Imperforate Anus Rapid Fire: Update Course 2015

Is anorectal malformations again a very broad topic we presented and Doctor Dickey helped me and this is a patient of hers. OK, perfect. So this is a newborn female, um, no issues with delivery, um, basically a normal echo, small PFO normal renal ultrasound, normal sacrum, no tethered cord. That's important information. And here's a, and you're called to the NICU to examine the patient's perineum because it looks abnormal. Uh, is there any Way to change. What you wanna do? I wanna change it, but this isn't working. So this is a picture of the patient's perineum. You can see there's a catheter within a fistula type opening within the vestibule and no other anal openings are present. So my question is, what is your next step for this management for this patient, a primary repair, colostomy, dilations, or just leave it and let's see how she grows up? Let's start with dilations, Mark, what, yeah, dilations to start. And how about what, what age would you consider repair for these patients? What I've noticed is maybe not this exact lesion, but ones that tend to be very close to the bottom, uh, the vestibule, especially if there's something that you see in the perineum that looks anal, is that the what looks horrible initially and a couple of months or even actually in a few weeks, you've noticed a difference that there is, um, Uh, it's not as widely the, the distance from where you expect the anus to be is not that great, uh, as, as, as in the initial examination. So I think you have to give them at least a month to see what happens before you do anything else. Um, but I'm not, as long as the child is stooling, I'm not in any hurry to do this. Yeah, so at least at our shop, this is a, this is managed by a variety of ways. Several folks dilate. Uh, several do the primary operation and, and a couple do the colostomies. So I, I'm always interested in this, this discussion from a, from an expert on, you know, what we as regular practicing pediatric surgeons should do because the experts can probably do the, uh, primary nest, excuse me, primary operation in the relative newborn period, but I'm not sure that the routine pediatric surgeon should be doing that. Belinda, you want to comment? So once again. I think it depends on your comfort level. I mean, a primary repair in a newborn is, um, not the easiest thing in the world, and it's hard to tell where the sphincter should be and the dissection between the vagina and the rectum is much thinner. So if you dilations in that case is very reasonable. Um, we had talked about this the other day, you know, in, in a situation where, um, we have the luxury of TPN, IV fluids, all that sort of stuff. If you don't have the luxury of that, you need your anoplasty to heal well, then maybe a colostomy at that point in time and a repair afterwards is reasonable for those people who aren't, um, in, in the United States, North America, um, where they have that. I also feel, do you, what are you, what are your feelings on if you do dilations for a long period of time, do you think that causes some inflammation and some difficult I think it causes scarring and inflammation. So I usually only go up to a 7 or 8 and put them on stool softeners. I've had some people come who've dilated up to 11 or 12 and. It, it's, it's not fun to repair at that point. That was a softball, but that, that was my point is I think you have to be very careful about the dilations and causing inflammation because your your dissection at age 3 months or 6 months can be just as tedious if you're causing local trauma I agree with that. So moving on a little further, hey Jason, just one other quick question. So I was always taught that you wanted, uh, you did not want to do the dilations because the meconium is sterile, and if you're going to do the operation, you ought to do it in the newborn period as opposed to dilating and doing it at 2 or 3 months of age when you've got stool, which is not sterile. And so if, if you're gonna wait for 2 or 3 months, you ought to do a colostomy to divert the stool. Is that a. Is that an old fashioned concept or where do you stand on that concept? I'll just call it a concept. I'm not sure if it's old fashioned, but, um, I think we are, we are very conservative in our treatment of, uh, anorectal malformations, especially in the postoperative care and feeding and trying to what I call a medical colostomy for the period of a week or so by making them NPO and not feeding them and giving them hyper alimentation. Um, but there is no data to support that. I know there are a number of pediatric surgeons that will repair an anorectal malformation at whatever age with dirty stool and feed the child the day 1 or 2 days post-op when they recover from the anesthesia, and I'm sure that incidence of complication is probably similar. So I don't think we, I think we more, we don't do the operation in the immediate newborn period, more for it's a difficult dissection. And Belinda and I have been discussing, I think it's harder to tell exactly where the center of the sphincter is in a 2 kg baby than in an 8 or 9 kg baby. So because it's my fault, I'm being told we are way, way over. So let's just do rapid fire questions without discussion for the rest of this. Just perfect answers, OK. Last question on this topic. You see this picture that's up on the screen, if you call it, and if you can't see, it's a vestibular fistula and there's no other hole, meaning an absent vagina, which is a situation you can get into. Um, in a patient that if you don't get a good perineal exam preoperatively, what should we do? That's my question. No, that's just, just go ahead and tell if in a patient, in a patient that has good prognosis for bowel control, you'll have to do either abort the operation and come back another day with a definitive plan, but if you have a plan in place where you think you could use a, a um. A graft, whether it be a piece of colon or a piece of small bowel, whatever you like to replace the vagina, and then bring your, your rectum down, uh, your fistula down as you pull through. If it's a patient that has a poor prognosis for bowel control, patient with sac. agenesis or tether cord or or other reasons why they may have poor bowel control, then you could use your rectum or your fistula as your as your vagina and then just take a more proximal piece of colon and bring it down as you pull through. Short answer. That's, that's good. I'm gonna skip the rest of this and just for the sake of time, uh, that's a vaginal septum, but move to my other topic which is another.