then have nothing pass for 24 hours, keeping the child clean in normal underwear for 23.5 hours between flushes. ↗
▶ Ep 93 · 42:24
clinical The bowel management program typically lasts 4-5 days with X-rays, but a lot of tinkering is required during the year through email interaction with nurses. ↗
▶ Ep 93 · 42:32
clinical An early study claimed 95% bowel management success at one week, but Levitt and Richard Wood's follow-up study showed over 80% success at one year, which is the meaningful outcome measure. ↗
▶ Ep 93 · 43:41
clinical Hirschsprung's patients are the hardest group for bowel management, likely because they have overly good sphincters rather than the poor sphincters typical of ARM patients. ↗
▶ Ep 93 · 44:31
epidemiological Approximately 75% of ARM patients should be able to develop their own voluntary bowel control based on good operation, good quality sacrum, and good quality spine. ↗
▶ Ep 93 · 44:53
epidemiological Approximately 25% of ARM patients will not achieve their own bowel control even with perfect operation because they lack adequate sphincters or have spinal issues, and these patients need bowel management. ↗
▶ Ep 93 · 45:31
clinical Levitt performs over 100 Malone procedures per year laparoscopically, with the operation taking one hour and most patients staying one night in the hospital. ↗
▶ Ep 93 · 45:54
clinical The Malone procedure makes it much easier for older children to administer their enema independently without parental help. ↗
▶ Ep 93 · 46:35
opinion An integrated psychologist who meets every patient is vital to a full-fledged colorectal center, rather than surgeons calling for help only when needed. ↗
▶ Ep 93 · 47:24
clinical The burden of therapy investigation led to the dilation study because the goal is to achieve correct anus size while minimizing cost to the family. ↗
▶ Ep 93 · 48:39
clinical Many patients receive psychological help when they actually need re-operation and good bowel management, and all psychological problems resolve once the child is clean and in normal underwear. ↗
▶ Ep 93 · 49:17
opinion Fecal incontinence is a physiologic problem, not a psychologic problem, though psychology still needs to be managed. ↗

Colorectal Quiz: Episode 2

▶ Ep 94 · 1:34
quote How many patients, Jason, have you seen on laxatives that comes with an anus in the wrong place? How many patients have you seen having had a cecostomy with perfect anatomy? ↗
▶ Ep 94 · 3:21
clinical The original malformation in case 1 was a prostatic fistula and the patient has a tethered cord with a sacral ratio of 0.66 ↗
▶ Ep 94 · 5:31
clinical Patients with myelomeningocele have much more trouble with continence than those with tethered cord ↗
▶ Ep 94 · 5:31
quote the family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work, and is the child going to be clean and in normal underwear, and just like all the other kids. ↗
▶ Ep 94 · 5:31
clinical Sacral ratio 0.7 or greater usually means normal sphincters and good muscle tone ↗
▶ Ep 94 · 5:31
clinical The higher the malformation, the worse the prognosis for bowel control ↗
▶ Ep 94 · 7:29
quote a key pitfall is not do that. Mark the sphincters first, then open the PSARP, because then you don't get confused at the end when you're trying to place the analplasty in the correct location. ↗
▶ Ep 94 · 7:29
quote I'm looking for the anal dimple. And there's like a midline where I say, and there seems to be a little raised area, which is where the sphincters are and where the analplasty ought to be. ↗
▶ Ep 94 · 7:29
clinical A key pitfall is opening the PSARP incision first; instead, mark the sphincters first with electrical stimulation, then open the PSARP ↗
▶ Ep 94 · 9:29
clinical The electrical stimulator used for sphincter mapping is the same one anesthesia uses for train of four ↗
▶ Ep 94 · 9:29
clinical Anesthesiologists should not give skeletal muscle relaxant when using the stimulator because it is weaker than traditional stimulators ↗
▶ Ep 94 · 13:28
opinion For patients presenting after potty training age with incontinence due to mislocated anus, do the redo and usually add a Malone at the same time ↗
▶ Ep 94 · 13:28
opinion If anatomy is off, redo should be done, and there is an advantage to getting anatomy right when the child is younger ↗
▶ Ep 94 · 13:28
clinical After redo with Malone, patients learn to get control with new anatomy before stopping Malone flushes and trying voluntary bowel movements; this process may take six to twelve months ↗
▶ Ep 94 · 13:28
opinion For a two-year-old with mislocated anus or bad prolapse, offer redo and let them live in diapers for a year or two with better anatomy before potty training ↗
▶ Ep 94 · 14:48
opinion For a patient with anus 50% within sphincter complex at age three and a half with incontinence, one approach is to redo and add Malone, get them clean mechanically, then see if they develop bowel control ↗
▶ Ep 94 · 15:45
opinion If patients haven't declared continence yet because they're not old enough behaviorally, give them a chance as they may succeed with current anatomy ↗

Colorectal Quiz: Episode 2

▶ Ep 86 · 1:34
quote How many patients, Jason, have you seen on laxatives that comes with an anus in the wrong place? How many patients have you seen having had a cecostomy with perfect anatomy? ↗
▶ Ep 86 · 1:34
clinical Many patients are seen on laxatives with an anus in the wrong place, and many patients have had cecostomy with perfect anatomy. ↗
▶ Ep 86 · 5:31
clinical A sacral ratio of 0.7 or greater usually means normal or close to normal sphincters and good muscle tone, indicating that spine innervation of that area is probably good. ↗
▶ Ep 86 · 5:31
quote I can tell you, the family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work, and is the child going to be clean and in normal underwear, and just like all the other kids. ↗
▶ Ep 86 · 5:31
clinical Higher anorectal malformations have worse prognosis for continence. ↗
▶ Ep 86 · 5:31
opinion Families care whether the anoplasty will work and whether the child will be clean and in normal underwear, not how technically elegant the surgery is. ↗
▶ Ep 86 · 5:31
clinical Patients with myelomeningocele have much more trouble with continence than those with tethered cord. ↗
▶ Ep 86 · 7:29
quote A key pitfall is not do that. Mark the sphincters first, then open the PSARP, because then you don't get confused at the end when you're trying to place the analplasty in the correct location. ↗
▶ Ep 86 · 7:29
clinical It is amazingly common to have a mislocated anus because surgeons either miss where the center is during laparoscopic pull-through or open the PSARP incision first before marking sphincters. ↗
▶ Ep 86 · 7:29
clinical Visual inspection looks for the anal dimple and a midline raised area where the sphincters are and where the anoplasty ought to be. ↗
▶ Ep 86 · 7:29
quote It's amazingly common to have a mislocated anus. ↗
▶ Ep 86 · 7:29
clinical A key pitfall is opening the PSARP incision first; instead, mark the sphincters first, then open the PSARP, to avoid confusion when placing the anoplasty. ↗
▶ Ep 86 · 9:29
clinical Anesthesiologists should not give skeletal muscle relaxant when using the electrical stimulator because it is weaker than the traditional expensive stimulator. ↗
▶ Ep 86 · 9:29
clinical The electrical stimulator used for sphincter mapping is the same one anesthesia uses for train of four, with an inexpensive connection with little pins. ↗
▶ Ep 86 · 13:28
opinion If the anatomy is known to be off, the redo should be done, and there is an advantage to getting the anatomy right when the child is younger. ↗
▶ Ep 86 · 13:28
clinical The process of learning control with new anatomy after redo may take six to twelve months. ↗
▶ Ep 86 · 13:28
clinical When doing a redo for incontinence in an older child, usually add a Malone at the same time so they can learn to get control with their new anatomy before attempting voluntary bowel movements. ↗
▶ Ep 86 · 13:28
clinical Many patients present after potty training age because they are incontinent, and evaluation reveals the reason is they did not have the best operation. ↗
▶ Ep 86 · 13:28
clinical For a two-year-old with mislocated anus or bad prolapse, offer a redo and let them live in diapers for a year or two with better anatomy, then see if they can successfully potty train. ↗
▶ Ep 86 · 14:48
clinical For a patient with an anoplasty 50% within the sphincter complex at three and a half years old who is incontinent, one approach is to redo them, do a Malone, get them perfectly clean mechanically, then see if they can develop bowel control. ↗
▶ Ep 86 · 15:45
opinion If patients have not declared their continence yet because they are not old enough behaviorally, give them a chance as they may succeed. ↗

The Colorectal Quiz: Episode 1

▶ Ep 95 · 3:01
clinical Sacral ratio should be measured at three months of age for true measurement, though early measurement gives a feel for how normally the pelvis has developed ↗
▶ Ep 95 · 3:01
quote V, vertebral abnormalities. Plain x-ray of the abdomen tells you about the spine, make sure there's no hemivertebra. A is anorectal malformations, which is why we're having this podcast. And then C, cardiac abnormalities. We want to make sure we check for any cardiac defect, both on exam and on echo. E is esophageal atresia. So they ought to get an NG2 pass. R for renal abnormalities. So they need a kidney ultrasound. And then L, limb abnormalities. ↗
▶ Ep 95 · 3:01
quote I always worry about a missed pre-sacral mass. ↗
▶ Ep 95 · 3:01
guideline VACTERL workup for anorectal malformations includes: V (vertebral abnormalities via plain x-ray), A (anorectal malformations), C (cardiac abnormalities via exam and echo), E (esophageal atresia via NG tube passage), R (renal abnormalities via kidney ultrasound), and L (limb abnormalities via physical exam) ↗
▶ Ep 95 · 5:43
quote it's important that if this baby was born today, we're not rushing to do anything. Because we need time to have this baby declare themselves to either be someone who's going to need a colostomy or someone who might be able to benefit from a primary repair, a meconium, if a perineal fistula bubbles up. ↗
▶ Ep 95 · 7:08
quote I bet this kid is going to have a pretty normal sacral ratio, certainly greater than 0.7, which connotes a very good prognosis for bowel control and really peace of mind for the family. They want to know what's going to happen to this baby in four years when they need to potty train and go to school. ↗
▶ Ep 95 · 7:08
clinical Sacral ratio greater than 0.7 connotes very good prognosis for bowel control and provides peace of mind for families regarding potty training at age four ↗
▶ Ep 95 · 9:11
clinical The key to deciding whether to approach perineally via posterior sagittal is knowing where the rectum is—must be confident the first structure encountered will be rectum, not urethra, bladder neck, or bladder ↗
▶ Ep 95 · 9:11
clinical Colostomies are done to know exactly where the rectum is via distal colostogram and to determine whether to approach perineally or laparoscopically ↗
▶ Ep 95 · 9:11
quote I think the key to deciding whether to dive into a perineon posterior sagittally is where is the rectum? You want to know what structure you will find if you make a posterior sagittal or even a mini posterior sagittal incision. And there is no question in my mind that if I open posterior sagittally here, the first structure I would find would be rectum. Because the danger is that you go in posterior sagittally, you don't know where the rectum is, and you find something midline and white, like the urethra or the bladder neck or the bladder itself. And that's why we do colostomies. And that's why we do distal colostograms. So we know exactly where the rectum is, and we know whether we should approach it perineally or whether we should do it laparoscopically. ↗
▶ Ep 95 · 10:16
opinion Colostomy is the safe choice and was the right decision in this case, though it carries its own complications including those from colostomy closure ↗
▶ Ep 95 · 10:16
opinion The anal repair is made safer by having a colostomy, though everything in medicine is a balance ↗
▶ Ep 95 · 10:16
quote I will tell you that the surgeon who sent me this case, they did not do that. They felt more comfortable doing a colostomy. And I want to tell you, that was the safe thing to do. Bravo to them. That was the right choice. Nothing wrong with that at all. But of course, we are giving the child a colostomy. And whatever complications can happen from that, and we are giving the child a colostomy closure and whatever complications can happen from that. So everything in medicine is a balance, but there is no question that the anal part has been made safer by having a colostomy. ↗
▶ Ep 95 · 10:54
quote if you went in and grabbed this rectum and did a primary analplasty and did not know there was a fistula, and unfortunately, I've seen this done by some very good surgeons where they went in, did a beautiful analplasty, but ignored the fistula. And the child down the road started peeing out their anus. ↗
▶ Ep 95 · 10:54
clinical Very good surgeons have done beautiful anoplasties but ignored fistulas, resulting in children urinating out their anus postoperatively ↗
▶ Ep 95 · 12:00
clinical During primary posterior sagittal approach, open the posterior wall of rectum and inspect the anterior wall to rule out fistula ↗
▶ Ep 95 · 12:00
quote when I do that, I open up the posterior wall of the rectum, and I inspect the anterior wall of the rectum. ↗
▶ Ep 95 · 13:15
guideline Distal colostogram should still be performed in Down syndrome patients with imperforate anus despite 95% having no fistula ↗
▶ Ep 95 · 13:15
epidemiological 95% of Down syndrome patients with imperforate anus have no fistula, but 5% do have a fistula ↗
▶ Ep 95 · 13:15
quote 95% of Downs patients have no fistula, but 5% do. So I would still do a distal colostogram and some of them might have a fistula. ↗

The Colorectal Quiz: Episode 1

▶ Ep 88 · 3:01
clinical Cardiac evaluation should include both physical exam and echocardiogram in anorectal malformation patients ↗
▶ Ep 88 · 3:01
quote I always worry about a missed pre-sacral mass. ↗
▶ Ep 88 · 3:01
clinical Kidney ultrasound is needed to evaluate for renal abnormalities in anorectal malformation patients ↗
▶ Ep 88 · 3:01
clinical NG tube should be passed to rule out esophageal atresia in anorectal malformation workup ↗
▶ Ep 88 · 3:01
clinical Plain x-ray of the abdomen can identify vertebral abnormalities including hemivertebra in anorectal malformation workup ↗
▶ Ep 88 · 3:01
clinical True sacral ratio measurements should wait until the child is three months of age ↗
▶ Ep 88 · 3:01
guideline VACTERL mnemonic stands for: V (vertebral abnormalities), A (anorectal malformations), C (cardiac abnormalities), E (esophageal atresia), R (renal abnormalities), and L (limb abnormalities) ↗
▶ Ep 88 · 5:43
quote It's important that if this baby was born today, we're not rushing to do anything. Because we need time to have this baby declare themselves to either be someone who's going to need a colostomy or someone who might be able to benefit from a primary repair, a meconium, if a perineal fistula bubbles up. ↗
▶ Ep 88 · 7:08
quote The sacrum looks quite normal. I bet this kid is going to have a pretty normal sacral ratio, certainly greater than 0.7, which connotes a very good prognosis for bowel control and really peace of mind for the family. They want to know what's going to happen to this baby in four years when they need to potty train and go to school. ↗
▶ Ep 88 · 7:08
clinical A sacral ratio greater than 0.7 connotes a very good prognosis for bowel control ↗
▶ Ep 88 · 9:11
quote I think the key to deciding whether to dive into a perineon posterior sagittally is where is the rectum? You want to know what structure you will find if you make a posterior sagittal or even a mini posterior sagittal incision. ↗
▶ Ep 88 · 9:11
quote Because the danger is that you go in posterior sagittally, you don't know where the rectum is, and you find something midline and white, like the urethra or the bladder neck or the bladder itself. And that's why we do colostomies. And that's why we do distal colostograms. So we know exactly where the rectum is, and we know whether we should approach it perineally or whether we should do it laparoscopically. ↗
▶ Ep 88 · 9:11
clinical Colostomy and distal colostogram are performed to know exactly where the rectum is and determine whether to approach perineally or laparoscopically ↗
▶ Ep 88 · 9:11
clinical The key to deciding whether to approach perineally via posterior sagittal incision is knowing where the rectum is located ↗
▶ Ep 88 · 9:11
clinical The danger of blind posterior sagittal approach is finding midline white structures like urethra, bladder neck, or bladder itself instead of rectum ↗
▶ Ep 88 · 10:16
quote I will tell you that the surgeon who sent me this case, they did not do that. They felt more comfortable doing a colostomy. And I want to tell you, that was the safe thing to do. Bravo to them. That was the right choice. Nothing wrong with that at all. ↗
▶ Ep 88 · 10:16
clinical Performing a colostomy is the safe choice and carries its own set of potential complications, as does colostomy closure ↗
▶ Ep 88 · 10:54
clinical Surgeons have performed primary anorectoplasty without identifying a fistula, resulting in children later urinating out of their anus ↗
▶ Ep 88 · 10:54
quote This is sort of scary. Because if you went in and grabbed this rectum and did a primary analplasty and did not know there was a fistula, and unfortunately, I've seen this done by some very good surgeons where they went in, did a beautiful analplasty, but ignored the fistula. And the child down the road started peeing out their anus. ↗
▶ Ep 88 · 12:00
quote I think that's the key point of this case, that I think a lot of people would have done a primary repair because they said, oh, that's a chip shot. The rectum's right there. But when I do that, I open up the posterior wall of the rectum, and I inspect the anterior wall of the rectum. ↗
▶ Ep 88 · 12:00
clinical During primary posterior sagittal approach, the posterior wall of the rectum should be opened and the anterior wall inspected to rule out fistula ↗
▶ Ep 88 · 13:15
epidemiological 95% of patients with Down syndrome and imperforate anus have no fistula, but 5% do have a fistula ↗
▶ Ep 88 · 13:15
clinical Distal colostogram should still be performed in Down syndrome patients with imperforate anus despite the low probability of fistula ↗

