# Anorectal Malformations & Cloacal Reconstruction — GCMD Library living collection

Updated: n/a · 52 episodes · 460 cited statements

## Episodes
### Fundamentals & Diagnosis
- [VACTERL Screening in Newborns With Anorectal Malformations - An Opportunity to Optimize Screening Practices, add Gynecologic and Spinal Conditions, and Utilize a New Acronym: VACTE(G)RLS](https://qa.library.globalcastmd.com/infographic/vacterl-screening-in-newborns-with-anorectal-malformations-an-opportunity-to-opt-10610) — article · [machine version](https://qa.library.globalcastmd.com/infographic/vacterl-screening-in-newborns-with-anorectal-malformations-an-opportunity-to-opt-10610.md)
- [A Genetics-First Approach Revealed Monogenic Disorders in Patients With ARM and VACTERL Anomalies](https://qa.library.globalcastmd.com/article/a-genetics-first-approach-revealed-monogenic-disorders-in-patients-with-arm-and-13802) — article · [machine version](https://qa.library.globalcastmd.com/article/a-genetics-first-approach-revealed-monogenic-disorders-in-patients-with-arm-and-13802.md)
- [Corrigendum: Sacral Curvature in Addition to Sacral Ratio to Assess Sacral Development and the Association With the Type of Anorectal Malformations](https://qa.library.globalcastmd.com/article/corrigendum-sacral-curvature-in-addition-to-sacral-ratio-to-assess-sacral-develo-13797) — article · [machine version](https://qa.library.globalcastmd.com/article/corrigendum-sacral-curvature-in-addition-to-sacral-ratio-to-assess-sacral-develo-13797.md)
- [Sacral Curvature in Addition to Sacral Ratio to Assess Sacral Development and the Association With the Type of Anorectal Malformations](https://qa.library.globalcastmd.com/article/sacral-curvature-in-addition-to-sacral-ratio-to-assess-sacral-development-and-th-13798) — article · [machine version](https://qa.library.globalcastmd.com/article/sacral-curvature-in-addition-to-sacral-ratio-to-assess-sacral-development-and-th-13798.md)
- [The cutback revisited - The posterior rectal advancement anoplasty for certain anorectal malformations with rectoperineal fistula](https://qa.library.globalcastmd.com/article/the-cutback-revisited-the-posterior-rectal-advancement-anoplasty-for-certain-ano-6150) — article · [machine version](https://qa.library.globalcastmd.com/article/the-cutback-revisited-the-posterior-rectal-advancement-anoplasty-for-certain-ano-6150.md)
- [Colorectal Quiz: Episode 41 - Perineal Hypospadias](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882) — video · 17:35 · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882.md)
- [Fetal and Newborn Management of Cloacal Malformations](https://qa.library.globalcastmd.com/article/fetal-and-newborn-management-of-cloacal-malformations-13765) — article · [machine version](https://qa.library.globalcastmd.com/article/fetal-and-newborn-management-of-cloacal-malformations-13765.md)

### Surgical Techniques
- [Laparoscopic Approach in Anorectal Malformations: How We Do It](https://qa.library.globalcastmd.com/article/laparoscopic-approach-in-anorectal-malformations-how-we-do-it-13799) — article · [machine version](https://qa.library.globalcastmd.com/article/laparoscopic-approach-in-anorectal-malformations-how-we-do-it-13799.md)
- [The Role of Laparoscopy in Anorectal Malformations](https://qa.library.globalcastmd.com/article/the-role-of-laparoscopy-in-anorectal-malformations-13803) — article · [machine version](https://qa.library.globalcastmd.com/article/the-role-of-laparoscopy-in-anorectal-malformations-13803.md)
- [Colorectal Quiz Episode 33: Cloaca Exstrophy](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819) — video · 22:24 · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819.md)
- [Preliminary Use of Indocyanine Green Fluorescence Angiography and Value in Predicting the Vascular Supply of Tissues Needed to Perform Cloacal, Anorectal Malformation, and Hirschsprung Reconstructions](https://qa.library.globalcastmd.com/article/preliminary-use-of-indocyanine-green-fluorescence-angiography-and-value-in-predi-13804) — article · [machine version](https://qa.library.globalcastmd.com/article/preliminary-use-of-indocyanine-green-fluorescence-angiography-and-value-in-predi-13804.md)
- [Factors predicting the need for vaginal replacement at the time of primary reconstruction of a cloacal malformation](https://qa.library.globalcastmd.com/article/factors-predicting-the-need-for-vaginal-replacement-at-the-time-of-primary-recon-13805) — article · [machine version](https://qa.library.globalcastmd.com/article/factors-predicting-the-need-for-vaginal-replacement-at-the-time-of-primary-recon-13805.md)
- [233. The timing of gynecologic management during cloaca repair with co-existing Müllerian agenesis: a paradigm shift](https://qa.library.globalcastmd.com/article/233-the-timing-of-gynecologic-management-during-cloaca-repair-with-co-existing-m-13881) — article · [machine version](https://qa.library.globalcastmd.com/article/233-the-timing-of-gynecologic-management-during-cloaca-repair-with-co-existing-m-13881.md)
- [Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299) — podcast · 43:47 · [machine version](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299.md)
- [Colorectal Quiz Episode 18: Cloaca Part 2](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862) — podcast · 23:10 · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862.md)
- [Colorectal Quiz Episode 17: Cloaca Part 1](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863) — podcast · 27:32 · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863.md)
- [Complications and Long-Term Outcomes of Patients With Cloacal Malformation After Bowel Neovagina...](https://qa.library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-12170) — video · 1:05 · [machine version](https://qa.library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-12170.md)
- [Colorectal Quiz: Episode 2](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865) — podcast · 18:15 · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865.md)
- [Transanal full thickness rectal mobilization with an ischiorectal fat pad to repair an H-Type rectovaginal fistula](https://qa.library.globalcastmd.com/watch/transanal-full-thickness-rectal-mobilization-with-an-ischiorectal-fat-pad-to-rep-7278) — video · [machine version](https://qa.library.globalcastmd.com/watch/transanal-full-thickness-rectal-mobilization-with-an-ischiorectal-fat-pad-to-rep-7278.md)

### Postoperative Care & Complications
- [Global Strategies for Postoperative Care and Bowel Management in Patients With Anorectal Malformations: Varied Practices and Barriers](https://qa.library.globalcastmd.com/article/global-strategies-for-postoperative-care-and-bowel-management-in-patients-with-a-13760) — article · [machine version](https://qa.library.globalcastmd.com/article/global-strategies-for-postoperative-care-and-bowel-management-in-patients-with-a-13760.md)
- [Colorectal Quiz Episode 29: Female ARM](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858) — podcast · 25:08 · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858.md)
- [Complications of Anorectal Malformations with Dr. Marc Levitt](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304) — podcast · 48:09 · [machine version](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304.md)
- [Battery Ingestion with Colonic Perforation after Colostomy Closure in a Toddler](https://qa.library.globalcastmd.com/article/battery-ingestion-with-colonic-perforation-after-colostomy-closure-in-a-toddler-13766) — article · [machine version](https://qa.library.globalcastmd.com/article/battery-ingestion-with-colonic-perforation-after-colostomy-closure-in-a-toddler-13766.md)

### Educational Resources
- [Colorectal Quiz  Episode 1 - Low Bulbar Fistua](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824) — video · 15:45 · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824.md)
- [Colorectal Quiz: Episode 40](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852) — podcast · 18:43 · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852.md)
- [The Colorectal Quiz: Episode 1](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868) — podcast · 15:45 · [machine version](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868.md)
- [Colorectal Quiz: Episode 50 - 16th Annual European Pediatric Colorectal and Pelvic Reconstruction Conference, Stockholm, Sweden, October 2025 - What did we learn?](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653) — podcast · 24:17 · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653.md)
- [Colorectal Quiz Ep. 50 -16th Annual European Pediatric Colorectal & Pelvic Reconstruction Conference](https://qa.library.globalcastmd.com/watch/colorectal-quiz-ep-50-16th-annual-european-pediatric-colorectal-pelvic-reconstru-13817) — video · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-quiz-ep-50-16th-annual-european-pediatric-colorectal-pelvic-reconstru-13817.md)
- [Update Course Rewind: Pediatric Colorectal Consortium 2021](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357) — podcast · 14:55 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357.md)
- [New and exciting advances in pediatric colorectal and pelvic reconstructive surgery - 2021 update](https://qa.library.globalcastmd.com/article/new-and-exciting-advances-in-pediatric-colorectal-and-pelvic-reconstructive-surg-3294) — article · [machine version](https://qa.library.globalcastmd.com/article/new-and-exciting-advances-in-pediatric-colorectal-and-pelvic-reconstructive-surg-3294.md)
- [Episode 19 - Interview with Dr Marc Levitt, Chief of Colorectal & Pelvic Reconstruction, Children‘s](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825) — video · 54:32 · [machine version](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825.md)
- [2019 Chandler Lecture: Dr. Marc Levitt](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827) — video · 41:23 · [machine version](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827.md)
- [Time for some patient driven change | Marc Levitt | TEDxColumbus](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828) — video · 10:41 · [machine version](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828.md)
