Colorectal Quiz Episode 29: Female ARM

In Phoenix, many surgeons start diet post-op day zero or post-op day one after primary perineal fistula repair, with breast milk or formula, and discharge home post-op day two or three if tolerating diet.

Alberto Pena's historical protocol kept patients mandatory NPO for seven days with central line and hyperalimentation, feeding on day seven if healed.

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.

The problem is not pooping itself but hard pooping that can disrupt the perineal body repair.

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.

Most repairs in Phoenix are performed before children are on anything except breast milk or formula, with early repairs and early discharge home.

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.

In redo cases seen by Dr. Levitt, patients were invariably fed right away and discharged home.

Dr. Frisher uses a midline catheter (not PICC line) with D10 until the repair is confirmed healed, typically five to seven days NPO.

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.

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.

The dilation RCT found that both dilated and non-dilated groups developed strictures somewhere between 10 and 20% of the time.

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.

The dilation RCT was prompted by families identifying dilations as their biggest concern in caring for patients with anorectal malformation.

Dilations can be traumatic for families, with one family member typically responsible for performing them, sometimes leading to relationship strain and reluctance to attend clinic visits.

In the presented case, the family was not comfortable doing dilations at home despite medical field experience, so the surgeon performed dilations in clinic twice weekly initially.

Jack Langer's routine is to see patients every week in clinic and pass a dilator without having families do it at home.

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.

Approximately 20% of patients in the dilation study required a redo operation, either local or total, with most being local procedures.

There is existing data showing that full continence can be restored with a redo operation, including for stricture as an indication.

Dr. Levitt has yet to meet a family that has chosen dilation when presented with the option of non-dilation with selective intervention.

Some families do choose dilation after being informed of the study results and uncertainties.

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.

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.

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.