Anorectal Malformations Complications

▶ Ep 96 · 2:55
clinical Perineal fistulas in males are commonly missed in the newborn period because the baby passes meconium through the small fistulous opening, and no one notices the abnormal anal anatomy. These patients typically present in the first year of life with severe constipation. ↗
▶ Ep 96 · 2:55
quote You'd be surprised how common these malformations are not properly diagnosed or completely missed in the newborn period. ↗
▶ Ep 96 · 3:43
clinical By the time a missed perineal fistula is diagnosed, the rectum and sigmoid have dilated because stool has been passing through a very tiny fistulous orifice which is not normal anal or rectal mucosa. ↗
▶ Ep 96 · 4:03
quote Nowadays, the standard is to not even check a rectal temperature, is to check a temperature on the forehead or in the ear, and therefore, you don't have to look. If you don't look, you might not know. ↗
▶ Ep 96 · 4:03
clinical The current standard is to check temperature on the forehead or in the ear rather than rectally, so if you don't look at the anus, you might not know there is a malformation. ↗
▶ Ep 96 · 4:53
clinical Relocating a perineal fistula into the sphincters does not completely fix the constipation, though it improves the anatomy by making the hole adequately sized and lined by mucosa. ↗
▶ Ep 96 · 5:23
clinical Patients with uncorrected perineal fistulas can have some semblance of continence with formed stool, but with loose stool or athletic activity they will soil because they cannot completely close the anteriorly located hole when squeezing their sphincters. ↗
▶ Ep 96 · 6:05
clinical A newborn anus should accept a size 12 Hagar dilator, and a one-year-old should accept a size 15. ↗
▶ Ep 96 · 6:41
clinical A bucket handle (a lifted skin tag that you can pass a probe underneath) is consistent with a perineal fistula even if you cannot see the fistula itself. ↗
▶ Ep 96 · 7:28
opinion Perineal fistula in females is probably the most confounding diagnosis in pediatric colorectal surgery, with many patients either being missed or overdiagnosed. ↗
▶ Ep 96 · 7:50
clinical Diagnostic criteria for perineal fistula in females: inadequate perineal body (hole too close to vagina), inadequate hole size, and hole not centered in the sphincter. ↗
▶ Ep 96 · 8:25
clinical If the anal opening in a female is adequate size and centered in the sphincter, even if it appears slightly anterior with a short perineal body, that patient does not need surgery. The perineal body will lengthen with growth. ↗
▶ Ep 96 · 10:50
clinical An anesthesia nerve stimulator ($150) with appropriate needle probes works as well as a dedicated Pena stimulator ($15,000) for intraoperative sphincter mapping. ↗
▶ Ep 96 · 11:30
quote I got no benefit from that $15,000 times two credit, but we use the anesthesia nerve stimulator. ↗
▶ Ep 96 · 12:38
clinical The vast majority of male ARM patients have a rectourethral fistula. It is important not to approach these primarily because you don't know where the rectum is—it could be at bladder neck, prostatic, or bulbar level. ↗
▶ Ep 96 · 13:20
clinical If you open posterior sagittal looking for a rectourethral fistula without knowing the location, you will find something midline, white, and shiny that might be the urinary tract, not the rectum. ↗
▶ Ep 96 · 14:04
quote Believe it or not, that has happened too. I just, in fact, last week saw a six-month-old who presented at age six months with constipation, and someone finally looked and saw there was no anus. ↗
▶ Ep 96 · 14:04
clinical Cloacas can be missed in the newborn period. Dr. Levitt saw a six-month-old who presented with constipation and was found to have an undiagnosed cloaca with no hint of an anal opening. ↗
▶ Ep 96 · 15:49
clinical Ambiguous genitalia (clitoromegaly from endocrine stimulation) presents with a urogenital sinus but a completely normal anus. This is different from a cloaca, which has no anus and no endocrine problem. ↗
▶ Ep 96 · 16:44
clinical The most common colostomy error is opening too distal in the sigmoid, which restricts the ultimate pull-through by the location of the colostomy or mucous fistula. ↗
▶ Ep 96 · 16:44
quote I think that operation of a colostomy needs to be taken very seriously, and every pediatric surgeon who deals with newborns, which is the art of our specialty, needs to be really, really good at this because there's a lot of morbidity that's conveyed to a patient with an improperly done colostomy. ↗
▶ Ep 96 · 17:20
clinical Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections. ↗
▶ Ep 96 · 17:50
clinical Transverse colostomies are problematic because they can prolapse, and if there is a large rectourethral fistula, the left colon absorbs all the urine (which doesn't come out the mucous fistula), causing acidosis. ↗
▶ Ep 96 · 18:35
clinical Dr. Levitt's preference is a very proximal sigmoid colostomy with separated stomas, leaving the entire sigmoid loop for the pull-through. He makes the mucous fistula very tiny and flat. ↗
▶ Ep 96 · 19:58
clinical Prolapse is related to where in the colon you choose to do the colostomy. Mid-transverse: both sides can prolapse. Hepatic flexure: only distal can prolapse. Proximal sigmoid: only distal (mucous fistula) can prolapse because left colon is fixed to retroperitoneum. ↗
▶ Ep 96 · 21:10
clinical Dr. Levitt marks the anoplasty location by drawing a circle around the pinkish ellipse where it stimulates on the skin surface BEFORE making the incision, to avoid getting lost when looking at jumping muscles from the stimulator. ↗
▶ Ep 96 · 21:10
quote I actually mark the anoplasty before I make the incision. And I think you can get lost when you're looking at a bunch of jumping muscles from a stimulator. ↗
▶ Ep 96 · 22:36
clinical Really good surgeons have put anuses in crazy places because they don't have a sense of what's the center once everything is disrupted and open. ↗
▶ Ep 96 · 22:36
quote I'm sure that's what's happened because really, really good surgeons have put anuses in crazy places. And I think it's because they don't have a sense of what's the center because everything's disrupted once it's open. ↗
▶ Ep 96 · 23:29
quote The distal colostagram is really an absolutely vital study. And a lot of mistakes are made because of a poorly done study, first of all, and then a misinterpretation of that study. ↗
▶ Ep 96 · 23:29
clinical The distal colostogram is an absolutely vital study. Many mistakes are made because of a poorly done study and misinterpretation. ↗
▶ Ep 96 · 23:55
clinical The basic questions the distal colostogram must answer: Where is the rectum? How low is it? Is it reachable posterior sagittally or better approached laparoscopically? What is its relationship to the urinary tract? ↗
▶ Ep 96 · 24:30
clinical The common colostogram mistake is not giving enough contrast and pressure into the distal segment, giving a false impression that the rectum is high or that there is no fistula. ↗
▶ Ep 96 · 25:00
clinical If you see a straight line flattening of the rectum corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure. You need to overcome the PC line (the sphincters compressing the distal rectum) to see the bulging rectum and fistula. ↗
▶ Ep 96 · 25:00
quote If you see that flattening of the rectum, you know the radiologist did not give enough contrast, enough pressure. Because you need to overcome the PC line because that's the sphincters. ↗
▶ Ep 96 · 25:55
clinical If the rectum is bulbous, it might be reachable posterior sagittally and hard to do laparoscopically because of the girth. If it's tapered, you're better off laparoscopically. ↗
▶ Ep 96 · 25:55
clinical Fistula classification: if the fistula is at the urethral 'elbow' or below, it's bulbar. Above the elbow is prostatic. At the bladder neck is bladder neck fistula. ↗
▶ Ep 96 · 26:52
clinical If you don't know where the rectum is and open posterior sagittal, you will find a whitish, shiny structure and may think it's the rectum. Often it's the bladder neck. ↗
▶ Ep 96 · 27:30
clinical You avoid bladder neck injury by knowing exactly where the rectum is from a properly done distal colostogram. When you open posterior sagittal, you know the rectum is right under the coccyx (prostatic) or distal to the coccyx (bulbar), or it isn't posterior sagittal at all (bladder neck—do laparoscopy). ↗
▶ Ep 96 · 29:20
quote You should never go to the operating room without knowing exactly what anatomy you're going to expect to find. And the big question is, where is the rectum? Is it the most posterior structure? And where is it the most posterior structure? ↗
▶ Ep 96 · 30:03
clinical Dr. Levitt will do posterior sagittal for bulbar fistulas and low prostatic fistulas with a bulge. High prostatic with tapered rectum and bladder neck fistulas are best served by laparoscopy. ↗
▶ Ep 96 · 30:50
clinical If you try laparoscopy for a rectum bulging below the peritoneal reflection at low prostatic or bulbar level, you may leave behind a remnant of the original fistula (ROOF)—the distal rectum left behind that causes trouble later. ↗
▶ Ep 96 · 31:38
clinical Laparoscopy replaces laparotomy, not PSARP. Dr. Levitt does a mini-PSARP when doing laparoscopy to safely enter the pelvis and tack the rectum to the posterior edge of the muscle complex to avoid prolapse. ↗
▶ Ep 96 · 31:38
quote I never look at it that way. I think that laparoscopy replaces laparotomy. It's an elegant dissection from above. But don't give away the advantages of the PSARP. ↗
▶ Ep 96 · 32:30
clinical Dr. Levitt calls his approach 'laparoscopic-assisted PSARP' rather than pure laparoscopy. ↗
▶ Ep 96 · 32:30
quote I like to call mine a laparoscopic-assisted PSARP. I think that's a better terminology. ↗
▶ Ep 96 · 32:55
clinical Prolapse prevention: put the rectum in the right location, close the levators properly, close the posterior wall to the posterior edge of the muscle complex for 3-4 stitches, don't dissect the rectum more than necessary. ↗
▶ Ep 96 · 33:49
epidemiological Prolapse occurs in about 3% of cases, particularly in those without great muscles. ↗
▶ Ep 96 · 33:54
clinical Rectal prolapse causes bleeding, mucus, and for patients with good continence potential, it inhibits bowel control because they can't close the opening with prolapsed tissue through it. ↗
▶ Ep 96 · 34:30
clinical Dr. Levitt trims prolapse of more than about 3mm. For circumferential prolapse, he does half the circumference in two different ambulatory settings so families don't need hospitalization and the patient doesn't need dilation (half the circumference is untouched so they won't stricture). ↗
▶ Ep 96 · 35:27
quote Perineal body dehiscence is the most common cause of reoperation that I do is a female repair in which the perineal body dehiscs. ↗
▶ Ep 96 · 35:27
clinical Perineal body dehiscence is the most common cause of reoperation Dr. Levitt performs in female ARM repairs. ↗
▶ Ep 96 · 35:55
clinical The key to preventing perineal body dehiscence is mobilizing the rectum well—you must get the anterior rectal wall completely separated from the posterior vaginal wall to the areolar plane. If you don't, the anoplasty will be under tension and can pull back, leak into the perineal body space, and dehisce. ↗
▶ Ep 96 · 36:50
clinical Dr. Levitt uses 3-0 suture for perineal body closure in a baby and 4-0 Vicryl on the perineal skin, then watches the perineum very closely. ↗
▶ Ep 96 · 37:15
clinical Traditionally Dr. Levitt kept patients NPO for 7 days on 10% dextrose after female ARM repair. Recently he has been trialing clear liquids only for a week because the major problem is hard stool—clear liquids won't make hard stool. ↗
▶ Ep 96 · 37:47
clinical If perineal body dehiscence is detected on days 5-8, Dr. Levitt will take the patient back to the OR and re-suture the perineal body, which can salvage the situation. This happens in maybe 1-2 cases out of about 200. ↗
▶ Ep 96 · 37:47
quote If you see it's opening, I actually will take... And this happens maybe one or two cases out of about 200, I can tell you. That's not insignificant. I will take them back to the OR and re-suture the perineal body. ↗
▶ Ep 96 · 38:31
clinical Laparoscopy causes trouble if you try to dissect a rectum that's too low—you get too close to the urinary tract or you're too timid and leave behind the distal rectum (remnant of original fistula). ↗
▶ Ep 96 · 39:10
clinical For high rectums, particularly bladder neck fistulas, the dissection of the distal rectum is quite challenging to make it reach with good blood supply. You must preserve the IMA because the colostomy may have disrupted collaterals down the left colic, making the rectum completely dependent on the IMA. ↗
▶ Ep 96 · 39:40
clinical The rectum has an excellent intramural blood supply from the IMA. If you take the IMA or take branches too close to the aorta, the rectum will die because there's no collateralization down the left colic. ↗
▶ Ep 96 · 40:12
clinical The biggest problem with posterior sagittal incision is going after a rectum when you don't know where it is. You open and find the bladder neck, urethra, seminal vesicles, vas deferens, ectopic ureter—everything but the distal rectum. ↗
▶ Ep 96 · 40:50
quote There are some famous cases of pull through bladder neck made into beautiful anoplasties. And post-op, the patient was draining liquid out their anoplasty. And in fact, it was the bladder neck. ↗
▶ Ep 96 · 40:50
clinical There are famous cases of pull-through of bladder neck made into beautiful anoplasties, and post-op the patient was draining liquid out their anoplasty—it was the bladder neck. ↗
▶ Ep 96 · 42:09
clinical To determine if an ARM patient has potential for bowel control, Dr. Levitt looks at three factors: original type of malformation, quality of sacrum and calculated sacral ratio, and quality of spine. He calls this the ARM continence index. ↗
▶ Ep 96 · 43:10
clinical Three A's (excellent malformation type, sacrum, and spine) predicts a continent patient. Three C's predicts an incontinent patient. Dr. Levitt's group is working on quantifying the in-between grades. ↗
▶ Ep 96 · 43:45
clinical A bulbar fistula with a good sacrum (sacral ratio of 1) and normal spine should absolutely have bowel control. A bladder neck fistula with poor sacrum (sacral ratio 0.4) and tethered cord or myelomeningocele has no real chance of good bowel control. ↗
▶ Ep 96 · 44:30
clinical For a soiling 4-year-old ARM patient, Dr. Levitt's first step is to get them clean mechanically with bowel management using enemas. For those with continence potential, when they're older and more mature, he tries to switch them to laxatives to achieve voluntary bowel movements. ↗
▶ Ep 96 · 45:20
clinical Indications for redo pull-through: any patient with potential for bowel control whose anatomy is not perfect—improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum). ↗
▶ Ep 96 · 46:05
opinion One of the biggest problems with ARM is that if you don't get it right, you don't know for a few years. Most surgical problems become obvious immediately, but with ARM, patients may not present with soiling until age 4, making it hard for surgeons to learn what to fix about their technique. ↗
▶ Ep 96 · 46:20
quote Most things in surgery, if you don't do it right, you know right away. Like, if you don't sew a hepatic artery together properly during a liver transplant, the next day, you have a thrombosed artery. If you don't put an anus in the right place, you think you did a perfectly fine operation, the patient goes home, everyone's happy, and only four years later do they come soiling. ↗