- [Tell Me a Story: Pediatric Surgeons Putting Colorectal Center on the Map](https://qa.library.globalcastmd.com/watch/tell-me-a-story-pediatric-surgeons-putting-colorectal-center-on-the-map-13829) — video · 2:20 · [machine version](https://qa.library.globalcastmd.com/watch/tell-me-a-story-pediatric-surgeons-putting-colorectal-center-on-the-map-13829.md)
- [The value and weakness of Medical Mission Work in ARM](https://qa.library.globalcastmd.com/watch/the-value-and-weakness-of-medical-mission-work-in-arm-13844) — video · [machine version](https://qa.library.globalcastmd.com/watch/the-value-and-weakness-of-medical-mission-work-in-arm-13844.md)

### More resources
- [Colorectal and Pelvic Reconstruction Techniques with Dr. Marc Levitt](https://qa.library.globalcastmd.com/watch/colorectal-and-pelvic-reconstruction-techniques-with-dr-marc-levitt-13835) — video · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-and-pelvic-reconstruction-techniques-with-dr-marc-levitt-13835.md)
- [Keynote Address on Pediatric Colorectal Surgery by Dr. Marc Levitt](https://qa.library.globalcastmd.com/watch/keynote-address-on-pediatric-colorectal-surgery-by-dr-marc-levitt-13836) — video · [machine version](https://qa.library.globalcastmd.com/watch/keynote-address-on-pediatric-colorectal-surgery-by-dr-marc-levitt-13836.md)
- [Patient Outreach and Communication in Pediatric Colorectal Surgery](https://qa.library.globalcastmd.com/watch/patient-outreach-and-communication-in-pediatric-colorectal-surgery-13839) — video · [machine version](https://qa.library.globalcastmd.com/watch/patient-outreach-and-communication-in-pediatric-colorectal-surgery-13839.md)
- [(500) Days of Summer (classic Movie Review: Zooey Deschanel, Joseph Gordon-Levitt, Marc Webb) by The Cory Baker Show](https://qa.library.globalcastmd.com/watch/days-of-summer-by-the-cory-baker-show-13883) — podcast · [machine version](https://qa.library.globalcastmd.com/watch/days-of-summer-by-the-cory-baker-show-13883.md)
- [Introducing Dr. Marc Levitt: Pediatric Colorectal Surgeon Profile](https://qa.library.globalcastmd.com/watch/introducing-dr-marc-levitt-pediatric-colorectal-surgeon-profile-13831) — video · [machine version](https://qa.library.globalcastmd.com/watch/introducing-dr-marc-levitt-pediatric-colorectal-surgeon-profile-13831.md)
- [Andrea Kesar Discusses Marc Levitt's Contributions to Pediatric Colorectal Surgery](https://qa.library.globalcastmd.com/watch/andrea-kesar-discusses-marc-levitt-s-contributions-to-pediatric-colorectal-surge-13832) — video · [machine version](https://qa.library.globalcastmd.com/watch/andrea-kesar-discusses-marc-levitt-s-contributions-to-pediatric-colorectal-surge-13832.md)
- [Meeting with Marc Levitt: Clinical Discussion with Ivon Martinez](https://qa.library.globalcastmd.com/watch/meeting-with-marc-levitt-clinical-discussion-with-ivon-martinez-13833) — video · [machine version](https://qa.library.globalcastmd.com/watch/meeting-with-marc-levitt-clinical-discussion-with-ivon-martinez-13833.md)
- [Dr. Marc Levitt on the CTO Mission in Pediatric Colorectal Surgery](https://qa.library.globalcastmd.com/watch/dr-marc-levitt-on-the-cto-mission-in-pediatric-colorectal-surgery-13834) — video · [machine version](https://qa.library.globalcastmd.com/watch/dr-marc-levitt-on-the-cto-mission-in-pediatric-colorectal-surgery-13834.md)
- [Integrated Care Concept in Pediatric Colorectal Surgery by Marc Levitt](https://qa.library.globalcastmd.com/watch/integrated-care-concept-in-pediatric-colorectal-surgery-by-marc-levitt-13837) — video · [machine version](https://qa.library.globalcastmd.com/watch/integrated-care-concept-in-pediatric-colorectal-surgery-by-marc-levitt-13837.md)
- [Addressing Ministers of Health: Pediatric Colorectal Surgery Advocacy and Global Healthcare Priorities](https://qa.library.globalcastmd.com/watch/addressing-ministers-of-health-pediatric-colorectal-surgery-advocacy-and-global-13838) — video · [machine version](https://qa.library.globalcastmd.com/watch/addressing-ministers-of-health-pediatric-colorectal-surgery-advocacy-and-global-13838.md)
- [Connecting Surgeons and Nurses: Collaborative Care in Pediatric Surgery](https://qa.library.globalcastmd.com/watch/connecting-surgeons-and-nurses-collaborative-care-in-pediatric-surgery-13840) — video · [machine version](https://qa.library.globalcastmd.com/watch/connecting-surgeons-and-nurses-collaborative-care-in-pediatric-surgery-13840.md)
- [The History of International Colorectal Surgery Team Development](https://qa.library.globalcastmd.com/watch/the-history-of-international-colorectal-surgery-team-development-13841) — video · [machine version](https://qa.library.globalcastmd.com/watch/the-history-of-international-colorectal-surgery-team-development-13841.md)
- [How the Colorectal and Pelvic Reconstruction Center Uses Donor Support](https://qa.library.globalcastmd.com/watch/how-the-colorectal-and-pelvic-reconstruction-center-uses-donor-support-13842) — video · [machine version](https://qa.library.globalcastmd.com/watch/how-the-colorectal-and-pelvic-reconstruction-center-uses-donor-support-13842.md)
- [Introduction to Dr. Marc Levitt's Pediatric Colorectal Surgery Practice](https://qa.library.globalcastmd.com/watch/introduction-to-dr-marc-levitt-s-pediatric-colorectal-surgery-practice-13843) — video · [machine version](https://qa.library.globalcastmd.com/watch/introduction-to-dr-marc-levitt-s-pediatric-colorectal-surgery-practice-13843.md)

## Chapters
- [0:00](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=0) Introduction and Missed Diagnoses in the Newborn Period (Ep 23)
- [2:57](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=177) Perineal Fistula in Males: Diagnosis and Management (Ep 23)
- [7:33](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=453) Perineal Fistula in Females: Diagnostic Challenges (Ep 23)
- [10:11](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=611) Examination Techniques and Missed Cloaca (Ep 23)
- [15:13](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=913) Colostomy Technique and Common Errors (Ep 23)
- [19:51](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1191) Anoplasty Placement and Stimulator Use (Ep 23)
- [23:17](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1397) Distal Colostogram Interpretation (Ep 23)
- [26:36](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1596) Avoiding Urinary Tract Injury During Dissection (Ep 23)
- [29:41](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1781) Choosing Between Posterior Sagittal and Laparoscopic Approach (Ep 23)
- [33:36](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2016) Preventing and Managing Perineal Body Dehiscence (Ep 23)
- [38:25](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2305) Complications Specific to Laparoscopic and PSARP Approaches (Ep 23)
- [40:51](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2451) Managing the Soiling 4-Year-Old and Indications for Redo (Ep 23)
- [0:00](https://qa.library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-12170?t=0) Introduction and Study Design (Ep 18)
- [0:24](https://qa.library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-12170?t=24) Study Findings and Complications (Ep 18)
- [0:51](https://qa.library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-12170?t=51) Clinical Takeaway (Ep 18)
- [0:00](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=0) Introduction and Prenatal Evaluation of Cloaca (Ep 15)
- [2:38](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=158) Prenatal Counseling and Indications for Fetal Intervention (Ep 15)
- [6:05](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=365) Newborn Physical Examination and Diagnosis (Ep 15)
- [9:46](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=586) Initial Workup and Management of Hydrocolpos (Ep 15)
- [13:26](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=806) Colostomy Creation and Vaginostomy Technique (Ep 15)
- [18:17](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1097) Pathophysiology of Hydrocolpos and Urogenital Sinus (Ep 15)
- [22:28](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1348) Timing and Imaging for Definitive Repair (Ep 15)
- [28:41](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1721) Multidisciplinary Team and Surgical Planning (Ep 15)
- [34:27](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2067) Urethral Length and Surgical Technique Selection (Ep 15)
- [37:34](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2254) Management of Non-Reaching Vagina and Vaginal Replacement (Ep 15)
- [40:21](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2421) Common Errors in Cloaca Repair and Contact Information (Ep 15)
- [0:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=0) Anal Dilations After PSARP: Evidence for Abandonment (Ep 32)
- [4:14](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=254) Timing of Repair for Low Anorectal Malformations (Ep 32)
- [6:57](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=417) Hirschsprung Disease: Long Segment Management and Timing (Ep 32)
- [9:48](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=588) Bowel Management in Anorectal Malformations (Ep 32)
- [11:35](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=695) Timing of Pull-Through for Hirschsprung Disease and Health Disparities (Ep 32)
- [12:58](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=778) Cloacal Reconstruction: Anatomic Considerations (Ep 32)
- [0:00](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=0) Introduction and Hirschsprung Irrigation Competency (Ep 30)
- [3:07](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=187) Skincare Management in Total Colonic Hirschsprung Patients (Ep 30)
- [4:43](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=283) Diet, Minimally Invasive Techniques, and Robotic Surgery (Ep 30)
- [7:40](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=460) Goblet Cells, Bowel Stress, and Pull-Through Decompensation (Ep 30)
- [10:27](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=627) Dedicated Nursing Programs and Allied Health Component (Ep 30)
- [13:39](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=819) Transition of Care and Multidisciplinary Adult Services (Ep 30)
