Update Course Rewind: Anal Dilation Following PSARP 2023

Dilations are a source of stress for families, with parents feeling like they're hurting their children and experiencing significant anxiety.

A 2021 single institution prospective randomized control trial included only primary patients (no redos or cloacas), all with anorectal malformation diagnosis, with 12 months follow-up and PSARP performed at average 5 months old.

In the RCT, stricture was defined as Hagar 10 or less.

The RCT had 25 patients in each arm (dilation vs non-dilation), with 3 strictures in the dilation group and 8 strictures in the non-dilation group.

Overall number of procedures were relatively the same between groups because many non-dilated patients with strictures got stricturoplasty at colostomy closure, with only 3 requiring a separate anesthetic.

Stricturoplasty is appropriate only for skin level strictures, not for longer strictures or anything deeper below the skin.

Stricturoplasty is a satisfying operation that takes about 20 minutes, allows same-day discharge, and babies tolerate it very well.

Stricturoplasty converts a Hagar 10 into a Hagar 13.

For children over 6 months old, especially close to 12 months, dilation is not typically offered to families.

When children are older than 6-8 months, dilations are sometimes not successful and may result in dealing with stricture anyway.

Follow-up is scheduled about 2-4 weeks after operation with anaplasty sizing in the office, and if it looks good, dilation can be skipped.

For patients with a colostomy, dilations are not usually discussed because they will return to the operating room for colostomy closure, which is a perfect time for stricturoplasty.

Strictures can develop in either dilation or non-dilation groups due to tension, ischemia, or reaction between epidermis and mucosa creating a band.

For international audiences where access to surgery is limited and patients cannot afford a second surgery, dilations should be encouraged.

Care for anorectal malformation patients varies highly depending on setting and patient resources, which should be taken into account in decision making between dilation and stricturoplasty approaches.