Anorectal Malformations Complications

▶ Ep 90 · 2:55
clinical Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period. ↗
▶ Ep 90 · 3:05
clinical Males with missed perineal fistula typically present in the first year of life with severe constipation after passing meconium through a very tiny fistulous orifice. ↗
▶ Ep 90 · 3:40
clinical By the time of presentation, the rectum and sigmoid have dilated because stool has been passing through a very tiny fistulous orifice which is not normal anal or rectal mucosa. ↗
▶ Ep 90 · 4:10
clinical The current standard is to check temperature on the forehead or in the ear rather than rectally, which means clinicians may not look at the anus and might not detect malformations. ↗
▶ Ep 90 · 4:30
quote If you don't look, you might not know. ↗
▶ Ep 90 · 4:53
clinical Relocating a perineal fistula into the sphincters does not completely fix constipation, though it improves anatomy by making the hole adequately sized and lined by mucosa. ↗
▶ Ep 90 · 5:20
clinical Patients with uncorrected perineal fistula can have some semblance of continence with formed stool, but will soil with loose stool or athletic activity because they cannot completely close the hole when squeezing sphincters. ↗
▶ Ep 90 · 6:05
clinical A newborn anus should accept a size 12 Hagar dilator, and a one-year-old should accept a size 15. ↗
▶ Ep 90 · 6:41
clinical A bucket handle (lifted skin tag that a probe can pass underneath) is consistent with a perineal fistula even when the fistula itself is not visible. ↗
▶ Ep 90 · 7:05
clinical Little beads of meconium (black) or mucus (white) along the scrotal raphae are consistent with a perineal fistula. ↗
▶ Ep 90 · 7:51
clinical Diagnostic criteria for perineal fistula in females: hole too close to vagina (inadequate perineal body), inadequate hole size, or hole not centered in sphincter. ↗
▶ Ep 90 · 8:40
clinical If the hole is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, the patient does not need surgery—the perineal body will lengthen with growth. ↗
▶ Ep 90 · 9:51
clinical Examination under anesthesia with stimulation can confirm whether a questionable hole is properly centered within the sphincter. ↗
▶ Ep 90 · 10:50
clinical An anesthesia nerve stimulator ($150) with appropriate needle probes works as well as commercial Peña stimulators ($15,000). ↗
▶ Ep 90 · 12:38
epidemiological The vast majority of male ARM patients have a rectourethral fistula at bladder neck, prostatic, or bulbar level. ↗
▶ Ep 90 · 12:55
opinion Rectourethral fistula patients should not be approached primarily because the surgeon does not know where the rectum is; colostomy with distal colostogram is safer. ↗
▶ Ep 90 · 13:20
clinical With posterior sagittal incision for unknown rectal location, the surgeon will find something midline, white, and shiny that might be urinary tract rather than rectum. ↗
▶ Ep 90 · 13:40
clinical With laparoscopy, all rectourethral fistulas go slightly below the peritoneal reflection, making it impossible to distinguish bladder neck, prostatic, or bulbar level. ↗
▶ Ep 90 · 15:49
clinical Cloaca patients have no anus and a urogenital sinus but have two completely normal ovaries with no endocrine problem. ↗
▶ Ep 90 · 16:34
clinical Urogenital sinus with normal anus is a unique entity often dealt with by urologists, distinct from cloaca. ↗
▶ Ep 90 · 17:04
clinical The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through by the location of the colostomy or mucous fistula. ↗
▶ Ep 90 · 17:30
clinical Incompletely dividing loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections. ↗
▶ Ep 90 · 18:15
clinical Transverse colostomies can prolapse and, with large rectourethral fistula, cause the left colon to absorb urine (which doesn't exit the mucous fistula), leading to acidosis. ↗
▶ Ep 90 · 18:45
clinical Distal colostogram through transverse colostomy is difficult because it requires high pressure and the entire distal segment is filled with meconium that's hard to clean out. ↗
▶ Ep 90 · 19:10
opinion Levitt's preference is proximal sigmoid colostomy with separated stomas, leaving the entire sigmoid loop for pull-through, with tiny flat mucous fistula. ↗
▶ Ep 90 · 20:03
clinical Prolapse location depends on colostomy site: mid-transverse (both sides), hepatic flexure (distal only), proximal sigmoid (distal only because left colon is fixed to retroperitoneum). ↗
▶ Ep 90 · 20:40
clinical Ileostomies prolapse frequently because they are free-floating unless tacked to the anterior abdominal wall. ↗
▶ Ep 90 · 21:10
clinical Levitt marks the anoplasty location by drawing a circle around the pinkish sphincter ellipse on the skin surface before making any incision to avoid getting lost when muscles are jumping from stimulation. ↗
▶ Ep 90 · 23:03
clinical Really good surgeons have put anuses in incorrect locations because they don't have a sense of center once everything is disrupted and open. ↗
▶ Ep 90 · 23:29
opinion The distal colostogram is an absolutely vital study; mistakes are made from poorly done studies and misinterpretation. ↗
▶ Ep 90 · 23:50
clinical The basic colostogram questions are: where is the rectum, how low is it, is it reachable posterior sagittally or better approached laparoscopically, and what is its relationship to the urinary tract. ↗
▶ Ep 90 · 24:20
clinical Common colostogram error: insufficient contrast and pressure give false impression that rectum is high or that there's no fistula. ↗
▶ Ep 90 · 24:40
clinical If the distal colostogram shows a straight line at the bottom of the rectum corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure to overcome sphincter compression. ↗
▶ Ep 90 · 25:20
clinical With adequate pressure, the colostogram shows a bulging rectum at the bottom and evidence of a fistula, revealing exactly where the rectum is. ↗
▶ Ep 90 · 25:45
clinical Fistula classification: if at the urethral 'elbow' or below, it's bulbar; above the elbow is prostatic; at bladder neck is bladder neck fistula. ↗
▶ Ep 90 · 26:52
clinical If opening posterior sagittal without knowing rectal location, the surgeon will find a whitish shiny structure that might be bladder neck rather than rectum. ↗
▶ Ep 90 · 27:40
clinical When opening posterior sagittal for rectourethral fistula, if the rectum is right under the coccyx it's usually prostatic; distal to coccyx is usually bulbar. ↗
▶ Ep 90 · 28:05
opinion Bladder neck fistulas are not reachable posterior sagittally and are better approached laparoscopically, as are very high prostatic fistulas with tapered rectums. ↗
▶ Ep 90 · 28:31
opinion Bulbar and bulbous prostatic fistulas can be found right under the coccyx and are preferably done posterior sagittally rather than laparoscopically. ↗
▶ Ep 90 · 28:50
clinical Some surgeons use a catheter with balloon in the mucous fistula or a gastroscope to look for light intraoperatively to locate the rectum, though Levitt doesn't use these techniques. ↗
▶ Ep 90 · 29:20
opinion Surgeons should never go to the operating room without knowing exactly what anatomy to expect; the key question is where is the rectum and is it the most posterior structure. ↗
▶ Ep 90 · 30:03
opinion Bulbar or low prostatic fistulas with bulging rectum are more easily approached posterior sagittally; high prostatic with tapered narrow rectum is best served by laparoscopy. ↗
▶ Ep 90 · 30:35
clinical Attempting laparoscopy for bulging rectum below peritoneal reflection (low prostatic/bulbar) requires unnecessary extra work and risks leaving behind a remnant of the original fistula (ROOF). ↗
▶ Ep 90 · 31:10
opinion Attempting posterior sagittal approach for high rectum is very difficult to mobilize and risks urinary tract injury; these cases are best served laparoscopically. ↗
▶ Ep 90 · 31:38
clinical Levitt performs a mini-PSARP when doing laparoscopy to safely enter the pelvis through the peritoneal reflection and to tack the rectum to the posterior edge of the muscle complex to avoid prolapse. ↗
▶ Ep 90 · 32:25
clinical Prolapse is very common after laparoscopic pull-through if the rectum is not hitched to the pelvis or tacked to the muscle complex. ↗
▶ Ep 90 · 32:40
quote I like to call mine a laparoscopic-assisted PSARP. ↗
▶ Ep 90 · 33:03
clinical Prolapse prevention measures include: putting rectum in right location, properly closing levators, closing posterior wall to posterior edge of muscle complex for 3-4 stitches, and not over-dissecting the rectum. ↗
▶ Ep 90 · 33:40
epidemiological Prolapse occurs in about 3% of cases, particularly in those without great muscles. ↗
▶ Ep 90 · 33:54
clinical Rectal prolapse causes bleeding, mucus, and can inhibit bowel control in patients with good potential because they cannot close the opening with prolapsed tissue through it. ↗
▶ Ep 90 · 34:30
clinical Levitt treats prolapse of more than 3mm, trimming it ideally while the colostomy is still in place. ↗
▶ Ep 90 · 34:50
clinical For circumferential prolapse, Levitt performs half the circumference in two different ambulatory settings, which families prefer to hospitalization and eliminates need for dilation since half the circumference is untouched. ↗
▶ Ep 90 · 35:35
epidemiological Perineal body dehiscence is the most common cause of reoperation in female ARM repairs. ↗
▶ Ep 90 · 35:50
clinical The key to preventing perineal body dehiscence is complete mobilization of the anterior rectal wall from the posterior vaginal wall to reach the areolar plane and avoid tension on the anoplasty. ↗
▶ Ep 90 · 36:20
clinical Levitt uses 3-0 suture for perineal body closure in babies and 4-0 Vicryl on perineal skin. ↗
▶ Ep 90 · 36:35
clinical Levitt traditionally used 7-day NPO on 10% dextrose but is now trialing clear liquids only for a week, recognizing the major problem is hard stool rather than stool volume. ↗
▶ Ep 90 · 37:10
clinical The major risk of regular diet and early discharge is hard stool passing through the repair, splitting it open and causing dehiscence. ↗
▶ Ep 90 · 37:47
clinical If perineal body dehiscence is detected on days 5-8, Levitt takes the patient back to OR to re-suture, which can salvage the situation; by 3-4 weeks the whole thing is dehisced and nothing can be done. ↗
▶ Ep 90 · 38:38
clinical Laparoscopy causes trouble if attempting to dissect a rectum that's too low, risking getting too close to urinary tract or being too timid and leaving behind remnant of original fistula. ↗
▶ Ep 90 · 39:10
clinical Passage of trocar through small perineal incision is risky; Levitt makes a 3-4cm posterior sagittal incision and hugs the hollow of the sacrum for safer passage into the pelvis. ↗
▶ Ep 90 · 39:40
clinical For high rectums (especially bladder neck fistulas), dissection of distal rectum is challenging to achieve adequate reach with good blood supply. ↗
▶ Ep 90 · 40:00
clinical The IMA must be preserved because prior colostomy disrupted collaterals down the left colic, making the rectum completely dependent on the IMA. ↗
▶ Ep 90 · 40:20
clinical The rectum has excellent intramural blood supply from the IMA; taking the IMA or branches too close to the aorta will cause rectal necrosis due to lack of collateralization. ↗
▶ Ep 90 · 40:46
clinical The biggest PSARP problem is operating without knowing where the rectum is, leading to finding bladder neck, urethra, seminal vesicles, vas deferens, or ectopic ureter instead of distal rectum. ↗
▶ Ep 90 · 41:15
clinical Famous cases exist of pull-through of bladder neck made into beautiful anoplasties, with the patient draining liquid (urine) postoperatively. ↗
▶ Ep 90 · 42:09
clinical Continence potential in ARM patients is assessed using three factors: original malformation type, sacral quality/sacral ratio, and spine quality (ARM continence index). ↗
▶ Ep 90 · 42:40
quote I like to call that the ARM continence index. ↗
▶ Ep 90 · 42:50
clinical Three A's (excellent in all three factors) predicts continence; three C's (poor in all three) predicts incontinence. ↗
▶ Ep 90 · 43:10
clinical A bulbar fistula with sacral ratio of 1 and normal spine should absolutely have bowel control. ↗
▶ Ep 90 · 43:25
clinical A bladder neck fistula with poor sacrum (sacral ratio 0.4) and tethered cord or myelomeningocele has no real chance of good bowel control. ↗
▶ Ep 90 · 43:45
clinical For four-year-olds with soiling, Levitt's first step is mechanical bowel management with enemas to achieve cleanliness, then trial laxatives when older/more mature for those with continence potential. ↗
▶ Ep 90 · 44:20
clinical If patients cannot be weaned off enemas, an antegrade option like Malone can be discussed. ↗
▶ Ep 90 · 44:35
clinical Redo pull-through is indicated for patients with any continence potential who have improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum). ↗
▶ Ep 90 · 45:10
clinical Redoing an anoplasty to center the rectum in the sphincter can change a patient to have potential for bowel control. ↗
▶ Ep 90 · 46:05
opinion One of the biggest problems with ARM is that if you don't get it right, you don't know for a few years, unlike most surgical complications which are immediately apparent. ↗
▶ Ep 90 · 46:40
opinion Surgeons cannot learn to fix their technique when problems only become obvious years later (e.g., soiling at age four), which is why there is so much morbidity in colorectal surgery. ↗
▶ Ep 90 · 46:50
quote How are you supposed to, as a surgeon, know what to fix about your technique if your problems are only becoming obvious years later? ↗