- [16:02](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=962) Anorectal Malformation Techniques and Cloaca Management (Ep 30)
- [20:45](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=1245) General Pediatric Proctology: Anal Fissure and Crohn Disease (Ep 30)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period. — Marc Levitt (clinical) [Ep 23 · 2:57](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=177)
- Male babies with perineal fistula may pass meconium and no one notices anything wrong with their anorectal anatomy, typically presenting in the first year of life with severe constipation. — Marc Levitt (clinical) [Ep 23 · 3:06](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=186)
- A newborn anus should accept a size 12 Hagar dilator and a 1-year-old should accept a size 15. — Marc Levitt (clinical) [Ep 23 · 6:13](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=373)
- Relocating a perineal fistula into the sphincters improves anatomy but does not completely fix constipation; patients will inherently have some constipation requiring aggressive treatment. — Marc Levitt (clinical) [Ep 23 · 4:54](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=294)
- If a perineal fistula is not centered in the sphincter, patients with loose stool will soil, and athletic activity will cause soiling because sphincter squeeze cannot completely close the hole. — Marc Levitt (clinical) [Ep 23 · 5:38](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=338)
- In females, diagnostic criteria for perineal fistula are: hole too close to vagina (inadequate perineal body), inadequate hole size by Hagar dilators, and hole not centered in sphincter. — Marc Levitt (clinical) [Ep 23 · 8:02](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=482)
- If a female's anal opening is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, no surgery is needed; the perineal body will lengthen with growth. — Marc Levitt (clinical) [Ep 23 · 8:47](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=527)
- The standard practice of checking temperature on forehead or ear rather than rectally makes it easier to miss anorectal malformations in newborns. — Marc Levitt (opinion) [Ep 23 · 4:25](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=265)
- An anesthesia nerve stimulator costing $150 with appropriate needle probes works as well as commercial $15,000 stimulators for identifying sphincter muscles. — Marc Levitt (clinical) [Ep 23 · 11:06](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=666)
- The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through by the location of the colostomy or mucous fistula. — Marc Levitt (clinical) [Ep 23 · 17:18](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1038)
- Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections. — Marc Levitt (clinical) [Ep 23 · 17:45](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1065)
- With transverse colostomy and large rectourethral fistula, the left colon absorbs urine which doesn't exit the mucous fistula, potentially causing acidosis from urine absorption. — Marc Levitt (clinical) [Ep 23 · 18:38](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1118)
- Prolapse risk depends on colostomy location: mid-transverse allows bilateral prolapse, hepatic flexure allows only distal prolapse, proximal sigmoid allows only distal prolapse because left colon is fixed to retroperitoneum. — Marc Levitt (clinical) [Ep 23 · 19:58](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1198)
- Marking the sphincter ellipse on skin surface before making any incision prevents confusion from muscle stimulation after dissection is open, avoiding misplaced anoplasty. — Marc Levitt (clinical) [Ep 23 · 21:30](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1290)
- A distal colostogram showing flattening of the rectum corresponding to the pubococcygeal line indicates insufficient contrast or pressure; more pressure is needed to overcome the sphincters and reveal the true rectal position and fistula. — Marc Levitt (clinical) [Ep 23 · 24:26](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1466)
- Fistula level is determined by viewing the urethra as a reverse C or elbow: fistula at or below the elbow is bulbar, above the elbow is prostatic, at bladder neck is bladder neck fistula. — Marc Levitt (clinical) [Ep 23 · 25:23](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1523)
- Bulbous rectum on colostogram may be reachable posterior sagittally and difficult laparoscopically; tapered rectum is better approached laparoscopically. — Marc Levitt (clinical) [Ep 23 · 25:55](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1555)
- Opening posterior sagittally without knowing exact rectal location risks finding and potentially mobilizing bladder neck instead of rectum. — Marc Levitt (clinical) [Ep 23 · 27:00](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1620)
- Bulbar and low prostatic fistulas with bulbous rectum are best approached posterior sagittally; high prostatic with tapered rectum and bladder neck fistulas are best approached laparoscopically. — Marc Levitt (clinical) [Ep 23 · 30:09](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1809)
- Attempting laparoscopy for bulging rectum below peritoneal reflection at low prostatic or bulbar level risks leaving behind a remnant of the original fistula (roof) if the surgeon is timid. — Marc Levitt (clinical) [Ep 23 · 30:43](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1843)
- Laparoscopy replaces laparotomy, not PSARP; a mini-PSARP during laparoscopy allows safe entry through peritoneal reflection and tacking rectum to posterior muscle complex to prevent prolapse. — Marc Levitt (opinion) [Ep 23 · 31:48](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1908)
- Rectal prolapse occurs in about 3% of cases, particularly in patients without great muscles. — Marc Levitt (epidemiological) [Ep 23 · 33:35](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2015)
- Rectal prolapse more than 3 millimeters should be treated because it causes bleeding, mucus, and can inhibit bowel control in patients with good muscle potential. — Marc Levitt (clinical) [Ep 23 · 34:14](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2054)
- Circumferential prolapse can be trimmed in two separate ambulatory sessions (half circumference each), avoiding hospitalization and eliminating need for dilation since half the circumference remains untouched. — Marc Levitt (clinical) [Ep 23 · 34:48](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2088)
- Perineal body dehiscence is the most common cause of reoperation in female ARM repairs. — Marc Levitt (clinical) [Ep 23 · 36:03](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2163)
- Complete anterior rectal wall mobilization to the areolar plane between rectum and vagina is essential to avoid tension on the anoplasty that can lead to perineal body dehiscence. — Marc Levitt (clinical) [Ep 23 · 35:41](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2141)
- Clear liquids only for one week postoperatively prevents hard stool formation while allowing more stool volume, showing good perineal body healing results without traditional 7-day NPO period. — Marc Levitt (clinical) [Ep 23 · 36:45](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2205)
- If perineal body dehiscence is recognized on days 5-8, taking the patient back to OR to re-suture can salvage the repair; by 3-4 weeks the entire perineal body is dehisced and unsalvageable. — Marc Levitt (clinical) [Ep 23 · 37:48](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2268)
- During laparoscopic approach for high rectums, the IMA must be preserved because prior colostomy may have disrupted collaterals down the left colic, making the rectum completely dependent on IMA blood supply. — Marc Levitt (clinical) [Ep 23 · 39:33](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2373)
- Continence potential in ARM patients is predicted by three factors: original malformation type, sacral ratio, and spine quality (ARM continence index). Three A's predicts continence, three C's predicts incontinence. — Marc Levitt (clinical) [Ep 23 · 42:14](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2534)
- A bulbar fistula with sacral ratio of 1 and normal spine should have bowel control; a bladder neck fistula with sacral ratio of 0.4 and tethered cord or myelomeningocele has no chance of good bowel control. — Marc Levitt (clinical) [Ep 23 · 43:19](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2599)
- Initial management of soiling 4-year-old with continence potential is bowel management with enemas to achieve cleanliness, then trial of laxatives when older and more mature to attempt voluntary bowel movements. — Marc Levitt (clinical) [Ep 23 · 43:52](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2632)
- Indications for redo pull-through include any patient with continence potential who has improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum). — Marc Levitt (clinical) [Ep 23 · 44:39](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2679)
- The major problem with anorectal malformations is that surgical errors may not become apparent for years; an improperly placed anus appears successful initially but presents with soiling at age 4. — Marc Levitt (opinion) [Ep 23 · 46:25](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2785)
- The study was a single institution retrospective study of 40 patients with cloacal malformations who underwent bowel neovagina creation during reconstruction — Megan Reed Ivaturi (clinical) [Ep 18 · 0:11](https://qa.library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-12170?t=11)
- Overall outcomes were similar between small bowel and colonic neovaginas — Megan Reed Ivaturi (clinical) [Ep 18 · 0:25](https://qa.library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-12170?t=25)
- Major complications were uncommon but not negligible — Megan Reed Ivaturi (clinical) [Ep 18 · 0:29](https://qa.library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-12170?t=29)
- Enterroidal stenosis was more common with colonic grafts — Megan Reed Ivaturi (clinical) [Ep 18 · 0:32](https://qa.library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-12170?t=32)
