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Problematic Anorectal Malformation Cases: Pediatric Colorectal Controversies...
Chapter 1 of 5 · Long-Term Care
Dilation protocols
Post-operative follow-up and dilation protocols after ARM repair
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Patients are typically seen back at 2 weeks post-discharge to start dilations.
Follow-up intervals for local patients are 1 month, 3 months, 6 months, then yearly thereafter.
For patients in remote areas (Alaska, Montana), local follow-up is arranged with efforts to bring them back at 3 and 6 months.
Parents are taught to dilate at home with Hagar dilators up to size 12 or 13 depending on patient size.
If the anastomosis is supple by size 12-13, follow-up is at 2 months to check for stricture, then every 3 months in the first year.
ARM patients have a tendency toward constipation; parents are warned not to let the child go more than 1.5 to 2 days without a stool.
Daily parental dilation is not necessary most of the time; weekly in-clinic calibration for about 6 weeks is an alternative approach.
Comparison of weekly in-clinic calibration versus parental home dilation showed no difference in stricture rate, perforation rate, or enterocolitis rate in Hirschsprung's patients.
About 10% of patients narrow during weekly calibration and require home dilation by parents.
Daily dilation by parents is a psychological hardship and not necessary most of the time.
Patients are asked to stay around Toronto for at least 3 to 4 weeks post-operatively for follow-up.
In 3- to 4-year-old patients who missed early anoplasty, parents cannot dilate at home; weekly or biweekly clinic dilation is performed with good outcomes.
A randomized trial comparing dilation protocols would be valuable, though some surgeons would not have equipoise to randomize children to daily dilation.
European centers are considering a protocol starting with 6 weeks of dilation to potentially reduce duration, but remain cautious about changing successful current practices.
A retained vestibular fistula after pull-through is of no consequence if the neo-anus is functioning well, but may need removal if large or if the perineal body lacks substance.
The surgical goal for perineal body reconstruction is to position healthy rectum down, healthy vagina up, and create a muscular perineal body in between.
Post-operative management options include colostomy for diversion or keeping the patient NPO.
A posteriorly mislocated anus in a patient with good sacrum and spine warrants redo surgery to position the anus where it will be concentrically closed by the sphincters.
The most common problem in cloacal repairs is addressing only the rectum without managing the urogenital sinus, requiring redo surgery.
Mistaking the bladder neck for the rectum during pull-through can occur if the anatomy is not known before surgery.
For rectal prolapse, performing hemi-anoplasty (half the circumference) as an ambulatory procedure, then the other half 3 months later, heals quickly and requires no dilations.
Often only half the circumference prolapses, allowing repair of just that half without dilation.
Circumferential dissection for prolapse repair requires monitoring for stricture, whereas hemi-anoplasty will not stricture.
A posterior urethral diverticulum is the retained original distal rectum after laparoscopic pull-through for bulbar fistula.
Laparoscopic ARM repair is a more complex operation than Hirschsprung's; surgeons should not overestimate their skill set.
If the anatomy is unclear during laparoscopic pull-through, the colon should be opened to find the fistula from inside.
Posterior urethral diverticulum occurs when dissection is not carried distally enough during laparoscopic pull-through.
A posterior urethral diverticulum (colonic mucosa bathed by urine for 30 years) developed adenocarcinoma in one 30-year-old patient.