Anorectal Malformations Complications

▶ Ep 91 · 2:55
quote You'd be surprised how common these malformations are not properly diagnosed or completely missed in the newborn period. ↗
▶ Ep 91 · 2:55
epidemiological Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period. ↗
▶ Ep 91 · 3:05
clinical Male infants with perineal fistula may pass meconium and present in the first year of life with severe constipation when the fistula is missed. ↗
▶ Ep 91 · 3:25
clinical In missed perineal fistula, the rectum and sigmoid dilate because stool passes through a very tiny fistulous orifice which is not normal anal or rectal mucosa. ↗
▶ Ep 91 · 4:00
clinical Missed anorectal malformation can lead to perforation if stool doesn't pass satisfactorily. ↗
▶ Ep 91 · 4:20
quote Nowadays, the standard is to not even check a rectal temperature, is to check a temperature on the forehead or in the ear, and therefore, you don't have to look. If you don't look, you might not know. ↗
▶ Ep 91 · 4:20
clinical The current standard is to check temperature on forehead or ear rather than rectally, which means the anus may not be examined. ↗
▶ Ep 91 · 4:53
clinical Relocating perineal fistula into sphincters does not completely fix constipation, though it improves anatomy. ↗
▶ Ep 91 · 5:30
clinical Patients with uncorrected perineal fistula can have some continence with formed stool but will soil with loose stool or athletic activity because they cannot completely close the hole when squeezing sphincters. ↗
▶ Ep 91 · 6:15
clinical A newborn anus should accept a size 12 Hagar dilator, and a one-year-old should accept size 15. ↗
▶ Ep 91 · 6:25
clinical In perineal fistula, the anal opening is in the anterior portion of the pinkish ellipse (sphincter) or completely anterior to it. ↗
▶ Ep 91 · 6:41
clinical A bucket handle skin tag is consistent with perineal fistula; a probe can be passed underneath it, and the fistula lies beneath. ↗
▶ Ep 91 · 7:05
clinical Beads of meconium (black) or mucus (white) along the scrotal raphae are consistent with perineal fistula. ↗
▶ Ep 91 · 8:00
clinical Diagnostic criteria for female perineal fistula: hole too close to vagina (inadequate perineal body), inadequate hole size, and hole not centered in sphincter. ↗
▶ Ep 91 · 8:50
clinical If the anal hole is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, no surgery is needed; the perineal body will lengthen with growth. ↗
▶ Ep 91 · 9:51
clinical Examination under anesthesia with stimulation can confirm whether the anal opening is properly centered in the sphincter when diagnosis is uncertain. ↗
▶ Ep 91 · 11:00
clinical An anesthesia nerve stimulator ($150) with appropriate needle probes works as well as a dedicated Pena stimulator ($15,000). ↗
▶ Ep 91 · 12:38
epidemiological The vast majority of male ARM patients have rectourethral fistula. ↗
▶ Ep 91 · 12:48
clinical Rectourethral fistula should not be approached primarily because the rectum location is unknown; it could be at bladder neck, prostatic, or bulbar level. ↗
▶ Ep 91 · 13:10
clinical If posterior sagittal incision is made without knowing rectal location, a midline white shiny structure will be found that might be urinary tract, not rectum. ↗
▶ Ep 91 · 13:30
clinical With laparoscopy for rectourethral fistula, all cases go slightly below peritoneal reflection, making it impossible to distinguish bladder neck, prostatic, or bulbar fistula. ↗
▶ Ep 91 · 13:45
guideline Rectourethral fistula patients should receive colostomy with distal colostogram. ↗
▶ Ep 91 · 13:53
clinical Exceedingly rarely, a cross-table lateral film at 20 hours showing very low rectum may allow safe primary posterior sagittal approach. ↗
▶ Ep 91 · 14:04
clinical Cloaca can be missed in the newborn period; a recent case presented at six months with constipation. ↗
▶ Ep 91 · 14:40
quote I just think that we need to standardize our newborn exam. I think their lost art of examining the anus and ensuring that someone's putting a rectal thermometer in is an unfortunate change into modern medicine because I think it's harder to miss an anal rectal malformation if someone's put a probe through. ↗
▶ Ep 91 · 14:40
guideline Newborn examination should be standardized to include conscious visual inspection of the anus and confirmation of adequate size and location. ↗
▶ Ep 91 · 15:49
clinical Ambiguous genitalia with clitoromegaly and normal anus represents urogenital sinus with virilization, an endocrine problem. ↗
▶ Ep 91 · 16:15
clinical Cloaca patients have no anus, a urogenital sinus, large clitoris (not from endocrine stimulation), and two completely normal ovaries with no endocrine problem. ↗
▶ Ep 91 · 17:04
quote I think that operation of a colostomy needs to be taken very seriously, and every pediatric surgeon who deals with newborns, which is the art of our specialty, needs to be really, really good at this because there's a lot of morbidity that's conveyed to a patient with an improperly done colostomy. ↗
▶ Ep 91 · 17:20
clinical The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through. ↗
▶ Ep 91 · 17:35
clinical Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections. ↗
▶ Ep 91 · 18:00
clinical Separated stomas prevent any chance of stool crossing to the distal segment. ↗
▶ Ep 91 · 18:20
clinical Transverse colostomies can prolapse and, with large rectourethral fistula, cause the left colon to absorb urine, leading to acidosis. ↗
▶ Ep 91 · 18:45
clinical Distal colostogram through transverse colostomy is difficult, requires high pressure, and leaves meconium in the entire distal segment for months. ↗
▶ Ep 91 · 19:10
guideline Proximal sigmoid colostomy leaves the entire sigmoid loop for pull-through and should be performed laparoscopically with separated stomas. ↗
▶ Ep 91 · 20:03
clinical Mid-transverse colostomy: both sides can prolapse. Hepatic flexure colostomy: only distal side prolapses. Proximal sigmoid colostomy: only distal (mucous fistula) can prolapse if not made tiny and flat. ↗
▶ Ep 91 · 20:40
clinical Ileostomies prolapse frequently because they are free-floating unless tacked to anterior abdominal wall. ↗
▶ Ep 91 · 21:20
clinical Anoplasty location should be marked on the skin surface before making any incision by drawing a circle around the pinkish ellipse where it stimulates. ↗
▶ Ep 91 · 21:50
quote I think what happens is if people don't do that, then they're open in, let's say, a posterior sagittal incision. And then they see a bunch of muscles jumping around with the stimulator and they choose the wrong place. ↗
▶ Ep 91 · 22:10
clinical Surgeons can choose the wrong anoplasty location when they see muscles jumping with stimulator after opening the incision, because they lack a reference landmark. ↗
▶ Ep 91 · 23:03
clinical Really good surgeons have put anuses in wrong locations because everything is disrupted once the incision is open and they lack a sense of center. ↗
▶ Ep 91 · 23:03
quote Really, really good surgeons have put anuses in crazy places. And I think it's because they don't have a sense of what's the center because everything's disrupted once it's open. ↗
▶ Ep 91 · 23:29
clinical Distal colostogram is an absolutely vital study; many mistakes result from poorly done studies and misinterpretation. ↗
▶ Ep 91 · 23:29
quote The distal colostagram is really an absolutely vital study. And a lot of mistakes are made because of a poorly done study, first of all, and then a misinterpretation of that study. ↗
▶ Ep 91 · 23:45
clinical The distal colostogram must answer: where is the rectum, how low is it, is it reachable posterior sagittally or better approached laparoscopically, and what is its relationship to the urinary tract. ↗
▶ Ep 91 · 24:15
clinical Common colostogram error: insufficient contrast and pressure, giving false impression that rectum is high or that there is no fistula. ↗
▶ Ep 91 · 24:35
clinical If the distal rectum shows a straight line flattening corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure. ↗
▶ Ep 91 · 25:00
quote You need to overcome the PC line because that's the sphincters. That's where the sphincters are compressing the distal rectum. ↗
▶ Ep 91 · 25:00
clinical The PC line is where the sphincters compress the distal rectum; more pressure is needed to overcome this and show the bulging rectum and fistula. ↗
▶ Ep 91 · 25:25
clinical Rectourethral fistula can be at bladder neck, prostatic level, or bulbar level. The urethra looks like a reverse C or elbow: fistula at or below the elbow is bulbar; above the elbow is prostatic; at bladder neck is bladder neck fistula. ↗
▶ Ep 91 · 26:05
clinical Colostogram should show whether the rectum is bulbous or tapered. Bulbous rectum may be reachable posterior sagittally but hard laparoscopically due to girth. Tapered rectum is better approached laparoscopically. ↗
▶ Ep 91 · 27:00
clinical Opening posterior sagittal incision without knowing rectal location will reveal a whitish shiny midline structure that may be bladder neck, not rectum. ↗
▶ Ep 91 · 27:25
clinical Proper distal colostogram tells the surgeon exactly where to look for the rectum: right under the coccyx for prostatic fistula, distal to coccyx for bulbar, or not reachable posterior sagittally for bladder neck. ↗
▶ Ep 91 · 28:00
clinical Bulbous prostatic fistulas can be found right under the coccyx and are preferably done posterior sagittally. ↗
▶ Ep 91 · 28:15
clinical Bulbar fistulas are nearly at the perineal skin and should definitely be done posterior sagittally, not laparoscopically, because transabdominal approach requires more work. ↗
▶ Ep 91 · 29:05
clinical If uncertain whether a structure is rectum, place stitches on either side and open in midline; if wrong, close it. Staying perfectly midline allows safe closure if urinary tract is opened. ↗
▶ Ep 91 · 29:20
quote You should never go to the operating room without knowing exactly what anatomy you're going to expect to find. And the big question is, where is the rectum? Is it the most posterior structure? And where is it the most posterior structure? ↗
▶ Ep 91 · 29:30
guideline Never go to the operating room without knowing exactly what anatomy to expect. The key question is: where is the rectum and is it the most posterior structure? ↗
▶ Ep 91 · 30:10
guideline Bulbar or low prostatic fistula with bulging rectum: approach posterior sagittally. High prostatic with tapered rectum or bladder neck fistula: approach laparoscopically. ↗
▶ Ep 91 · 30:40
clinical Attempting laparoscopy for bulging rectum below peritoneal reflection (low prostatic or bulbar) requires unnecessary extra work and risks leaving behind a remnant of the original fistula (roof). ↗
▶ Ep 91 · 31:15
clinical Attempting posterior sagittal approach for high rectum is very difficult to mobilize and risks urinary tract injury. ↗
▶ Ep 91 · 31:45
clinical Laparoscopy replaces laparotomy, not PSARP. A mini-PSARP incision (3-4 cm) allows safe entry hugging the sacral hollow and permits rectal fixation to posterior muscle complex to prevent prolapse. ↗
▶ Ep 91 · 32:10
quote I don't see any advantage of that. There's really nothing that you're cutting if you make the incision a little bit bigger. It's much safer. ↗
▶ Ep 91 · 32:30
clinical Prolapse is very common if the rectum is not fixed; some hitch to pelvis, but Dr. Levitt prefers fixation to muscle complex through posterior sagittal incision. ↗
▶ Ep 91 · 32:40
quote I like to call mine a laparoscopic-assisted PSARP. I think that's a better terminology. ↗
▶ Ep 91 · 33:03
clinical Prolapse prevention: proper anoplasty location, adequate levator closure, posterior wall fixation to muscle complex (3-4 stitches), and minimal rectal dissection so rectum lands where anus should be without excessive trimming. ↗
▶ Ep 91 · 33:40
epidemiological Prolapse occurs in about 3% of cases, particularly in patients without great muscles. ↗
▶ Ep 91 · 34:00
clinical Rectal prolapse causes bleeding, mucus discharge, and in patients with good continence potential, inhibits bowel control because they cannot close the opening with prolapsed tissue through it. ↗
▶ Ep 91 · 34:30
clinical Dr. Levitt trims prolapse greater than about 3 millimeters. Ectropium versus prolapse distinction is not critical; both are extra reddish tissue, usually circumferential but can be unilateral. ↗
▶ Ep 91 · 34:55
clinical For circumferential prolapse, Dr. Levitt trims half the circumference in two different ambulatory settings, which families prefer to hospitalization and eliminates need for dilation because half the circumference is untouched. ↗
▶ Ep 91 · 35:45
epidemiological Perineal body dehiscence is the most common cause of reoperation Dr. Levitt performs. ↗
▶ Ep 91 · 35:55
clinical The key to preventing perineal body dehiscence is complete mobilization of anterior rectal wall from posterior vaginal wall, reaching the areolar plane between them. ↗
▶ Ep 91 · 36:15
clinical Inadequate anterior rectal wall mobilization leaves the anoplasty under tension, which can pull back, leak into perineal body space, and cause dehiscence. ↗
▶ Ep 91 · 36:35
clinical Perineal body closure should use 3-0 suture in a baby (secure closure) and 4-0 Vicryl on perineal skin. ↗
▶ Ep 91 · 36:50
clinical Dr. Levitt traditionally used 7-day NPO on 10% dextrose (Hyper-L only if longer than 7 days) but now trials clear liquids only for one week to prevent hard stool while allowing more stool volume. ↗
▶ Ep 91 · 37:15
quote The major problem was hard stool. We didn't want them to pass hard stool. And if you give a kid clear liquids, they won't make hard stool. They may make more stool, but they won't make hard stool. ↗
▶ Ep 91 · 37:25
clinical The major problem causing dehiscence is hard stool passing through the repair. Clear liquids prevent hard stool formation. ↗
▶ Ep 91 · 37:41
clinical Feeding regular diet in a day or two and sending the patient home without perineal monitoring risks dehiscence from hard stool passage. ↗
▶ Ep 91 · 37:55
clinical If perineal body dehiscence is detected on day 5-8, taking the patient back to OR for re-suturing can salvage the repair. This occurs in about 1-2 cases per 200. ↗
▶ Ep 91 · 37:55
quote If you see it's opening, I actually will take them back to the OR and re-suture the perineal body. You can actually save it by doing that. ↗
▶ Ep 91 · 38:17
clinical If dehiscence is not detected until 3-4 weeks later, the whole perineal body is dehisced and nothing can be done. ↗
▶ Ep 91 · 38:38
clinical Laparoscopy causes trouble when used to dissect a rectum that is too low, risking proximity to urinary tract or leaving behind remnant of original fistula from timidity. ↗
▶ Ep 91 · 39:05
clinical Blind trocar passage through small perineal incision is dangerous. A 3-4 cm posterior sagittal incision allows safer passage hugging the sacral hollow. ↗
▶ Ep 91 · 39:30
clinical For high rectums, especially bladder neck fistulas, distal rectal dissection is challenging to achieve adequate reach with good blood supply. ↗
▶ Ep 91 · 39:50
clinical The IMA must be preserved because prior colostomy disrupted left colic collaterals, making the rectum completely dependent on IMA. ↗
▶ Ep 91 · 40:05
clinical Tiny distal vessels along the rectal wall can be taken because the rectum has excellent intramural blood supply from the IMA. ↗
▶ Ep 91 · 40:17
clinical The biggest problem with posterior sagittal incision is opening without knowing where the rectum is, leading to finding bladder neck, urethra, seminal vesicles, vas deferens, ectopic ureter—everything but distal rectum. ↗
▶ Ep 91 · 40:20
clinical Taking the IMA or taking branches too close to the aorta will cause rectal necrosis because there is no collateralization down the left colic. ↗
▶ Ep 91 · 41:00
clinical There are famous cases of bladder neck being pulled through and made into anoplasty, with patients draining liquid (urine) postoperatively. ↗
▶ Ep 91 · 41:00
quote There are some famous cases of pull through bladder neck made into beautiful anoplasties. And post-op, the patient was draining liquid out their anoplasty. And in fact, it was the bladder neck. ↗
▶ Ep 91 · 42:15
clinical To assess continence potential in a four-year-old with soiling, Dr. Levitt evaluates three factors: original malformation type, sacral quality (sacral ratio), and spine quality. This is the ARM continence index. ↗
▶ Ep 91 · 42:40
quote I usually tell parents that I'll give you a grade in type of malformation, quality of sacrum, and quality of spine. And three A's is a continent patient. And three C's is an incontinent patient. ↗
▶ Ep 91 · 42:50
clinical Three A's (excellent malformation type, sacrum, and spine) predicts continence. Three C's predicts incontinence. The in-between grades are being studied. ↗
▶ Ep 91 · 43:15
clinical A bulbar fistula with sacral ratio of 1 and normal spine should absolutely have bowel control. ↗
▶ Ep 91 · 43:30
clinical A bladder neck fistula with poor sacrum (sacral ratio 0.4) and tethered cord or myelomeningocele has no real chance of good bowel control. ↗
▶ Ep 91 · 44:00
clinical For four-year-old with soiling, first step is mechanical cleanliness with bowel management using enemas, then trial of laxatives when older and more mature if continence potential exists. ↗
▶ Ep 91 · 44:30
clinical If patient cannot be weaned off enemas, an antegrade option like Malone can be discussed. ↗
▶ Ep 91 · 44:55
clinical Indications for redo pull-through: any continence potential with imperfect anatomy (improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula/posterior urethral diverticulum). ↗
▶ Ep 91 · 45:25
clinical Redoing anoplasty to center the rectum in the sphincter can change a patient to have continence potential. ↗
▶ Ep 91 · 45:37
clinical If patient has absolutely no continence potential, they only need a hole through which to do enemas; redo is not indicated. ↗
▶ Ep 91 · 46:50
opinion ARM surgery is unique because errors may not become apparent for years, making it difficult for surgeons to learn from mistakes and improve technique. ↗
▶ Ep 91 · 47:00
quote Most things in surgery, if you don't do it right, you know right away. Like, if you don't sew a hepatic artery together properly during a liver transplant, the next day, you have a thrombosed artery. If you don't put an anus in the right place, you think you did a perfectly fine operation, the patient goes home, everyone's happy, and only four years later do they come soiling. ↗
▶ Ep 91 · 47:12
opinion In most surgery, errors are immediately apparent (e.g., thrombosed hepatic artery after liver transplant), but misplaced anus only becomes obvious years later when child presents with soiling. ↗
▶ Ep 91 · 47:40
quote How are you supposed to, as a surgeon, know what to fix about your technique if your problems are only becoming obvious years later? And I think that's why there is so much morbidity in colorectal. ↗
Marc's statements about Anorectal Malformations 224 statements