- A subset of patients required roidoplasty — Megan Reed Ivaturi (clinical) [Ep 18 · 0:32](https://qa.library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-12170?t=32)
- Vaginal prolapse was rare — Megan Reed Ivaturi (clinical) [Ep 18 · 0:38](https://qa.library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-12170?t=38)
- Menstrual obstruction occurred in only a few patients — Megan Reed Ivaturi (clinical) [Ep 18 · 0:40](https://qa.library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-12170?t=40)
- About 25% of patients reported bothersome discharge — Megan Reed Ivaturi (clinical) [Ep 18 · 0:43](https://qa.library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-12170?t=43)
- Among the small number who were sexually active, dyspareunia was reported — Megan Reed Ivaturi (clinical) [Ep 18 · 0:46](https://qa.library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-12170?t=46)
- Bowel neovaginas are a reasonable and durable option — Megan Reed Ivaturi (opinion) [Ep 18 · 0:52](https://qa.library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-12170?t=52)
- Patients with bowel neovaginas need long term follow up with attention to function, stenosis and quality of life — Megan Reed Ivaturi (guideline) [Ep 18 · 0:57](https://qa.library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-12170?t=57)
- The most common prenatal ultrasound finding in cloaca is a pelvic mass, often representing a dilated vagina (hydrocolpos). — Marc Levitt (clinical) [Ep 15 · 2:38](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=158)
- Fetal intervention for cloaca is unlikely to be necessary; babies should typically go to term. — Marc Levitt (clinical) [Ep 15 · 3:56](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=236)
- Fetal hydrocolpos drainage has been performed at least once (case report from Japan) for massive hydronephrosis with impending renal loss, similar to bladder drainage for urethral valves. — Marc Levitt (clinical) [Ep 15 · 5:14](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=314)
- In cloaca, there is one perineal hole below the clitoris and no anus; this is not ambiguous genitalia, there is no adrenal problem, and the baby is a normal female with two normal ovaries. — Marc Levitt (clinical) [Ep 15 · 6:37](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=397)
- A urogenital sinus (single hole with normal anus present) may be associated with virilization and requires evaluation for adrenal hyperplasia and electrolyte abnormalities. — Marc Levitt (clinical) [Ep 15 · 6:57](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=417)
- To examine a newborn for cloaca, grab the labia and lift them up and out with very good lighting to see if there is a single hole or distinct urethral, vaginal, and rectal orifices. — Marc Levitt (clinical) [Ep 15 · 8:36](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=516)
- Many patients considered cloacas actually have vestibular fistulas; with better examination you can see three holes (urethra, vagina, and rectal opening in vestibule). — Marc Levitt (clinical) [Ep 15 · 9:03](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=543)
- Initial workup for cloaca includes ultrasound for hydronephrosis and kidney number, spinal ultrasound for tethered cord, cardiac auscultation, and plain X-ray of spine to assess sacrum. — Marc Levitt (clinical) [Ep 15 · 9:59](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=599)
- Intermittent catheterization of the common channel may decompress hydrocolpos, but is not reliable because the catheter may enter the urethra, right or left vagina, or rectum; success should be confirmed by ultrasound. — Marc Levitt (clinical) [Ep 15 · 11:14](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=674)
- If hydrocolpos is bilateral, open into both vaginas at the dome, remove some of the common wall (septum), and one tube will drain both sides. — Marc Levitt (clinical) [Ep 15 · 13:14](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=794)
- For vaginostomy, use an 8 or 10 French pigtail catheter (not a straight catheter) because as hydrocolpos recedes, straight catheters fall out but curled catheters do not. — Marc Levitt (clinical) [Ep 15 · 14:15](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=855)
- Vesicostomy is rarely needed in cloaca; the problem is usually hydrocolpos compressing the trigone and distal ureters, not bladder drainage. Draining the hydrocolpos relieves the ureteral obstruction. — Marc Levitt (clinical) [Ep 15 · 15:05](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=905)
- Vesicostomy is indicated only when the bladder does not drain after successful hydrocolpos decompression, which occurs in very rare circumstances with very long narrow common channels or absent urethra. — Marc Levitt (clinical) [Ep 15 · 16:28](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=988)
- Vesicostomy is also indicated in the rare circumstance of massive bilateral ureteral reflux, where decompressing the system protects the ureters until later repair. — Marc Levitt (clinical) [Ep 15 · 17:54](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1074)
- Hydronephrosis in cloaca is caused by hydrocolpos pressing forward on the trigone and compressing the distal ureters where they enter the bladder. — Marc Levitt (clinical) [Ep 15 · 20:11](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1211)
- Hydrocolpos develops because urine preferentially fills the vagina through the vaginal fistula rather than exiting the common channel, likely due to mechanical factors (steep urethral angle). — Marc Levitt (clinical) [Ep 15 · 18:21](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1101)
- Hydrocolpos fluid is typically a turbid combination of mucus and urine; maternal estrogen effect can increase mucus production and rarely cause blood in the hydrocolpos. — Marc Levitt (clinical) [Ep 15 · 18:48](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1128)
- Cystoscopy in the newborn period is not advantageous; the required scope is tiny, visualization is poor, the perineum is swollen, and it is better to minimize OR time in newborns. — Marc Levitt (opinion) [Ep 15 · 20:29](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1229)
- Laparoscopic approach to colostomy and hydrocolpos drainage (described by Michigan group) provides excellent visualization and is a valuable technique. — Marc Levitt (clinical) [Ep 15 · 20:49](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1249)
- For massive hydrocolpos extending above the umbilicus, use a lower midline incision to access the dome, and consider a tubeless vaginostomy sutured to the abdominal wall like a G-tube. — Marc Levitt (clinical) [Ep 15 · 21:17](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1277)
- Urogenital sinus (single perineal opening with normal anus) requires workup for adrenal problems causing virilization, though it can occur without virilization. — Marc Levitt (clinical) [Ep 15 · 22:28](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1348)
- Most urogenital sinuses can be managed with perineal urogenital mobilization without touching the rectum; high UG sinus cases may require a transrectal (Astra) approach. — Marc Levitt (clinical) [Ep 15 · 23:17](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1397)
- Definitive cloaca repair timing: perform endoscopy and cloacography at 2–3 months of age, then repair anytime thereafter within one year, ideally before 6 months if managing from birth. — Marc Levitt (clinical) [Ep 15 · 23:57](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1437)
- The two critical endoscopic measurements are common channel length (from perineum to urethral takeoff) and urethral length (from urethral takeoff to bladder neck); urethral length determines the surgical approach. — Marc Levitt (clinical) [Ep 15 · 25:25](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1525)
- Traditional classification uses 3 cm common channel length (≤3 cm straightforward, >3 cm complicated), but urethral length is equally important and not mentioned in published papers. — Marc Levitt (clinical) [Ep 15 · 25:27](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1527)
- Endoscopy can falsely suggest the rectum is reachable when it is actually a long narrow fistula with healthy rectum high in the abdomen; contrast study (cloacogram) is needed to assess this. — Marc Levitt (clinical) [Ep 15 · 26:21](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1581)
- 3D cloacogram reconstruction is superior to 2D fluoroscopy; experienced surgeons answer anatomy questions more correctly with 3D imaging, and printed 3D models may be even better. — Marc Levitt (clinical) [Ep 15 · 28:34](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1714)
- Cloaca patients benefit from collaborative multidisciplinary approach; the days of a single surgeon handling these cases alone are over. — Marc Levitt (opinion) [Ep 15 · 30:29](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1829)
- Urogenital mobilization, first described by Alberto Pena in 1996, mobilizes urethra and vagina as a unit without operating on the wall between them, eliminating the 10% urethral-vaginal fistula rate of prior techniques. — Marc Levitt (clinical) [Ep 15 · 32:15](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1935)
- Urogenital mobilization is appropriate when common channel is ≤3 cm AND urethral length above the takeoff is at least 1.5–2 cm; this leaves adequate urethral length after splitting the common channel. — Marc Levitt (clinical) [Ep 15 · 33:39](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2019)
- With inadequate urethral length, do not perform total urogenital mobilization; instead leave the common channel to become the urethra and separate the vagina from it—a technically demanding operation. — Marc Levitt (clinical) [Ep 15 · 34:26](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2066)
- After separating vagina from common channel, repair the common channel and cover with anorectal fat pad and possibly SIS to ensure well-healed urethra and avoid urethral-vaginal fistula. — Marc Levitt (clinical) [Ep 15 · 34:50](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2090)
