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GlobalCast MD, along with Cincinnati Children's Hospital,

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sharing knowledge to improve child health around the globe.

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Hello, Pediatric Surgery family.

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I'm Em Gootee, a research fellow from Cincinnati Children's Hospital Medical Center.

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Our 11th annual update course in pediatric surgery was held past August.

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In this video series, we'll recap the sessions and share the main highlights with you.

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Today, our topic is anal dilation following PSARP.

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Joining the discussions are Dr. Stephen Lee,

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Kaitlyn Smith,

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and Julia Grabowski.

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Let's see our case.

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We have a three-month-old male with a history of rectoblade or neck.

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Fischula presents two weeks following a laparoscopic assisted anal rectoplast.

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He has a colostomy and mucus fistula.

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What is your next step in management?

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Well, I used to be an A, a protocol-driven Hagar dilation sort of gal.

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And over time, I realized that it wasn't always necessary.

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In terms of the quality of life changes, dilations are really a source of stress for families.

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Parents feel like they're hurting their children and there's a lot of anxiety.

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So we've sort of moved a little bit away.

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This is a single-institution, prospective randomized controlled trial study from 2021.

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And the important thing is that these patients, the decision was made at the beginning.

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So you couldn't change stream partway through, which I think is really important.

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They were all primary patients, so no redo's or cloacas were included.

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All patients had a diagnosis of anoreptal malformation.

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The length of follow-up was 12 months, and the PSARP was performed at an average of five months old.

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And a stricture was defined as a Hagar 10 or less, which is what that picture denotes.

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So there are two arms, 25 patients in each arm.

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There were three strictures in the dilation and eight strictures in the non-dilation group.

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But I think what's important is that overall, the number of procedures were relatively the same.

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So a lot of the patients who had strictures in the non-dilated group ended up getting the stricture of plasty at the time of their colostomy closure.

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So only three of those patients actually got a separate anesthetic.

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So I think that's some of the concern with the non-dilation group is that they're getting extra procedures.

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One of my hesitations around saying, OK, great, we're not going to dilate.

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And we just moved to a place where if they end up with this persistent stricture, they get an anoplasty.

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But how does that impact the continence?

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I think the important thing is to know the type of stricture that this is appropriate for.

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So it has to really be like a skin level stricture and not anything deeper.

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And if you're talking about a longer stricture or anything that's just below or deeper, you really shouldn't be doing a stricture plasty.

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I didn't do stricture plasties for a very long time.

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And then I was dilating routinely and I realized that there was this other option.

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It is actually a very, very satisfying operation for a skin level stricture.

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Precision just takes about 20 minutes and kids can usually go home the same day.

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And it's just sort of cutting that stricture and making your 10 into a 13.

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And the baby's really tolerated very well.

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And then I do not dilate after the stricture plasty.

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And Dr. Smith shares with us that she talks to the family about the options when they're talking about doing a PSAR.

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According to her experience, babies generally tolerate dilations pretty well and they're not as bothered by it.

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It's not as problematic for the family, but I still talk about all of the options.

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But anyone over like getting especially close to 12 months, usually over six months, I don't dilate.

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I don't tend to offer dilation to those families.

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I agree. And I sometimes think when you're getting older than six, eight months, sometimes those dilations are actually not that successful.

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And maybe you're going to be dealing with the stricture anyway.

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Is your follow up different because we used to have to come back every week.

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And I don't know about you, but all babies didn't tolerate my dilation.

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So, I mean, are the families happier?

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The families seem happier.

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I see them about two to four weeks after the operation.

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And then I size the enoplasty in the office.

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Here's the time where we can talk about what dilations look like.

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We can do them or not.

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But if it looks really good, I will skip it.

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I will skip the dilation.

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I agree. Yes.

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And I don't usually even really discuss dilations if they have a colostomy because I know they're going back to the operating room at some point for a colostomy closure, which is a perfect time for a strictureplasty.

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Dr. Grabowski recommends considering seeing patients closely and doing the follow ups, but not necessarily dilating them, knowing that there is a very easy day surgery as a backup plan.

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This conversation is really new to me.

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The concept has been a me since I grew up in the era of making a small anal opening and then dilating it big.

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Do you feel like the stricture requiring a strictureplasty develops because you aren't dilating them or because you are dilating them?

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I'm just trying to sort out the cause of the stricture.

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Well, stricture can develop in either group.

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So anything under tension, ischemia, all those sorts of reasons.

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I just think sometimes it's that reaction between like the epidermis and the mucosa.

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It just sort of like creates this band.

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We're talking to an international audience.

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I could interpret that data differently and be like, actually, I'll recommend dilations for places where access would be an issue.

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And just coming back to surgery a second time, most people cannot afford that.

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Yes.

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Which means it's the more reason why you should encourage dilation in that scenario.

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I think that's a really good point is that the care definitely, especially for this patient population, highly varies depending on your setting, the resources of the patients you're taking care of.

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And I agree that should be taken account into the decision making of which sort of arm you're going to fall into.

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In summary, there is a growing shift in the view on routinely using Hagar dilation after surgery, mainly because it can be very stressful for families.

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Instead, stricture plasticity and effective treatment for skin level strictures is gaining favor.

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While babies usually handle dilations well, its effectiveness seems to decrease for children older than six months.

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For patients with a colostomy, deciding on dilation can often be postponed since they'll be coming back for a colostomy closure, which is an ideal time for a stricture plasticity.

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Crucially, when deciding between dilation and stricture plasticity, it's essential to take into account local resources and conditions as regular access to surgical services can determine the best strategy.

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Thank you for watching this video.

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Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.