Open the Anorectal Malformations collection →

Complications of Anorectal Malformations with Dr. Marc Levitt

▶ Ep 7 · 2:57
clinical Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period. ↗
▶ Ep 7 · 3:06
clinical Male babies with perineal fistula may pass meconium and no one notices anything wrong with their anorectal anatomy, typically presenting in the first year of life with severe constipation. ↗
▶ Ep 7 · 4:25
opinion The standard practice of checking temperature on forehead or ear rather than rectally makes it easier to miss anorectal malformations in newborns. ↗
▶ Ep 7 · 4:54
clinical Relocating a perineal fistula into the sphincters improves anatomy but does not completely fix constipation; patients will inherently have some constipation requiring aggressive treatment. ↗
▶ Ep 7 · 5:38
clinical If a perineal fistula is not centered in the sphincter, patients with loose stool will soil, and athletic activity will cause soiling because sphincter squeeze cannot completely close the hole. ↗
▶ Ep 7 · 6:13
clinical A newborn anus should accept a size 12 Hagar dilator and a 1-year-old should accept a size 15. ↗
▶ Ep 7 · 8:02
clinical In females, diagnostic criteria for perineal fistula are: hole too close to vagina (inadequate perineal body), inadequate hole size by Hagar dilators, and hole not centered in sphincter. ↗
▶ Ep 7 · 8:47
clinical If a female's anal opening is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, no surgery is needed; the perineal body will lengthen with growth. ↗
▶ Ep 7 · 11:06
clinical An anesthesia nerve stimulator costing $150 with appropriate needle probes works as well as commercial $15,000 stimulators for identifying sphincter muscles. ↗
▶ Ep 7 · 11:06
quote You don't need to order those because you can take the anesthesia stimulator, which is $150 and then put these two nice little probes into the stimulator and connected to little needles and you get a beautiful sphincteric response. ↗
▶ Ep 7 · 17:00
quote I think that operation of a colostomy needs to be taken very seriously, and every pediatric surgeon who deals with newborns, which is the art of our specialty, needs to be really, really good at this because there's a lot of morbidity that's conveyed to a patient with an improperly done colostomy. ↗
▶ Ep 7 · 17:18
clinical The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through by the location of the colostomy or mucous fistula. ↗
▶ Ep 7 · 17:45
clinical Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections. ↗
▶ Ep 7 · 18:38
clinical With transverse colostomy and large rectourethral fistula, the left colon absorbs urine which doesn't exit the mucous fistula, potentially causing acidosis from urine absorption. ↗
▶ Ep 7 · 19:58
clinical Prolapse risk depends on colostomy location: mid-transverse allows bilateral prolapse, hepatic flexure allows only distal prolapse, proximal sigmoid allows only distal prolapse because left colon is fixed to retroperitoneum. ↗
▶ Ep 7 · 21:30
clinical Marking the sphincter ellipse on skin surface before making any incision prevents confusion from muscle stimulation after dissection is open, avoiding misplaced anoplasty. ↗
▶ Ep 7 · 21:30
quote I actually make mark the anoplasty before I make the incision. I think you can get lost when you're looking at a bunch of jumping muscles from a stimulator. ↗
▶ Ep 7 · 24:26
clinical A distal colostogram showing flattening of the rectum corresponding to the pubococcygeal line indicates insufficient contrast or pressure; more pressure is needed to overcome the sphincters and reveal the true rectal position and fistula. ↗
▶ Ep 7 · 24:26
quote If you see that flattening of the rectum, you know the radiologist did not give enough of contrast, enough pressure, because you need to overcome the PC line because that's the sphincters, that's where the sphincters are compressing the distal rectum. ↗
▶ Ep 7 · 25:23
clinical Fistula level is determined by viewing the urethra as a reverse C or elbow: fistula at or below the elbow is bulbar, above the elbow is prostatic, at bladder neck is bladder neck fistula. ↗
▶ Ep 7 · 25:55
clinical Bulbous rectum on colostogram may be reachable posterior sagittally and difficult laparoscopically; tapered rectum is better approached laparoscopically. ↗
▶ Ep 7 · 27:00
clinical Opening posterior sagittally without knowing exact rectal location risks finding and potentially mobilizing bladder neck instead of rectum. ↗
▶ Ep 7 · 29:28
quote You should never go to the operating room without knowing exactly what anatomy you're going to expect to find. ↗
▶ Ep 7 · 30:09
clinical Bulbar and low prostatic fistulas with bulbous rectum are best approached posterior sagittally; high prostatic with tapered rectum and bladder neck fistulas are best approached laparoscopically. ↗
▶ Ep 7 · 30:43
clinical Attempting laparoscopy for bulging rectum below peritoneal reflection at low prostatic or bulbar level risks leaving behind a remnant of the original fistula (roof) if the surgeon is timid. ↗
▶ Ep 7 · 31:48
quote I think that laparoscopy replaces laparotomy. It's an elegant dissection from above, but don't give away the advantages of the PSARP. ↗
▶ Ep 7 · 31:48
opinion Laparoscopy replaces laparotomy, not PSARP; a mini-PSARP during laparoscopy allows safe entry through peritoneal reflection and tacking rectum to posterior muscle complex to prevent prolapse. ↗
▶ Ep 7 · 33:35
epidemiological Rectal prolapse occurs in about 3% of cases, particularly in patients without great muscles. ↗
▶ Ep 7 · 34:14
clinical Rectal prolapse more than 3 millimeters should be treated because it causes bleeding, mucus, and can inhibit bowel control in patients with good muscle potential. ↗
▶ Ep 7 · 34:48
clinical Circumferential prolapse can be trimmed in two separate ambulatory sessions (half circumference each), avoiding hospitalization and eliminating need for dilation since half the circumference remains untouched. ↗
▶ Ep 7 · 35:41
clinical Complete anterior rectal wall mobilization to the areolar plane between rectum and vagina is essential to avoid tension on the anoplasty that can lead to perineal body dehiscence. ↗
▶ Ep 7 · 36:03
clinical Perineal body dehiscence is the most common cause of reoperation in female ARM repairs. ↗
▶ Ep 7 · 36:45
clinical Clear liquids only for one week postoperatively prevents hard stool formation while allowing more stool volume, showing good perineal body healing results without traditional 7-day NPO period. ↗
▶ Ep 7 · 37:48
clinical If perineal body dehiscence is recognized on days 5-8, taking the patient back to OR to re-suture can salvage the repair; by 3-4 weeks the entire perineal body is dehisced and unsalvageable. ↗
▶ Ep 7 · 39:33
clinical During laparoscopic approach for high rectums, the IMA must be preserved because prior colostomy may have disrupted collaterals down the left colic, making the rectum completely dependent on IMA blood supply. ↗
▶ Ep 7 · 42:14
clinical Continence potential in ARM patients is predicted by three factors: original malformation type, sacral ratio, and spine quality (ARM continence index). Three A's predicts continence, three C's predicts incontinence. ↗
▶ Ep 7 · 43:19
clinical A bulbar fistula with sacral ratio of 1 and normal spine should have bowel control; a bladder neck fistula with sacral ratio of 0.4 and tethered cord or myelomeningocele has no chance of good bowel control. ↗
▶ Ep 7 · 43:52
clinical Initial management of soiling 4-year-old with continence potential is bowel management with enemas to achieve cleanliness, then trial of laxatives when older and more mature to attempt voluntary bowel movements. ↗
▶ Ep 7 · 44:39
clinical Indications for redo pull-through include any patient with continence potential who has improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum). ↗
▶ Ep 7 · 46:25
quote If you don't do it right, you don't really know for a few years. Most things in surgery, if you don't do it right, you know right away. ↗
▶ Ep 7 · 46:25
opinion The major problem with anorectal malformations is that surgical errors may not become apparent for years; an improperly placed anus appears successful initially but presents with soiling at age 4. ↗
▶ Ep 7 · 46:59
quote How are you supposed to as a surgeon, know what to fix about your technique if your problems are only becoming obvious years later? And I think that's why there is so much morbidity in colorectal. ↗

Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison

▶ Ep 8 · 2:38
clinical The most common prenatal ultrasound finding in cloaca is a pelvic mass, often representing a dilated vagina (hydrocolpos). ↗
▶ Ep 8 · 3:56
clinical Fetal intervention for cloaca is unlikely to be necessary; babies should typically go to term. ↗
▶ Ep 8 · 5:14
clinical Fetal hydrocolpos drainage has been performed at least once (case report from Japan) for massive hydronephrosis with impending renal loss, similar to bladder drainage for urethral valves. ↗
▶ Ep 8 · 6:37
clinical In cloaca, there is one perineal hole below the clitoris and no anus; this is not ambiguous genitalia, there is no adrenal problem, and the baby is a normal female with two normal ovaries. ↗
▶ Ep 8 · 6:57
clinical A urogenital sinus (single hole with normal anus present) may be associated with virilization and requires evaluation for adrenal hyperplasia and electrolyte abnormalities. ↗
▶ Ep 8 · 8:36
clinical To examine a newborn for cloaca, grab the labia and lift them up and out with very good lighting to see if there is a single hole or distinct urethral, vaginal, and rectal orifices. ↗
▶ Ep 8 · 9:03
clinical Many patients considered cloacas actually have vestibular fistulas; with better examination you can see three holes (urethra, vagina, and rectal opening in vestibule). ↗
▶ Ep 8 · 9:59
clinical Initial workup for cloaca includes ultrasound for hydronephrosis and kidney number, spinal ultrasound for tethered cord, cardiac auscultation, and plain X-ray of spine to assess sacrum. ↗
▶ Ep 8 · 11:14
clinical Intermittent catheterization of the common channel may decompress hydrocolpos, but is not reliable because the catheter may enter the urethra, right or left vagina, or rectum; success should be confirmed by ultrasound. ↗
▶ Ep 8 · 13:14
clinical If hydrocolpos is bilateral, open into both vaginas at the dome, remove some of the common wall (septum), and one tube will drain both sides. ↗
▶ Ep 8 · 14:15
clinical For vaginostomy, use an 8 or 10 French pigtail catheter (not a straight catheter) because as hydrocolpos recedes, straight catheters fall out but curled catheters do not. ↗
▶ Ep 8 · 15:05
clinical Vesicostomy is rarely needed in cloaca; the problem is usually hydrocolpos compressing the trigone and distal ureters, not bladder drainage. Draining the hydrocolpos relieves the ureteral obstruction. ↗
▶ Ep 8 · 16:28
clinical Vesicostomy is indicated only when the bladder does not drain after successful hydrocolpos decompression, which occurs in very rare circumstances with very long narrow common channels or absent urethra. ↗
▶ Ep 8 · 17:54
clinical Vesicostomy is also indicated in the rare circumstance of massive bilateral ureteral reflux, where decompressing the system protects the ureters until later repair. ↗
▶ Ep 8 · 18:21
clinical Hydrocolpos develops because urine preferentially fills the vagina through the vaginal fistula rather than exiting the common channel, likely due to mechanical factors (steep urethral angle). ↗
▶ Ep 8 · 18:48
clinical Hydrocolpos fluid is typically a turbid combination of mucus and urine; maternal estrogen effect can increase mucus production and rarely cause blood in the hydrocolpos. ↗
▶ Ep 8 · 20:11
clinical Hydronephrosis in cloaca is caused by hydrocolpos pressing forward on the trigone and compressing the distal ureters where they enter the bladder. ↗
▶ Ep 8 · 20:29
opinion Cystoscopy in the newborn period is not advantageous; the required scope is tiny, visualization is poor, the perineum is swollen, and it is better to minimize OR time in newborns. ↗
▶ Ep 8 · 20:49
clinical Laparoscopic approach to colostomy and hydrocolpos drainage (described by Michigan group) provides excellent visualization and is a valuable technique. ↗
▶ Ep 8 · 21:17
clinical For massive hydrocolpos extending above the umbilicus, use a lower midline incision to access the dome, and consider a tubeless vaginostomy sutured to the abdominal wall like a G-tube. ↗
▶ Ep 8 · 22:28
clinical Urogenital sinus (single perineal opening with normal anus) requires workup for adrenal problems causing virilization, though it can occur without virilization. ↗
▶ Ep 8 · 23:17
clinical Most urogenital sinuses can be managed with perineal urogenital mobilization without touching the rectum; high UG sinus cases may require a transrectal (Astra) approach. ↗
▶ Ep 8 · 23:57
clinical Definitive cloaca repair timing: perform endoscopy and cloacography at 2–3 months of age, then repair anytime thereafter within one year, ideally before 6 months if managing from birth. ↗
▶ Ep 8 · 25:25
clinical The two critical endoscopic measurements are common channel length (from perineum to urethral takeoff) and urethral length (from urethral takeoff to bladder neck); urethral length determines the surgical approach. ↗
▶ Ep 8 · 25:27
clinical Traditional classification uses 3 cm common channel length (≤3 cm straightforward, >3 cm complicated), but urethral length is equally important and not mentioned in published papers. ↗
▶ Ep 8 · 26:06
quote You must leave the patient with an adequate length urethra. ↗
▶ Ep 8 · 26:21
clinical Endoscopy can falsely suggest the rectum is reachable when it is actually a long narrow fistula with healthy rectum high in the abdomen; contrast study (cloacogram) is needed to assess this. ↗
▶ Ep 8 · 28:34
clinical 3D cloacogram reconstruction is superior to 2D fluoroscopy; experienced surgeons answer anatomy questions more correctly with 3D imaging, and printed 3D models may be even better. ↗
▶ Ep 8 · 30:29
opinion Cloaca patients benefit from collaborative multidisciplinary approach; the days of a single surgeon handling these cases alone are over. ↗
▶ Ep 8 · 30:29
quote We like to joke that it's a Cloaca by committee. ↗
▶ Ep 8 · 30:38
quote I think the days of a single surgeon being able to handle a case of this complexity are over. ↗
▶ Ep 8 · 32:15
clinical Urogenital mobilization, first described by Alberto Pena in 1996, mobilizes urethra and vagina as a unit without operating on the wall between them, eliminating the 10% urethral-vaginal fistula rate of prior techniques. ↗
▶ Ep 8 · 32:33
quote I still remember that I was a trainee standing behind Alberto Pena as he explained to Hardy Hendren this concept, this new concept he had. Oh, you're a general scientist and immobilization. He was drawing pictures. I remember like it was yesterday. It was a moment of history. ↗
▶ Ep 8 · 33:39
clinical Urogenital mobilization is appropriate when common channel is ≤3 cm AND urethral length above the takeoff is at least 1.5–2 cm; this leaves adequate urethral length after splitting the common channel. ↗
▶ Ep 8 · 34:26
clinical With inadequate urethral length, do not perform total urogenital mobilization; instead leave the common channel to become the urethra and separate the vagina from it—a technically demanding operation. ↗
▶ Ep 8 · 34:50
clinical After separating vagina from common channel, repair the common channel and cover with anorectal fat pad and possibly SIS to ensure well-healed urethra and avoid urethral-vaginal fistula. ↗
▶ Ep 8 · 35:09
clinical If urogenital mobilization is attempted but the complex does not reach, the only option is abdominal delivery of the urogenital complex; if this fails, separating the vagina from a circumferentially dissected common channel risks devascularizing and losing the urethra. ↗
▶ Ep 8 · 35:52
clinical Urogenital mobilization with inadequate urethral length leaves the patient with urinary leakage that cannot be controlled without tightening or closing the bladder neck. ↗
▶ Ep 8 · 36:05
clinical Separating the vagina from the common channel and leaving the common channel as the entire urethra gives the patient about a 4 cm urethra, allowing intermittent catheterization and continence. ↗
▶ Ep 8 · 36:40
clinical Type 1 cloaca (common channel ~1 cm with adequate urethral length): mobilize the vagina and leave the urethra slightly hypospadiac; patient will void if no neurogenic bladder component. ↗
▶ Ep 8 · 37:11
clinical Patients with tethered cord or neurogenic bladder need a visible urethral orifice that is easily catheterized; slightly hypospadiac urethra is acceptable only if certain the patient will void and not need intermittent catheterization. ↗
▶ Ep 8 · 38:00
clinical When native vagina does not reach after full mobilization, options include vaginal switch (disconnect one side preserving ovarian blood supply, switch dome down, remove septum) or vaginal replacement. ↗
▶ Ep 8 · 38:46
opinion For vaginal replacement, left colon is the preferred option; sigmoid may be used depending on the vascular arcade. ↗
▶ Ep 8 · 39:10
clinical Tissue engineering of vaginas using patient stem cells is on the horizon (work at Wake Forest and Mexico); this would revolutionize cloaca care by eliminating the need for vaginal replacement. ↗
▶ Ep 8 · 39:48
clinical Complex cloacas requiring specialized expertise include those with common channel >3 cm or urethral length (takeoff to bladder neck) <1.5 cm. ↗
▶ Ep 8 · 40:27
clinical The most common problem in redo cloacas is the surgeon never realized it was a cloaca and only fixed the rectum, leaving the urogenital sinus untouched. ↗
▶ Ep 8 · 40:58
clinical The second most common redo problem is inadequate mobilization of structures, leaving the patient with a stenosed or lost vagina. ↗