- If urogenital mobilization is attempted but the complex does not reach, the only option is abdominal delivery of the urogenital complex; if this fails, separating the vagina from a circumferentially dissected common channel risks devascularizing and losing the urethra. — Marc Levitt (clinical) [Ep 15 · 35:09](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2109)
- Urogenital mobilization with inadequate urethral length leaves the patient with urinary leakage that cannot be controlled without tightening or closing the bladder neck. — Marc Levitt (clinical) [Ep 15 · 35:52](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2152)
- Separating the vagina from the common channel and leaving the common channel as the entire urethra gives the patient about a 4 cm urethra, allowing intermittent catheterization and continence. — Marc Levitt (clinical) [Ep 15 · 36:05](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2165)
- Type 1 cloaca (common channel ~1 cm with adequate urethral length): mobilize the vagina and leave the urethra slightly hypospadiac; patient will void if no neurogenic bladder component. — Marc Levitt (clinical) [Ep 15 · 36:40](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2200)
- Patients with tethered cord or neurogenic bladder need a visible urethral orifice that is easily catheterized; slightly hypospadiac urethra is acceptable only if certain the patient will void and not need intermittent catheterization. — Marc Levitt (clinical) [Ep 15 · 37:11](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2231)
- When native vagina does not reach after full mobilization, options include vaginal switch (disconnect one side preserving ovarian blood supply, switch dome down, remove septum) or vaginal replacement. — Marc Levitt (clinical) [Ep 15 · 38:00](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2280)
- For vaginal replacement, left colon is the preferred option; sigmoid may be used depending on the vascular arcade. — Marc Levitt (opinion) [Ep 15 · 38:46](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2326)
- Tissue engineering of vaginas using patient stem cells is on the horizon (work at Wake Forest and Mexico); this would revolutionize cloaca care by eliminating the need for vaginal replacement. — Marc Levitt (clinical) [Ep 15 · 39:10](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2350)
- Complex cloacas requiring specialized expertise include those with common channel >3 cm or urethral length (takeoff to bladder neck) <1.5 cm. — Marc Levitt (clinical) [Ep 15 · 39:48](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2388)
- The most common problem in redo cloacas is the surgeon never realized it was a cloaca and only fixed the rectum, leaving the urogenital sinus untouched. — Marc Levitt (clinical) [Ep 15 · 40:27](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2427)
- The second most common redo problem is inadequate mobilization of structures, leaving the patient with a stenosed or lost vagina. — Marc Levitt (clinical) [Ep 15 · 40:58](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2458)
- Dr. Rentia currently sizes the anus at 2 weeks and 1 month in practice to understand the diameter of the anoplasty so that stooling is not obstructed by an unrecognized strictured anoplasty. — Rebecca Rentea (opinion) [Ep 32 · 3:19](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=199)
- Dr. Rentia would only consider initiating full dilations for slightly older children where dilations are more traumatic and if concerned about needing general anesthesia, given that HM anoplasty is an option. — Rebecca Rentea (opinion) [Ep 32 · 3:38](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=218)
- About 5 to 8% of patients require a strictureplasty at the two-month period. — Rebecca Rentea (epidemiological) [Ep 32 · 4:04](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=244)
- Dr. Rentia is a fan of doing dilations in the neonatal period for low malformations and having the family discharged as soon as possible to home. — Rebecca Rentea (opinion) [Ep 32 · 5:03](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=303)
- Dr. Smith finds that for neonates and infants up to several months old, dilations are really well tolerated, but avoids them in older age groups. — Caitlin Smith (opinion) [Ep 32 · 6:22](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=382)
- Formula-fed infants who need caloric concentration have thicker stools, which might push toward earlier repair, while breastfed infants can delay until 2-3 months. — Caitlin Smith (clinical) [Ep 32 · 6:32](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=392)
- Repair should be done before infants start solids because that makes the dilation strategy at home much more difficult. — Caitlin Smith (clinical) [Ep 32 · 6:47](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=407)
- Dr. Rentia performs pull-through when the child is toilet trained for urine, typically at age 4, because waiting too long can result in horrible anal sphincter spasm and pelvic disease that makes keeping a pull-through challenging. — Rebecca Rentea (opinion) [Ep 32 · 9:25](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=565)
- Dr. Smith wonders if the PCPLC, being made up of specialty centers, may miss some race and ethnic disparities since patients who can afford to travel to these centers may be captured while those without means are not. — Caitlin Smith (opinion) [Ep 32 · 12:40](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=760)
- Many centers are starting irrigation competency even with an ostomy in place, particularly for total colonic Hirschsprung patients, to ease the transition after takedown. — Lindsey Clarke (clinical) [Ep 30 · 1:17](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=77)
- Total colonic Hirschsprung patients with a stoma are the highest risk group for enterocolitis and must receive irrigation teaching before pull-through. — Marc Levitt (clinical) [Ep 30 · 2:45](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=165)
- Diet management for Hirschsprung patients is not one size fits all; families must identify individual food triggers through pattern recognition. — Lindsey Clarke (clinical) [Ep 30 · 4:48](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=288)
- Most Hirschsprung pull-throughs that decompensate had good original pathology but were not aggressively managed post-operatively with laxatives and Botox when needed. — Marc Levitt (clinical) [Ep 30 · 9:39](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=579)
- The 16th European Pediatric Colorectal meeting had the largest nursing attendance of any of the previous 15 meetings. — Marc Levitt (epidemiological) [Ep 30 · 10:35](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=635)
- Without nursing partners, surgeons cannot achieve good functional outcomes; two patients with identical technical repairs can have totally different results based on nursing care quality. — Marc Levitt (opinion) [Ep 30 · 11:41](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=701)
- Adult colorectal surgeons need to understand what Hirschsprung disease and anorectal malformation patients might need when they are 50 years old with complications like rectal prolapse. — Marc Levitt (opinion) [Ep 30 · 15:29](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=929)
- In vestibular fistula repair, dissection does not need to reach the areolar plane between anterior rectum and posterior vagina; the key is ensuring the rectum has no tension during anoplasty. — Marc Levitt (clinical) [Ep 30 · 17:18](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=1038)
- Mullerian structures that look atretic may actually grow into real useful structures, supporting a strategy of waiting rather than immediate reconstruction. — Marc Levitt (clinical) [Ep 30 · 19:24](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=1164)
- A bowel neovagina can bridge the gap when native vagina does not reach after urogenital separation, and can be removed in the future when the native vagina is pulled through after puberty. — Marc Levitt (clinical) [Ep 30 · 19:50](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=1190)
- The 16th European Pediatric Colorectal meeting had well over 250 attendees from diverse international locations including Asia, Bangladesh, Thailand, Vietnam, and multiple U.S. states. — Marc Levitt (epidemiological) [Ep 30 · 22:20](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=1340)
- Anorectal malformation occurs more commonly in females and has a prevalence of about one in 5,000 births. — Marc Levitt (epidemiological) [Ep 28 · 1:39](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=99)
- About 60% of anorectal malformation patients in Chris Westgarth-Taylor's practice were discharged home without being identified as having an anorectal malformation. — Chris Westgarth-Taylor (epidemiological) [Ep 28 · 1:05](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=65)
- When you look in laparoscopically and see an end of the colon with nothing else visible, you do not have to do a divided colostomy—you can bring out that distal end as your stoma rather than interfering with the blood supply for the distal segment. — Marc Levitt (clinical) [Ep 28 · 2:21](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=141)
- The only potential benefit of doing a divided colostomy when encountering blind-ending colon is protecting the ultimate rectal repair, but this risks the blood supply to the distal rectum. — Marc Levitt (opinion) [Ep 28 · 2:59](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=179)
- A single perineal orifice with no rectal or vaginal fistula must be called a cloaca. — Chris Westgarth-Taylor (clinical) [Ep 28 · 3:23](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=203)
- Meyer-Rokitansky-Küster-Hauser syndrome can present with anorectal malformation, creating Meyer-Rokitansky-like anatomy where ovaries and remnant tubes are present but no midline Müllerian structures. — Marc Levitt (clinical) [Ep 28 · 5:32](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=332)
- The more common scenario of anorectal malformation with absent vagina is a recto-vestibular fistula with completely normal urethra but no vagina in between—this is called recto-vestibular fistula with distal vaginal atresia, where the rectum ends as a fistula in the vestibule. — Marc Levitt (clinical) [Ep 28 · 6:37](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=397)