The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula

▶ Ep 9 · 3:01
guideline Anorectal malformation patients require screening for VACTERL association: vertebral abnormalities (plain X-ray), cardiac defects (exam and echo), esophageal atresia (NG tube pass), renal abnormalities (kidney ultrasound), and limb abnormalities (physical exam). ↗
▶ Ep 9 · 3:34
quote We want to make sure we've checked for any cardiac defect, both on exam and on echo. ↗
▶ Ep 9 · 3:55
clinical Sacral ratio measurement should wait until the child is 3 months of age for true measurements, though early imaging gives a feel for pelvic development. ↗
▶ Ep 9 · 4:22
clinical Spinal ultrasound in anorectal malformation patients should include evaluation of the presacral space to screen for presacral masses. ↗
▶ Ep 9 · 4:33
epidemiological Presacral masses are rare in typical imperforate anus but occur in almost half of anal stenosis or rectal atresia cases, which require MRI evaluation. ↗
▶ Ep 9 · 7:11
quote The sacrum looks quite normal. I bet this kid is gonna have a pretty normal sacral ratio, certainly greater than 0.7. Which connotes a very good prognosis for bowel control and really peace of mind for the family. ↗
▶ Ep 9 · 7:20
clinical A sacral ratio greater than 0.7 connotes very good prognosis for bowel control and provides peace of mind for families regarding potty training and school readiness at 4 years of age. ↗
▶ Ep 9 · 7:31
quote They want to know what's going to happen to this baby in 4 years when they need to potty train and go to school. ↗
▶ Ep 9 · 9:06
clinical The key to deciding whether to perform primary posterior sagittal anorectoplasty is knowing where the rectum is located; the danger is finding midline white structures like urethra, bladder neck, or bladder instead of rectum. ↗
▶ Ep 9 · 9:06
quote I think the key to deciding whether to dive into a perineum and posterior sagittal is, where is the rectum? ↗
▶ Ep 9 · 9:25
quote The danger is that you go in posterior sagittal, you don't know where the rectum is, and you find something midline and white, like the urethra, the bladder neck or the bladder itself. ↗
▶ Ep 9 · 9:42
clinical Colostomies and distal colostograms are performed to know exactly where the rectum is and whether to approach it perineally or laparoscopically. ↗
▶ Ep 9 · 10:18
quote I will tell you that the surgeon who sent me this case, they did not do that. They felt more comfortable doing a colostomy, and I wanna tell you, that was the safe thing to do. Bravo to them. That was the right choice. ↗
▶ Ep 9 · 10:24
clinical Colostomy is the safe choice for anorectal malformation repair, though it carries risks of complications from both the colostomy creation and the subsequent closure. ↗
▶ Ep 9 · 10:34
quote We are giving the child a colostomy. And whatever complications can happen from that, and we are giving the child a colostomy closure, and whatever complications can happen from that. ↗
▶ Ep 9 · 11:10
quote This is sort of scary, because if you went in and grabbed this rectum and did a primary anoplasty. And did not know there was a fistula, and unfortunately, I have seen this done by some very good surgeons where they went in, did a beautiful anoplasty, but ignored the fistula, and the child down the road started peeing out their anus. ↗
▶ Ep 9 · 11:10
clinical Surgeons have performed primary anorectoplasty on low anorectal malformations without knowing about a fistula, resulting in children later urinating out of the anus. ↗
▶ Ep 9 · 12:09
clinical During primary posterior sagittal anorectoplasty, the surgeon should open the posterior wall of the rectum and inspect the anterior wall to rule out a fistula. ↗
▶ Ep 9 · 12:09
quote When I do that, I open up the posterior wall of the rectum and I inspect the anterior wall of the rectum. ↗
▶ Ep 9 · 13:44
epidemiological 95% of Down syndrome patients with imperforate anus have no fistula, but 5% do have a fistula, so distal colostogram is still indicated. ↗
▶ Ep 9 · 13:48
quote 95% of Down's patients have no fistula, but 5% do. So I would still do a distal colostogram, and some of them might have a fistula. ↗

Colorectal Quiz Episode 2: When to redo a PSARP

▶ Ep 10 · 4:30
clinical The original malformation in Case 1 was a prostatic fistula. ↗
▶ Ep 10 · 4:40
clinical The patient in Case 1 has a tethered cord and a sacral ratio of 0.66. ↗
▶ Ep 10 · 7:29
clinical Visual cues for identifying correct sphincter location include the anal dimple, a midline raised area where the sphincters are, the ellipse, color change, indentation or raised area, and appropriate perineal body length. ↗
▶ Ep 10 · 8:40
clinical Case 2 patient was born with a vestibular fistula, has a normal spine and an excellent sacrum, indicating a much better prognosis for bowel control. ↗
▶ Ep 10 · 9:50
clinical The electrical stimulator used is the same one that anesthesia uses for their train of four, with an inexpensive connection with little pins. ↗
▶ Ep 10 · 9:50
quote I get asked all the time about the stimulator. It's the same electrical stimulator that anesthesia uses for their train of four. And then there's a connection that you can make that has little pins. Really, really inexpensive. And you just have to tell your anesthesiologist not to give skeletal muscle relaxant because it's a little bit weaker than the traditional stimulator, which was super expensive. ↗
▶ Ep 10 · 10:10
clinical You have to tell your anesthesiologist not to give skeletal muscle relaxant because the stimulator is a little bit weaker than the traditional stimulator. ↗
▶ Ep 10 · 13:28
opinion If you know the anatomy is off, you should do the redo, and there's an advantage to getting the anatomy right the younger the child is. ↗
▶ Ep 10 · 13:50
opinion For a two-year-old with a mislocated anus or bad prolapse, offer a redo and let them live in diapers for a year or two with better anatomy, then see if they can successfully potty train. ↗
▶ Ep 10 · 14:20
clinical Many patients present after the age of potty training because they're incontinent, and evaluation reveals the reason is they don't have the best operation—their anus isn't in the right place. ↗
▶ Ep 10 · 14:30
opinion For patients presenting with incontinence after potty training age, do the redo and usually add a Malone at the same time so they can learn how to get control with their new anatomy before attempting voluntary bowel movements. ↗
▶ Ep 10 · 14:35
clinical The process of learning control with new anatomy after redo and Malone may take 6 to 12 months. ↗
▶ Ep 10 · 15:03
opinion For a patient with a mislocated anus that's 50% within the sphincter complex, three and a half years old and fecally incontinent, one approach is to redo them, do a Malone, get them perfectly clean mechanically, then see if they can develop bowel control. ↗
▶ Ep 10 · 15:45
opinion If patients haven't declared their continence yet because they're not old enough to do so from a behavioral point of view, give them a chance—they may succeed. ↗

Colorectal Quiz Episode 17: Cloaca Part 1

▶ Ep 13 · 5:41
epidemiological In the majority of cloaca patients, diagnosis is made at birth rather than prenatally. ↗
▶ Ep 13 · 10:06
quote I really want to emphasize, Richard, what you just said, because I really think that that dogma is no longer valid. ↗
▶ Ep 13 · 10:06
clinical Seattle Children's (Paul McGarrian, Jeff Evansino, Caitlin Smith) demonstrated that many hydrocolpi can be drained perineally, changing prior dogma of routine vaginostomy. ↗
▶ Ep 13 · 10:25
quote I really give Seattle Children's a lot of credit here because they were the ones that said, Paul McGarrian and Jeff Evansino and Caitlin Smith, et cetera, they were the ones that were really saying you can drain a lot of these hydrocolpi, I guess, is that a word? Perineally. ↗
▶ Ep 13 · 10:40
clinical When catheterizing the common channel, the anatomy of the urethral takeoff makes it more likely to enter the vagina than the bladder. ↗
▶ Ep 13 · 10:50
quote If you know the anatomy of the urethral takeoff or to the bladder neck, you're more likely to get into the vagina, frankly, than into the bladder. ↗
▶ Ep 13 · 13:01
clinical Live ultrasound during catheter drainage shows that as the hydrocolpos drains, the bladder fills—demonstrating the pathophysiology of ureteral obstruction by the hydrocolpos. ↗
▶ Ep 13 · 13:40
quote A vesicostomy is the wrong move here. In almost every cloaca, a vesicostomy is not necessary, but the hydrocolpos needs to be drained. ↗
▶ Ep 13 · 13:40
guideline In almost every cloaca, vesicostomy is unnecessary; the hydrocolpos must be drained, and perineal catheterization can relieve bladder outlet obstruction by decompressing the hydrocolpos and allowing ureters to drain. ↗
▶ Ep 13 · 21:37
clinical For massive hydrocolpos requiring open vaginostomy, use a lower midline incision to get above the hydrocolpos, which is very adherent and inflamed against the anterior abdominal wall. A standard left lower quadrant incision will not provide adequate access. ↗
▶ Ep 13 · 21:37
quote If you have a massive hydrocolpos, then you basically should do a lower midline incision. You have to get above the hydrocolpos. And the hydrocolpos is very adherent to the anterior abdominal wall and very inflamed. ↗
▶ Ep 13 · 22:10
clinical For large hydrocolpos, a tubeless vaginostomy can be created by opening the dome, removing part of the septum, and suturing the vagina to the abdominal wall like a vesicostomy or gastrostomy, avoiding an indwelling tube as a nidus for infection. ↗
▶ Ep 13 · 23:08
guideline Single perineal orifice with no anal opening is a cloaca and does NOT require endocrine workup. A perineal orifice with a normal anus is a urogenital sinus and DOES require endocrine workup (e.g., for congenital adrenal hyperplasia). ↗
▶ Ep 13 · 23:30
quote If there is no anus, it is a cloaca. It is not ambiguous genitalia. It is a cloaca. It is a female. And you go on from there. ↗
▶ Ep 13 · 23:40
clinical Urogenital sinus patients can also have hydrocolpos and hydronephrosis, requiring similar drainage management but no colostomy. ↗

Colorectal Quiz Episode 18: Cloaca Part 2

▶ Ep 14 · 7:41
opinion Endoscopy performed by a general pediatric surgeon without extensive cloaca experience has value in distinguishing straightforward from complex cloacas and identifying cases that should be referred to specialized centers. ↗
▶ Ep 14 · 7:59
quote I think one of the major changes in cloacal management is surgeons realized that they needed to do some evaluation of the complexity of the Cloaca before they attempted a repair. And if they realized that it was a very difficult one, they didn't do the case. They referred the patient to a center that does a lot of these. ↗
▶ Ep 14 · 7:59
clinical A major change in cloacal management occurred when surgeons began evaluating complexity before attempting repair and referring difficult cases to high-volume centers, reducing the need for reoperations that were common 10-15 years ago. ↗
▶ Ep 14 · 8:44
opinion Lower confluence cloacas, if the surgeon knows the technique, are a beautiful and elegant operation; higher confluence cloacas requiring vaginal replacement and management of ectopic ureters should be done at specialized centers. ↗
▶ Ep 14 · 8:52
quote The lower confluence, if you know how to do it, is a beautiful, elegant operation. The higher confluence one where vaginal replacements and high vaginas and all of those kind of things, ectopic ureters come into play, probably ought to be done by specialized centers. ↗
▶ Ep 14 · 14:05
quote It is absolutely amazing to me to see this level of detail on a single slide, which I hope everyone recognizes, and I suspect many don't, is probably something like 50 years of work culminated in a single slide. ↗
▶ Ep 14 · 14:11
clinical Hardy Hendren was the father of cloacal management in the late 1960s and 1970s, with specific focus on urology and urethral reconstruction. ↗
▶ Ep 14 · 14:11
quote Hardy Hendren was really the father of cloacal management in the late 1960s and 1970s with a very specific focus on the urology part and urethral reconstruction. ↗
▶ Ep 14 · 14:36
clinical Alberto Peña made a major advance in 1996 with the development of total urogenital mobilization (TUM), which kept the urethra and vagina together as a unit and mobilized them forward; prior to that, all patients had urogenital separation. ↗
▶ Ep 14 · 14:36
quote Alberto Pena, who I was blessed to be mentored by from a young age as a medical student, in 1996, made a major advance in the care of Cloacas with the development of the total urogenital mobilization. Prior to that, all patients had a urogenital separation. He said, why don't we keep the urethra and vagina together as a unit and mobilize that forward? ↗
▶ Ep 14 · 15:05
quote That was in 1996, not that long ago, and then 21 years went by before the next major change in the cloaca protocol. ↗
▶ Ep 14 · 15:10
clinical The next major change in the cloaca protocol occurred 21 years later, in 2017, when the algorithm incorporating urethral length measurement was presented at ABSA. ↗
▶ Ep 14 · 15:28
quote I was in the room in 1996 as Alberto Pena's fellow when he showed Hardy Hendren the TUM and he drew pictures and Hardy Hendren's eyes lit up and said, wow, this is a major advance in cloacal management. ↗
▶ Ep 14 · 16:14
quote Richard, you presented this at ABSA in 2017, and I was there watching and amazed, and Hardy Hendren himself at the age of 91, got to the microphone and we shuddered a little bit, wondering if he was gonna say something that our work was no good. And he got to the microphone and he said, I have no question. I just have a statement. I agree with everything that's been said. And he sat down. ↗
▶ Ep 14 · 16:14
clinical At the 2017 ABSA presentation, 91-year-old Hardy Hendren stated from the microphone that he agreed with everything presented and had no questions. ↗
▶ Ep 14 · 17:03
quote I just think we need a little bit of historical context because this algorithm that Richard just described is really for the first time, and I've been looking at this stuff for 25 years, the first time that it is reproducible, what to do for Cloacas. ↗
▶ Ep 14 · 17:03
opinion The 2017 algorithm is the first reproducible approach to cloacal management after 50 years of work on this challenging problem. ↗
▶ Ep 14 · 18:24
quote The major change in this presentation was to make sure you measure the urethral length, because before that, it was common channel less than 3 or greater than 3, and that was it. But now we know that we got to know the urethral length because that will obviously influence what to do for the surgery cause the patient needs appropriately lengthed urethra at the end of the operation. ↗
▶ Ep 14 · 18:24
clinical The major change in the 2017 algorithm was the addition of urethral length measurement; previously the decision was based only on common channel length (less than or greater than 3 cm). ↗
▶ Ep 14 · 18:39
clinical Measuring urethral length is critical because the patient needs an appropriately lengthed urethra at the end of the operation. ↗

Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula

▶ Ep 15 · 2:25
quote the conversations that go around a female, the perineal fistula are more time-consuming than the conversations that need to happen about a cloaca. ↗
▶ Ep 15 · 2:25
opinion Conversations about female perineal fistula management are more time-consuming than those about cloaca, and patients seek multiple opinions for this relatively benign malformation. ↗
▶ Ep 15 · 3:12
clinical If the hole is in the center of the sphincter with adequate lumen and a perineal body is present, the patient does not need surgery. ↗
▶ Ep 15 · 3:12
quote if the hole is in the center of the sphincter or it's in somewhat of the sphincter, and if the hole is enough of a lumen, and if there's a perineal body, that patient does not need to be touched. ↗
▶ Ep 15 · 3:24
clinical If the hole is too small or outside of the sphincter, surgery is required. ↗
▶ Ep 15 · 4:20
clinical There are five valid management options for perineal fistula: colostomy then repair, primary repair, dilation then repair, simultaneous colostomy and repair, and dilation alone. ↗
▶ Ep 15 · 5:23
clinical Diverting with a colostomy does not necessarily prevent perineal body dehiscence, and colostomy carries significant morbidity including closure complications. ↗
▶ Ep 15 · 5:23
quote diverting with a colostomy doesn't necessarily stop that from happening and You have the morbidity of a colostomy and of the colostomy closure, which is nothing to sneeze at. ↗
▶ Ep 15 · 5:46
quote this is not an emergency. They are passing stool, so the diversion of stool is not the reason for the colostomy, unless it's a very, very tiny fistula, and they can't pass stool, but that can be managed by, by dilation. ↗
▶ Ep 15 · 6:07
clinical Dilation alone is potentially acceptable but could be problematic if the fistulous distal end will not grow, leading to proximal distension. ↗
▶ Ep 15 · 7:38
clinical Anal stenosis (position 5 on the classification) requires screening for Currarino syndrome. ↗
▶ Ep 15 · 9:14
quote this vestibular fistula is not a vaginal fistula because the vaginal wall, the posterior vaginal wall is intact. There's no fistula to it. ↗
▶ Ep 15 · 9:14
clinical A vestibular fistula is not a vaginal fistula because the posterior vaginal wall is intact with no fistula to it. ↗
▶ Ep 15 · 9:34
epidemiological True vaginal fistulas are exceedingly rare in anorectal malformations. ↗
▶ Ep 15 · 10:50
clinical Some perineal fistulas (position 4 on the classification) can be managed with posterior wall mobilization without touching the anterior wall. ↗
▶ Ep 15 · 14:09
clinical Surgeons performing vaginoscopy should look for single versus duplicated cervix, distal vaginal atresia, and vaginal septum. ↗
▶ Ep 15 · 14:21
epidemiological The incidence of distal vaginal atresia is quite rare in anorectal malformations. ↗
▶ Ep 15 · 14:21
quote Incidence of vaginal atresia is quite rare, and vaginal septums are a little bit more common, somewhere around 3 to 5% of vestibulars. ↗
▶ Ep 15 · 14:28
epidemiological Vaginal septums occur in approximately 3 to 5% of vestibular fistulas. ↗
▶ Ep 15 · 14:36
clinical Perineal fistulas can be associated with distal vaginal atresia, though less commonly than vestibular fistulas. ↗
▶ Ep 15 · 16:36
clinical For patients with anorectal malformations and ureteral abnormalities, differential renal function assessment (such as DMSA scan) is important to determine whether to reimplant the ureter or remove a non-functional kidney. ↗
▶ Ep 15 · 17:20
quote absent kidney, quote unquote. And it's usually not absent, it's more non-functional and it's often multicystic and dysplastic, not absent ↗
▶ Ep 15 · 17:20
clinical Absent kidneys in anorectal malformation patients are usually not truly absent but rather non-functional, often multicystic and dysplastic. ↗
▶ Ep 15 · 17:44
guideline Every surgeon caring for anorectal malformations should know the malformation type, spinal status (tethered cord, myelomeningocele, or normal), and sacral anatomy including sacral ratio. ↗
▶ Ep 15 · 17:44
quote every surgeon takes care of an interectal malformation, ought to know the type of malformation, the status of the spine, i.e., tethered cord or myelomeningocele, or in most cases, luckily normal, and the status of the sacrum ↗
▶ Ep 15 · 18:15
clinical Sacral ratio calculation is valuable for informing family conversations about potential for bowel control in anorectal malformation patients. ↗
▶ Ep 15 · 18:15
clinical A patient with a low-type anorectal malformation (such as perineal fistula) but with associated spinal pathology has a different prognosis for bowel control than the same malformation with a normal spine. ↗
▶ Ep 15 · 18:15
quote this is an interesting patient with a very low type of malformation, however, with an associated spinal problem, and therefore their prognosis is not the same as a perineal fistula patient with a normal spine ↗

Colorectal Quiz Episode 29: Female ARM-Post Op Management

▶ Ep 16 · 1:17
quote So are you trying to say that I am a conservative surgeon because I may have a different protocol? ↗
▶ Ep 16 · 1:37
clinical Alberto Pena's original protocol mandated 7 days NPO with central line and hyperalimentation after ARM repair, feeding only on day 7 if healed. ↗
▶ Ep 16 · 2:42
quote And I had a fellow that said, why exactly are you keeping these patients NPO? ↗
▶ Ep 16 · 2:42
quote I had a fellow that said, why exactly are you keeping these patients NPO? And I said, well, because I don't want them to stool, because if they stool, they're more likely to hiss their perineal body. And the fellow said, you know, they still stool. Even if they're NPO. And I said yes, but not as much. ↗
▶ Ep 16 · 3:04
clinical A study by Carlos Reck (now in Vienna, Austria) compared NPO for 7 days versus clear liquids for 7 days and found the same amount of stool output in both groups. ↗
▶ Ep 16 · 3:29
quote Same amount of poop. ↗
▶ Ep 16 · 3:30
quote So then I came to the conclusion that it's not the pooping that's the problem, it's the hard pooping that's the problem. ↗
▶ Ep 16 · 3:30
clinical The problem is not stool passage itself but hard stool passage that can disrupt the perineal body anastomosis. ↗
▶ Ep 16 · 3:37
clinical Dr. Levitt's current protocol is regular IV (no PICC line), clear liquids or breast milk for 5 days, with very low dehiscence rate. Day 5 provides better healing than day 1-2. ↗
▶ Ep 16 · 3:58
opinion There is no published article showing post-op day 1 regular diet (not breast milk, but actual food or formula) with a very low dehiscence rate. ↗
▶ Ep 16 · 5:45
quote And invariably, a perineal body dehiscence usually leads to no perineal body over several months, and needing for a redo because the anterior anoplasty has no sphincter around it, it's split. ↗
▶ Ep 16 · 5:45
clinical Perineal body dehiscence usually leads to no perineal body over several months, requiring redo surgery because the anterior anoplasty has no sphincter around it (it's split). ↗
▶ Ep 16 · 5:59
quote And every single one of those that I see nearly, I ask them what was the feeding protocol, and in invariably they were fed right away and discharged to home. ↗
▶ Ep 16 · 5:59
clinical Nearly every redo case Dr. Levitt sees for perineal body dehiscence involved patients who were fed right away and discharged home. ↗
▶ Ep 16 · 7:43
quote All right, my friend, give them clear liquids. You're gonna make a lot happier families and kids. We tested it. We have a nice paper about clear liquids. ↗
▶ Ep 16 · 9:06
clinical A randomized controlled trial by Richard Wood and Dr. Levitt compared dilation versus non-dilation for primary PSARP (cloacas excluded). Families were randomized and knew the backup plan for stricture was dilation ± Heineke-Mikulicz anoplasty. ↗
▶ Ep 16 · 9:06
quote Richard Wood and I ran a randomized controlled trial of dilation and non-dilation for primary PSAP. Cloacass were excluded, and families knew that they were going to be randomized into one of two groups, and the backup plan, if a patient developed um a stricture was dilation, plus or minus a Heineke McCulitz anoplasty. ↗
▶ Ep 16 · 9:33
clinical In the dilation trial, both groups (dilation and non-dilation) had stricture rates somewhere between 10 and 20%. ↗
▶ Ep 16 · 10:25
clinical Many patients' anoplasties look absolutely fine 8 weeks later at colostomy closure if they were never touched with a dilator, provided the anoplasty was healthy with no tension and good blood supply. ↗
▶ Ep 16 · 10:45
clinical The dilation study was prompted by asking families their biggest concern about ARM care, and by far number one was dilations. This was family-driven research, not doctor-driven problem-solving. ↗
▶ Ep 16 · 10:50
quote And what prompted the paper was, and this was Richard's idea, was to ask the families, what is their biggest concern relative to care of patients with an anorectal malformation, and by far, number one was dilations. ↗
▶ Ep 16 · 11:21
quote This was a real family-driven research. ↗
▶ Ep 16 · 11:25
clinical The non-dilation protocol offers families a choice: dilate twice daily for 4 months, or accept a 10-15% risk of stricture requiring Heineke-Mikulicz anoplasty, with the child already going under anesthesia in 8 weeks for colostomy closure. ↗
▶ Ep 16 · 13:45
clinical Jack Langer's protocol is to see patients weekly in clinic and pass a dilator himself rather than having families do it at home. ↗
▶ Ep 16 · 15:35
quote We don't know the answer to that question. That's a more longer term follow up. ↗
▶ Ep 16 · 15:58
quote Have you negatively affected their continence 3 years hence? And I don't know the answer to that question. ↗
▶ Ep 16 · 16:38
clinical Full continence can be restored with a redo operation for stricture, and data is available showing this. One indication for redo is stricture. ↗
▶ Ep 16 · 16:56
quote I personally have come to the conclusion that the amount of morbidity that we're putting families through by dilating them, and the minimal risk to them of even needing an intervention. And then if they do need an intervention, it's relatively minor, and the vast majority of those, they're already undergoing surgery for their colostomy closure. ↗
▶ Ep 16 · 17:12
clinical The vast majority of patients needing intervention for stricture in the non-dilation protocol are already undergoing surgery for colostomy closure, making the intervention relatively minor. ↗
▶ Ep 16 · 17:21
quote I can tell you, I have yet to, I have yet to meet a family that has chosen dilation. ↗
▶ Ep 16 · 17:21
clinical Dr. Levitt has yet to meet a family that has chosen dilation when presented with the non-dilation option and its risks/benefits. ↗
▶ Ep 16 · 18:31
quote I think the good news is that there's no right answer, we just have to all work together and suffer together on these difficult problems and try to, uh, improve lives as best we can. ↗
▶ Ep 16 · 19:37
clinical In Ghana, a colleague makes anoplasties slightly bigger knowing patients won't return for follow-up, anticipating some contraction will occur. ↗
▶ Ep 16 · 20:18
clinical For redo ARM cases, Dr. Levitt makes the anoplasty a little bigger knowing there will be contraction. Redos are not dilated at all, but are examined under anesthesia at one month to check for early stricture. ↗
▶ Ep 16 · 20:26
quote We don't dilate the redos, period. We EUA them at a month just to make sure no early stricture is developing. ↗
▶ Ep 16 · 20:33
clinical For primary repairs, Dr. Levitt makes the lumen match what the maximal rectal lumen can be. With good mobilization (not overdoing it, throwing away as little rectum as possible), the anoplasty is usually a good size, about Hegar 13 or 14 at the end. ↗
▶ Ep 16 · 20:33
quote In the primaries, I basically make the lumen what the rectum needs, what the maximal rectal lumen can be. And whatever that is, that fills the sphincter, that's how I make the anoplasty. ↗
Marc's statements about Anorectal Malformations & Cloacal Reconstruction 33 statements

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Colorectal Quiz Episode 1 - Low Bulbar Fistua