- In this case, the rectum ended blind and quite high in the pelvis, making it unreachable through a posterior sagittal incision. — Marc Levitt (clinical) [Ep 28 · 7:08](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=428)
- The foreshortened sacrum in this case suggests caudal regression, where everything below that level forgot to develop. — Marc Levitt (clinical) [Ep 28 · 7:18](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=438)
- In the past, vaginal replacement would have been done at the same time as rectal repair in these patients, but time and research have shown that colonic neovaginas are not great for patients 20 years down the road, and surgeons should try very hard to avoid them. — Marc Levitt (clinical) [Ep 28 · 11:04](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=664)
- In most cloacas, you should be able to get the native vagina to reach without needing vaginal replacement. — Marc Levitt (clinical) [Ep 28 · 11:35](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=695)
- Options for vaginal reconstruction when native vagina cannot reach include: dilating the existing introitus, opening the area and laying in a buccal graft, or waiting for tissue engineering options expected within 20 years or less. — Jason Frischer (clinical) [Ep 28 · 11:35](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=695)
- If a neovagina bridge is functioning well without problems, there may be no reason to remove it later. — Jason Frischer (opinion) [Ep 28 · 13:09](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=789)
- Vascular anomalies associated with anorectal malformation have not been much written about in the literature. — Marc Levitt (clinical) [Ep 28 · 14:50](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=890)
- An aberrant external iliac artery can loop up within the abdominal wall, looking very much like the obliterated umbilical artery, while actually being a blood supply to one of the extremities. — Marc Levitt (clinical) [Ep 28 · 15:11](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=911)
- Not diverting after limited posterior sagittal anorectoplasty is safe when you have a colocolonic anastomosis at the colostomy closure site and only an anoplasty with a couple of posterior sutures. — Marc Levitt (clinical) [Ep 28 · 10:12](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=612)
- The limited posterior sagittal incision was deliberately kept out of the perineal body to avoid destroying or scarring it for future incorporation of gynecologic structures after puberty. — Chris Westgarth-Taylor (clinical) [Ep 28 · 10:53](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=653)
- 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. — Christine (clinical) [Ep 22 · 0:48](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=48)
- Alberto Pena's historical protocol kept patients mandatory NPO for seven days with central line and hyperalimentation, feeding on day seven if healed. — Marc Levitt (clinical) [Ep 22 · 1:13](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=73)
- 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. — Marc Levitt (clinical) [Ep 22 · 1:13](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=73)
- The problem is not pooping itself but hard pooping that can disrupt the perineal body repair. — Marc Levitt (clinical) [Ep 22 · 1:13](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=73)
- 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. — Marc Levitt (clinical) [Ep 22 · 1:13](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=73)
- Most repairs in Phoenix are performed before children are on anything except breast milk or formula, with early repairs and early discharge home. — Christine (clinical) [Ep 22 · 4:32](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=272)
- 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. — Marc Levitt (clinical) [Ep 22 · 5:23](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=323)
- In redo cases seen by Dr. Levitt, patients were invariably fed right away and discharged home. — Marc Levitt (clinical) [Ep 22 · 5:23](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=323)
- Dr. Frisher uses a midline catheter (not PICC line) with D10 until the repair is confirmed healed, typically five to seven days NPO. — Jason Frischer (clinical) [Ep 22 · 7:17](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=437)
- 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. — Marc Levitt (clinical) [Ep 22 · 8:05](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=485)
- 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. — Marc Levitt (clinical) [Ep 22 · 9:05](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=545)
- The dilation RCT found that both dilated and non-dilated groups developed strictures somewhere between 10 and 20% of the time. — Marc Levitt (clinical) [Ep 22 · 9:05](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=545)
- 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. — Marc Levitt (clinical) [Ep 22 · 9:05](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=545)
- The dilation RCT was prompted by families identifying dilations as their biggest concern in caring for patients with anorectal malformation. — Marc Levitt (clinical) [Ep 22 · 9:05](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=545)
- 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. — Kathy (opinion) [Ep 22 · 12:06](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=726)
- 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. — Christine (clinical) [Ep 22 · 13:14](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=794)
- Jack Langer's routine is to see patients every week in clinic and pass a dilator without having families do it at home. — Marc Levitt (clinical) [Ep 22 · 13:48](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=828)
- 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. — Marc Levitt (clinical) [Ep 22 · 14:04](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=844)
- Approximately 20% of patients in the dilation study required a redo operation, either local or total, with most being local procedures. — Jason Frischer (clinical) [Ep 22 · 15:02](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=902)
- There is existing data showing that full continence can be restored with a redo operation, including for stricture as an indication. — Marc Levitt (clinical) [Ep 22 · 16:30](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=990)
- Dr. Levitt has yet to meet a family that has chosen dilation when presented with the option of non-dilation with selective intervention. — Marc Levitt (clinical) [Ep 22 · 16:30](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=990)
- Some families do choose dilation after being informed of the study results and uncertainties. — Kathy (clinical) [Ep 22 · 17:36](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=1056)
- 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. — Marc Levitt (clinical) [Ep 22 · 19:37](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=1177)
- 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. — Marc Levitt (clinical) [Ep 22 · 19:37](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=1177)
- 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. — Marc Levitt (clinical) [Ep 22 · 19:37](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=1177)
- Definitive diagnostic workup for cloaca is usually performed at about 5-6 months of age — Jason Fisher (clinical) [Ep 16 · 1:45](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=105)
- The workup includes multidisciplinary team evaluation (urology, gynecology, colorectal) followed by cystovaginoscopy and examination under anesthesia — Richard Wood (clinical) [Ep 16 · 1:56](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=116)
- Preoperative urodynamics catheter is placed in the bladder as part of the examination — Richard Wood (clinical) [Ep 16 · 2:31](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=151)
- During cystoscopy of the common channel, the easiest structure to enter is usually the vagina or vaginas; entering the urethra and bladder is challenging because it requires pointing very far up — Richard Wood (clinical) [Ep 16 · 3:08](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=188)
- During endoscopy, surgeons measure the length of the urethra, common channel, and vagina, and assess for the presence of a septum and location of the rectal fistula — Richard Wood (clinical) [Ep 16 · 3:30](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=210)
- 3D cloacogram is acquired by injecting contrast into all three structures (urethra, vagina, rectum) and using vascular C-arm software to reconstruct three-dimensional images — Richard Wood (clinical) [Ep 16 · 4:00](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=240)
- During cystoscopy it is important to look for cervices to determine if there is one or two vaginas and assess Müllerian development — Jason Fisher (clinical) [Ep 16 · 4:34](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=274)
- Surgeons should look for ureteral orifices during cystoscopy because in complex malformations there can be anomalous ureteral attachments to the bladder or bladder neck that come in very low and could be treacherous — Jason Fisher (clinical) [Ep 16 · 5:00](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=300)
- Endoscopy performed by general pediatric surgeons has value in determining whether a cloaca is straightforward or complex, helping surgeons decide whether to refer to a specialized center — Jason Fisher (opinion) [Ep 16 · 7:41](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=461)
- As recently as 10-15 years ago, there was much more redoing of cloacas required because surgeons attempted repairs without adequate evaluation and realized the cases were more complicated than imagined — Jason Fisher (clinical) [Ep 16 · 8:30](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=510)