▶ Ep 14 · 3:01
guideline Patients with anorectal malformations require evaluation for associated VACTERL anomalies: vertebral abnormalities (plain X-ray), cardiac defects (exam and echo), esophageal atresia (NG tube passage), renal abnormalities (kidney ultrasound), and limb abnormalities (physical exam). ↗
▶ Ep 14 · 3:34
quote We want to make sure we've checked for any cardiac defect both on exam and on echo. ↗
▶ Ep 14 · 3:55
clinical Sacral ratio measurements should wait until the child is 3 months of age for true accuracy, though early imaging gives a preliminary sense of pelvic development. ↗
▶ Ep 14 · 4:33
epidemiological Presacral masses are rare in typical imperforate anus but occur in almost half of patients with anal stenosis or rectal atresia defects, requiring MRI evaluation. ↗
▶ Ep 14 · 5:44
quote It's important that if this baby was born today, we're not rushing to do anything, because we need time to have this baby declare themselves to either be someone who's going to need a colostomy or someone who might be able to benefit from a primary repair. ↗
▶ Ep 14 · 5:44
clinical The 24-hour waiting period allows the baby to declare whether they need a colostomy or might benefit from primary repair if a perineal fistula develops. ↗
▶ Ep 14 · 7:01
quote The air column has really risen very nicely, and boy is that thing close to the perineal skin. It's right there, isn't it? ↗
▶ Ep 14 · 7:20
quote I bet this kid is gonna have a pretty normal acle ratio, certainly greater than 0.7. Which connotes a very good prognosis for bowel control and really peace of mind for the family. ↗
▶ Ep 14 · 7:20
clinical A sacral ratio greater than 0.7 connotes very good prognosis for bowel control and provides peace of mind for families regarding potty training and school readiness at age 4 years. ↗
▶ Ep 14 · 9:06
clinical The key to deciding whether to perform primary posterior sagittal anorectoplasty is knowing where the rectum is located—the first structure encountered should be rectum, not urethra, bladder neck, or bladder. ↗
▶ Ep 14 · 9:06
quote The key to deciding whether to dive into a perineum and posterior sagiti is where is the rectum. You wanna know that the what structure you will find if you make a posterior sagittal or even a mini posterior sagittal incision. ↗
▶ Ep 14 · 9:25
quote The danger is that you go in posterior sagitary, you don't know where the rectum is, and you find something midline and white, like the urethra, the bladder neck or the bladder itself. ↗
▶ Ep 14 · 9:42
clinical Colostomies and distal colostograms are performed to know exactly where the rectum is and whether to approach it perineally or laparoscopically. ↗
▶ Ep 14 · 10:18
quote I will tell you that the surgeon who sent me this case, they did not do that. They felt more comfortable doing a colostomy, and I wanna tell you, that was the safe thing to do. Bravo to them. That was the right choice. ↗
▶ Ep 14 · 10:24
opinion Performing a colostomy is the safe choice and was the right decision in this case, though it subjects the child to colostomy-related complications and later colostomy closure with its own complications. ↗
▶ Ep 14 · 10:34
quote We are giving the child a colostomy. And whatever complications can happen from that, and we are giving the child a colostomy closure, and whatever complications can happen from that. So everything in medicine is a balance, but there is no question that the anal part has been made safer by having a colostomy. ↗
▶ Ep 14 · 10:48
opinion Colostomy makes the definitive anoplasty safer, representing a balance of risks in medical decision-making. ↗
▶ Ep 14 · 11:10
quote If you went in and grabbed this rectum and did a primary anoplasty. And did not know there was a fistula, and unfortunately, I have seen this done by some very good surgeons where they went in, did a beautiful anoplasty, but ignored the fistula, and the child down the road started peeing out their anus. ↗
▶ Ep 14 · 11:20
clinical Very good surgeons have performed primary anorectoplasty on low defects without knowing about a fistula, resulting in children who later urinate through the anus. ↗
▶ Ep 14 · 12:09
clinical During primary posterior sagittal repair, the surgeon should open the posterior wall of the rectum and inspect the anterior wall to rule out a fistula. ↗
▶ Ep 14 · 12:09
quote When I do that, I open up the posterior wall of the rectum and I inspect the anterior wall of the rectum. ↗
▶ Ep 14 · 13:44
epidemiological 95% of patients with Down syndrome and imperforate anus have no fistula, but 5% do have a fistula, so distal colostogram is still indicated. ↗
▶ Ep 14 · 13:48
quote 95% of Down's patients have no fistula, but 5% do. So I would still do a distal colostogram, and some of them might have a fistula. ↗

Colorectal Quiz: Episode 40

▶ Ep 16 · 1:39
epidemiological Anorectal malformation occurs more commonly in females and has a prevalence of about one in 5,000 births. ↗
▶ Ep 16 · 2:21
quote When you look in and you see an end of the colon and that's all you see, you do not have to do a divided colostomy. That can be the end. That can be your colostomy. ↗
▶ Ep 16 · 2:21
quote We've talked about this before on some of these rare circumstances. ↗
▶ Ep 16 · 2:21
clinical When you look in laparoscopically and see an end of the colon with nothing else visible, you do not have to do a divided colostomy—you can bring out that distal end as your stoma rather than interfering with the blood supply for the distal segment. ↗
▶ Ep 16 · 2:59
quote I think the smartest thing to do in this very rare case is make a true end colostomy. ↗
▶ Ep 16 · 2:59
opinion The only potential benefit of doing a divided colostomy when encountering blind-ending colon is protecting the ultimate rectal repair, but this risks the blood supply to the distal rectum. ↗
▶ Ep 16 · 5:32
clinical Meyer-Rokitansky-Küster-Hauser syndrome can present with anorectal malformation, creating Meyer-Rokitansky-like anatomy where ovaries and remnant tubes are present but no midline Müllerian structures. ↗
▶ Ep 16 · 6:37
clinical The more common scenario of anorectal malformation with absent vagina is a recto-vestibular fistula with completely normal urethra but no vagina in between—this is called recto-vestibular fistula with distal vaginal atresia, where the rectum ends as a fistula in the vestibule. ↗
▶ Ep 16 · 7:08
clinical In this case, the rectum ended blind and quite high in the pelvis, making it unreachable through a posterior sagittal incision. ↗
▶ Ep 16 · 7:18
clinical The foreshortened sacrum in this case suggests caudal regression, where everything below that level forgot to develop. ↗

Summaries Marc gave as host · 50 summaries

Recaps of other experts' statements, not Marc's own clinical position.

Summaries Marc gave as host · Anorectal Malformation 40 summaries

Open the Anorectal Malformation collection →

Complications of Anorectal Malformations with Dr. Marc Levitt

▶ Ep 15 · 9:08
host summary Marc Levitt summarizing a resource: It's very hard to improve on an asymptomatic patient. ↗

Posterior Sagittal Anorectaplasty in a Female: Pediatric Colorectal...

▶ Ep 27 · 1:22:15
host summary Marc Levitt summarizing the discussion: MRI has limited ability to determine presence of vaginal lumen in very young patients unless there is clear hematocolpos or hydrocolpos ↗

Complications of Anorectal Malformations with Dr. Marc Levitt

▶ Ep 34 · 9:08
host summary Marc Levitt summarizing a resource: It's very hard to improve on an asymptomatic patient. ↗

Colorectal Quiz Episode 2: When to redo a PSARP

▶ Ep 36 · 12:00
host summary Marc Levitt summarizes what Dr. Jason Frischer said: The vast majority of patients who get redos had mislocation, followed by stricture, then less common reasons including remnant of the original fistula (roof), rectal prolapse, and others. ↗
▶ Ep 36 · 12:30
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Quality of life improved with a redo operation. ↗
▶ Ep 36 · 12:40
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Patients had an improved ability to achieve continence after redo operations. ↗
▶ Ep 36 · 12:50
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Patients who did not develop voluntary bowel movements after redo were still able to be clean with a bowel management program using enemas or antegrade via a Malone. ↗
▶ Ep 36 · 12:55
host summary Marc Levitt summarizes what Dr. Jason Frischer said: In the JPS study, 20% of patients with a poor sacrum or poor spine actually developed bowel control after their redo. ↗
▶ Ep 36 · 13:10
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Patients with good potential (good sacrum and good spine) did extremely well after redo operations. ↗
▶ Ep 36 · 13:10
host summary Marc Levitt summarizes what Dr. Jason Frischer said: The average age of patients in the JPS study is about three and a half years, give or take. ↗

Colorectal Quiz Episode 29: Female ARM-Post Op Management

▶ Ep 43 · 3:10
host summary Marc Levitt summarizing the discussion: I think it's about the same, and we studied it. ↗
▶ Ep 43 · 19:37
host summary Marc Levitt summarizing the discussion: I asked him where, when would the patient come back for Clinic to start dilation. And he said, this patient will not be coming back for any follow-up. So therefore, he likes to make the anoplasty, and I know you've probably had this experience when you've been, been in the developing world, when he says, I make my anoplasties a little bit bigger, so that I know everything's gonna be fine when it contracts a little bit. ↗

Is Multi-disciplinary care the future of medicine?

▶ Ep 52 · 5:40
host summary Marc Levitt summarizing a resource: if an infant whose anus is not visible, is born, they should be rubbed with oil and stood in the sun, and where it shows transparent, should be torn crosswise with a barley grain ↗

Episode 19 - Interview with Dr Marc Levitt, Chief of Colorectal & Pelvic Reconstruction, Children‘s

▶ Ep 84 · 31:25
host summary Marc Levitt summarizing a resource: It's not the unanswered questions that matter the most, it's the unquestioned answers. ↗

2019 Chandler Lecture: Dr. Marc Levitt

▶ Ep 85 · 2:29
host summary Marc Levitt summarizing a resource: If the Office line rang and they said, Can I speak to the colorectal surgeon? he would say, um, uh, that's me. All right, can you now connect me? I have, uh, my daughter has a urology problem and he would say, that's me. I'll take care of that as well. Oh, and I'm gonna need to talk to a gynecologist, and he would say, I got you covered. How about social work, psychology, nutrition? I'll take care of all of that. ↗
▶ Ep 85 · 36:30
host summary Marc Levitt summarizing a resource: The aim of pediatric surgery is to set a standard, not to seek a monopoly. ↗
▶ Ep 85 · 40:19
host summary Marc Levitt summarizing a resource: Dr. Levitt, you make good promises. ↗

Time for some patient driven change | Marc Levitt | TEDxColumbus

▶ Ep 86 · 10:23
host summary Marc Levitt summarizing a resource: Doctor Levitt. You make good promises. ↗

Colorectal Quiz: Episode 40

▶ Ep 90 · 12:46
host summary Marc Levitt summarizing the discussion: A theoretical approach proposed by gynecologist Alison May for cloaca cases where native vagina doesn't reach is to provide a neovagina as a bridge so the patient can menstruate through it, then potentially remove it 20 years later. ↗

Dr. Marc Levitt on building global pediatric colorectal surgery programs

▶ Ep 93 · 2:25
host summary Marc Levitt summarizing a resource: there's a specialty that's called pediatric surgery. You can actually do both. ↗
▶ Ep 93 · 31:39
host summary Marc Levitt summarizing a resource: it's not the unanswered questions that matter the most, it's the unquestioned answers. ↗

Colorectal Quiz: Episode 2

▶ Ep 94 · 11:38
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Twenty percent of patients with a poor sacrum or poor spine developed bowel control after their redo ↗
▶ Ep 94 · 11:38
host summary Marc Levitt summarizes what Dr. Jason Frischer said: In the JPS study, the vast majority of reoperations were for mislocation, followed by stricture ↗
▶ Ep 94 · 11:38
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Patients with good potential (good sacrum and spine) did extremely well after redo ↗
▶ Ep 94 · 11:38
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Patients had improved ability to achieve continence after redo ↗
▶ Ep 94 · 11:38
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Less common reasons for redo included remnant of original fistula (roof), rectal prolapse, and others ↗
▶ Ep 94 · 11:38
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Quality of life improved with redo operations ↗
▶ Ep 94 · 11:38
host summary Marc Levitt summarizes what Dr. Jason Frischer said: The average age of patients in the JPS study was about three and a half years ↗
▶ Ep 94 · 11:38
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Patients who did not develop voluntary bowel movements after redo were still able to be clean with bowel management program using enemas or antegrade Malone ↗

Colorectal Quiz: Episode 2

▶ Ep 86 · 11:38
host summary Marc Levitt summarizes what Dr. Jason Frischer said: The average age of patients in the redo study was about three and a half years. ↗
▶ Ep 86 · 11:38
host summary Marc Levitt summarizes what Dr. Jason Frischer said: In the Journal of Pediatric Surgery study on reoperations for fecal incontinence after anorectal malformation repair, the vast majority of redos were for mislocation, followed by stricture. ↗
▶ Ep 86 · 11:38
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Less common reasons for redo included remnant of original fistula (roof), rectal prolapse, and others. ↗
▶ Ep 86 · 11:38
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Quality of life improved with a redo operation. ↗
▶ Ep 86 · 11:38
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Patients had improved ability to achieve continence after redo operations. ↗
▶ Ep 86 · 11:38
host summary Marc Levitt summarizes what Dr. Jason Frischer said: In the study, 20% of patients with a poor sacrum or poor spine developed bowel control after their redo. ↗
▶ Ep 86 · 11:38
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Patients with good potential (good sacrum and good spine) did extremely well after redo. ↗
▶ Ep 86 · 11:38
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Patients who did not develop voluntary bowel movements after redo were still able to be clean with a bowel management program using enemas or antegrade via Malone. ↗

Anorectal Malformations Complications

▶ Ep 96 · 9:10
host summary Marc Levitt summarizing a resource: It's very hard to improve on an asymptomatic patient. ↗

Anorectal Malformations Complications

▶ Ep 90 · 9:10
host summary Marc Levitt summarizing a resource: It's very hard to improve on an asymptomatic patient. ↗

Anorectal Malformations Complications

▶ Ep 91 · 9:05
host summary Marc Levitt summarizing a resource: One of my professors like to say it's very hard to improve on an asymptomatic patient. ↗
Summaries Marc gave as host · Anorectal Malformations 10 summaries

Open the Anorectal Malformations collection →

Complications of Anorectal Malformations with Dr. Marc Levitt

▶ Ep 7 · 9:08
host summary Marc Levitt summarizing a resource: It's very hard to improve on an asymptomatic patient. ↗

Colorectal Quiz Episode 2: When to redo a PSARP

▶ Ep 10 · 12:00
host summary Marc Levitt summarizes what Dr. Jason Frischer said: The vast majority of patients who get redos had mislocation, followed by stricture, then less common reasons including remnant of the original fistula (roof), rectal prolapse, and others. ↗
▶ Ep 10 · 12:30
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Quality of life improved with a redo operation. ↗
▶ Ep 10 · 12:40
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Patients had an improved ability to achieve continence after redo operations. ↗
▶ Ep 10 · 12:50
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Patients who did not develop voluntary bowel movements after redo were still able to be clean with a bowel management program using enemas or antegrade via a Malone. ↗
▶ Ep 10 · 12:55
host summary Marc Levitt summarizes what Dr. Jason Frischer said: In the JPS study, 20% of patients with a poor sacrum or poor spine actually developed bowel control after their redo. ↗
▶ Ep 10 · 13:10
host summary Marc Levitt summarizes what Dr. Jason Frischer said: Patients with good potential (good sacrum and good spine) did extremely well after redo operations. ↗
▶ Ep 10 · 13:10
host summary Marc Levitt summarizes what Dr. Jason Frischer said: The average age of patients in the JPS study is about three and a half years, give or take. ↗

Colorectal Quiz Episode 29: Female ARM-Post Op Management

▶ Ep 16 · 3:10
host summary Marc Levitt summarizing the discussion: I think it's about the same, and we studied it. ↗
▶ Ep 16 · 19:37
host summary Marc Levitt summarizing the discussion: I asked him where, when would the patient come back for Clinic to start dilation. And he said, this patient will not be coming back for any follow-up. So therefore, he likes to make the anoplasty, and I know you've probably had this experience when you've been, been in the developing world, when he says, I make my anoplasties a little bit bigger, so that I know everything's gonna be fine when it contracts a little bit. ↗