- Lower confluence cloacas are elegant operations if the surgeon knows how to perform them, while higher confluence cases with vaginal replacements and ectopic ureters should be done at specialized centers — Jason Fisher (opinion) [Ep 16 · 9:00](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=540)
- For common channel less than 1 cm (type one cloaca), the malformation is essentially a hypospadiac urethra with a rectovaginal fistula — Richard Wood (clinical) [Ep 16 · 10:07](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=607)
- In type one cloaca (common channel <1 cm), the hypospadiac urethral orifice is not touched, and the plan is vaginoplasty, introitoplasty, and PSARP — Richard Wood (clinical) [Ep 16 · 10:40](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=640)
- Even in type one cloaca with short common channel, the true rectum can still be high, so knowing rectal height is important — Richard Wood (clinical) [Ep 16 · 11:10](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=670)
- A normal urethra should be at least 1.5 cm in length — Richard Wood (clinical) [Ep 16 · 11:30](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=690)
- For common channel 1-3 cm with urethral length >1.5 cm, the patient is amenable to total urogenital mobilization (TUM) and PSARP — Richard Wood (clinical) [Ep 16 · 11:40](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=700)
- For common channel >3 cm, patients often have urethral length <1.5 cm, and urogenital separation with repair of the common channel as the urethra is advocated — Richard Wood (clinical) [Ep 16 · 12:46](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=766)
- If the rectum is high, surgeons may want to consider an abdominal approach to mobilize first, changing the PSARP approach to LARP (laparoscopic-assisted PSARP) — Richard Wood (clinical) [Ep 16 · 13:32](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=812)
- Hardy Hendren was the father of cloacal management in the late 1960s and 70s with specific focus on urology and urethral reconstruction — Marc Levitt (clinical) [Ep 16 · 14:04](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=844)
- Alberto Pena made a major advance in cloacal care in 1996 with development of total urogenital mobilization (TUM), which kept the urethra and vagina together as a unit for mobilization — Marc Levitt (clinical) [Ep 16 · 14:30](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=870)
- Prior to 1996, all cloaca patients had urogenital separation — Marc Levitt (clinical) [Ep 16 · 14:50](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=890)
- The next major change in cloaca protocol after TUM came 21 years later in 2017 with the algorithmic approach incorporating urethral length measurement — Marc Levitt (clinical) [Ep 16 · 15:14](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=914)
- Hardy Hendren at age 91 attended the 2017 APSA presentation of the new algorithm and stated he agreed with everything presented — Marc Levitt (clinical) [Ep 16 · 16:10](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=970)
- The 2017 algorithm is the first time cloacal management has been reproducible — Marc Levitt (opinion) [Ep 16 · 16:50](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1010)
- Following the algorithm, 116 consecutive patients have been managed without needing to change the surgical plan — Richard Wood (clinical) [Ep 16 · 17:36](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1056)
- The major change in the 2017 algorithm was ensuring measurement of urethral length, whereas previously only common channel length (<3 cm or >3 cm) was considered — Marc Levitt (clinical) [Ep 16 · 18:13](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1093)
- Urethral length is defined as the distance from where the common channel splits (where urethra leaves the common channel) to where it enters the bladder, not from the single orifice to the bladder neck — Richard Wood (clinical) [Ep 16 · 19:09](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1149)
- Measuring urethral length accurately with cystoscopy is difficult because of the curve behind the pubis, which can lead to significant under- and over-reading — Richard Wood (clinical) [Ep 16 · 19:40](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1180)
- The goal is to position the bladder neck above the urogenital diaphragm where the external sphincter complex lies, so that intra-abdominal pressure does not compromise continence — Richard Wood (clinical) [Ep 16 · 20:10](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1210)
- The most accurate urethral measurement comes from 3D imaging rather than cystoscopy because imaging does not straighten the structures and falsely measure them — Richard Wood (clinical) [Ep 16 · 20:20](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1220)
- The original malformation in case 1 was a prostatic fistula and the patient has a tethered cord with a sacral ratio of 0.66 — Marc Levitt (clinical) [Ep 19 · 3:21](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=201)
- The higher the malformation, the worse the prognosis for bowel control — Marc Levitt (clinical) [Ep 19 · 5:31](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=331)
- Sacral ratio 0.7 or greater usually means normal sphincters and good muscle tone — Marc Levitt (clinical) [Ep 19 · 5:31](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=331)
- Patients with myelomeningocele have much more trouble with continence than those with tethered cord — Marc Levitt (clinical) [Ep 19 · 5:31](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=331)
- A key pitfall is opening the PSARP incision first; instead, mark the sphincters first with electrical stimulation, then open the PSARP — Marc Levitt (clinical) [Ep 19 · 7:29](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=449)
- The electrical stimulator used for sphincter mapping is the same one anesthesia uses for train of four — Marc Levitt (clinical) [Ep 19 · 9:29](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=569)
- Anesthesiologists should not give skeletal muscle relaxant when using the stimulator because it is weaker than traditional stimulators — Marc Levitt (clinical) [Ep 19 · 9:29](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=569)
- In higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated — Jason Frischer (clinical) [Ep 19 · 10:19](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=619)
- If anatomy is off, redo should be done, and there is an advantage to getting anatomy right when the child is younger — Marc Levitt (opinion) [Ep 19 · 13:28](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=808)
- For a two-year-old with mislocated anus or bad prolapse, offer redo and let them live in diapers for a year or two with better anatomy before potty training — Marc Levitt (opinion) [Ep 19 · 13:28](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=808)
- For patients presenting after potty training age with incontinence due to mislocated anus, do the redo and usually add a Malone at the same time — Marc Levitt (opinion) [Ep 19 · 13:28](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=808)
- After redo with Malone, patients learn to get control with new anatomy before stopping Malone flushes and trying voluntary bowel movements; this process may take six to twelve months — Marc Levitt (clinical) [Ep 19 · 13:28](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=808)
- For a patient with anus 50% within sphincter complex at age three and a half with incontinence, one approach is to redo and add Malone, get them clean mechanically, then see if they develop bowel control — Marc Levitt (opinion) [Ep 19 · 14:48](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=888)
- Alternative approach for borderline anatomy: let the child try their current anatomy first; if it works well, stay with it; if not, consider redo — Jason Frischer (opinion) [Ep 19 · 15:20](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=920)
- If patients haven't declared continence yet because they're not old enough behaviorally, give them a chance as they may succeed with current anatomy — Marc Levitt (opinion) [Ep 19 · 15:45](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=945)
- A single perineal orifice in a newborn indicates cloaca, where the vagina, urethra, and rectum are fused together inside creating a single common channel. — Richard Wood (clinical) [Ep 17 · 2:05](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=125)
- Hydrocolpos is the distension of the vagina caused by accumulation of fluid. — Richard Wood (clinical) [Ep 17 · 2:25](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=145)
- Cloaca or anorectal malformation is associated with VACTERL and needs to be worked up as such. — Richard Wood (guideline) [Ep 17 · 2:45](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=165)
- VACTERL association requires three or more anomalies: vertebral, imperforate anus, cardiovascular, tracheoesophageal fistula, esophageal atresia, renal/radial, and limb defects. — Amanda Jensen (clinical) [Ep 17 · 3:10](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=190)
- The diagnostic yield for cloaca on prenatal ultrasound is still much lower than desired. — Richard Wood (epidemiological) [Ep 17 · 3:44](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=224)
- Hydrocolpos on prenatal ultrasound should alert to the possibility of cloaca. — Richard Wood (clinical) [Ep 17 · 4:00](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=240)
- Prenatal findings suggestive of cloaca include abnormal kidneys, single kidney, and two-vessel cord association. — Richard Wood (clinical) [Ep 17 · 4:12](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=252)
- A smart perinatologist seeing a female fetus with pelvic mass and kidney abnormalities should consider cloaca diagnosis, which influences delivery location. — Marc Levitt (opinion) [Ep 17 · 4:43](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=283)
- Neonatologists might incorrectly conclude cloaca is ambiguous genitalia and do unnecessary endocrine workup. — Marc Levitt (clinical) [Ep 17 · 5:57](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=357)
- Good physical exam with good lighting is the first step in evaluating suspected cloaca. — Richard Wood (clinical) [Ep 17 · 6:19](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=379)
- On exam, distracting the labia reveals more of a clitoral hood than real labia minora, with a single perineal orifice posterior to the clitoral hood. — Richard Wood (clinical) [Ep 17 · 6:28](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=388)
- A perineal groove behind the labia structures and dimpling representing muscle complex suggests the perineum is not completely flat. — Richard Wood (clinical) [Ep 17 · 6:40](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=400)
- Children with cloacal malformation who do not have an anus do not need investigation for ambiguous genitalia or disorders of sexual differentiation because they are known to be female. — Richard Wood (guideline) [Ep 17 · 7:20](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=440)
- Initial urgent management priorities are ensuring kidney decompression/urine drainage, diagnosing hydrocolpos, and confirming safety for OR (ruling out TEF and cardiac issues). — Richard Wood (guideline) [Ep 17 · 7:56](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=476)
- Initial workup should consist of NG tube and chest x-ray, cardiac echo, and pelvic and renal ultrasound to assess for TEF, cardiac anomalies, hydrocolpos, and hydronephrosis. — Richard Wood (guideline) [Ep 17 · 8:30](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=510)
- Bilateral hydronephrosis with hydrocolpos requires management of the hydrocolpos as part of initial treatment. — Richard Wood (clinical) [Ep 17 · 8:50](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=530)
- The modern approach has moved heavily away from vaginostomy toward clean intermittent catheterization through the common channel for hydrocolpos drainage. — Richard Wood (guideline) [Ep 17 · 9:11](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=551)
- To perform CIC for hydrocolpos, pass a tube through the common channel, drain fluid, get ultrasound to confirm the tube is in the hydrocolpos/vagina, confirm decompression, then continue recurrently. — Richard Wood (clinical) [Ep 17 · 9:24](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=564)
- If CIC effectively drains the hydrocolpos, proceed with colostomy only and continue drainage postoperatively; if unsuccessful, can return to formal vaginostomy. — Richard Wood (guideline) [Ep 17 · 9:55](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=595)
- Seattle Children's (Paul McGarrian, Jeff Evan Sino, Caitlin Smith) demonstrated that many hydrocolpi can be drained perineally, changing the previous dogma of routine vaginostomy. — Marc Levitt (clinical) [Ep 17 · 10:06](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=606)
- When catheterizing for hydrocolpos drainage, you are more likely to get into the vagina than the bladder due to the anatomy of the urethral takeoff to the bladder neck. — Marc Levitt (clinical) [Ep 17 · 10:40](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=640)
- The modern hydrocolpos drainage approach is published in a Seminars in Pediatric Surgery article but not yet in textbooks. — Marc Levitt (clinical) [Ep 17 · 11:45](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=705)
- To confirm proper catheter placement, pass the tube, leave it in, get bedside ultrasound within first 24 hours to confirm it's in the hydrocolpos and decompressing it. — Richard Wood (guideline) [Ep 17 · 12:33](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=753)
- During ultrasound-guided drainage, when you drain the hydrocolpos, the bladder immediately fills, demonstrating the physiology where hydrocolpos obstructs the ureters. — Marc Levitt (clinical) [Ep 17 · 13:11](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=791)
- A vesicostomy is the wrong move in almost every cloaca; the hydrocolpos needs to be drained instead. — Marc Levitt (opinion) [Ep 17 · 13:40](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=820)
- Once hydrocolpos is drained, ureters are no longer compressed at the trigone and can empty into the bladder, which then empties out the common channel or back into hydrocolpos for sequential drainage. — Marc Levitt (clinical) [Ep 17 · 13:59](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=839)
- Catheterization frequency is typically three times daily initially, then twice daily when family takes over, with serial ultrasounds every 2-3 days initially, then weekly, then monthly after discharge. — Richard Wood (guideline) [Ep 17 · 15:01](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=901)
- The most important measure of successful hydrocolpos drainage is kidney decompression, not the hydrocolpos itself; if kidneys are completely normal, the hydrocolpos doesn't matter. — Richard Wood (clinical) [Ep 17 · 15:01](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=901)
- Even with vaginostomy tubes, you must continue checking that kidneys remain decompressed; don't assume the tube is doing its job without verification. — Richard Wood (guideline) [Ep 17 · 16:20](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=980)
- Newborn management bullet points: good exam with good light to diagnose, no endocrine workup for cloaca, renal/pelvic ultrasound plus tests for anesthesia safety, drain hydrocolpos by CIC, and colostomy within 24-48 hours. — Richard Wood (guideline) [Ep 17 · 17:02](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1022)
- Colostomy should be done as proximally as possible (descending-sigmoid junction) to ensure enough length for distal work, rather than lower sigmoid. — Richard Wood (guideline) [Ep 17 · 17:53](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1073)
- Laparoscopy for newborn colostomy in non-distended patients provides good pelvic anatomy visualization, allows precise colostomy site selection, and avoids wound between stomas. — Richard Wood (clinical) [Ep 17 · 18:42](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1122)
- Laparoscopic technique: mobilize lateral attachments of descending colon, bring bowel up through mucous fistula site, staple it, wash out distal limb completely, then make separate incision for proximal stoma with no surrounding incision for clean skin and easy bagging. — Richard Wood (clinical) [Ep 17 · 19:25](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1165)
- For vaginostomy in patients with vaginal septum, open the anterior wall of the hydrocolpos vagina and remove a small portion of septum to drain both sides through one hole. — Richard Wood (clinical) [Ep 17 · 20:15](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1215)
- Vaginostomy can be done with or without tubes; tubes can become encrusted and colonized, so tubeless has some advantage if anatomy allows easy reach to abdominal wall. — Richard Wood (opinion) [Ep 17 · 20:45](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1245)
- For massive hydrocolpos requiring open approach, use lower midline incision to get above the hydrocolpos, which is very adherent to anterior abdominal wall and inflamed; standard left lower quadrant incision will cause trouble. — Marc Levitt (clinical) [Ep 17 · 21:37](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1297)
- For large hydrocolpos via midline: open into dome, remove bit of septum, close it, put in tube to drain both sides, or suture to abdominal wall like vesicostomy/gastrostomy to avoid indwelling tube as nidus for infection. — Marc Levitt (clinical) [Ep 17 · 22:20](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1340)
- Critical distinction: single perineal orifice with no anal opening is cloaca (female, no endocrine workup); completely normal anus with perineal orifice is urogenital sinus (needs endocrine workup for CAH, electrolyte check). — Marc Levitt (clinical) [Ep 17 · 22:51](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1371)
- Urogenital sinus patients can also have hydrocolpos and hydronephrosis with similar management, but no colostomy needed since they have an anus. — Marc Levitt (clinical) [Ep 17 · 23:55](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1435)
- Post-discharge follow-up focuses on ensuring kidneys are well decompressed, patient is growing well, following kidney function tests, and ensuring parents manage stoma effectively. — Richard Wood (guideline) [Ep 17 · 24:36](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1476)
- With effective urine and stool drainage, patients should be thriving unless other underlying issues exist. — Richard Wood (clinical) [Ep 17 · 25:20](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1520)
- VACTERL workup for anorectal malformations includes: V (vertebral abnormalities via plain x-ray), A (anorectal malformations), C (cardiac abnormalities via exam and echo), E (esophageal atresia via NG tube passage), R (renal abnormalities via kidney ultrasound), and L (limb abnormalities via physical exam) — Marc Levitt (guideline) [Ep 29 · 3:01](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=181)
- Sacral ratio should be measured at three months of age for true measurement, though early measurement gives a feel for how normally the pelvis has developed — Marc Levitt (clinical) [Ep 29 · 3:01](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=181)
- Pre-sacral masses are rare in typical imperforate anus but occur in almost half of anal stenosis or rectal atresia cases, requiring MRI — Jason Frischer (epidemiological) [Ep 29 · 4:15](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=255)
- Cross-table lateral x-ray should be obtained at approximately 24 hours of life to assess gas column height and guide surgical planning — Jason Frischer (guideline) [Ep 29 · 5:05](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=305)
- Sacral ratio greater than 0.7 connotes very good prognosis for bowel control and provides peace of mind for families regarding potty training at age four — Marc Levitt (clinical) [Ep 29 · 7:08](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=428)
- Well-formed buttocks, good muscle, true sphincter mechanism area, and well-developed sacrum together indicate likely good prognosis — Jason Frischer (clinical) [Ep 29 · 7:36](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=456)
- With air column 8.8mm from skin, primary posterior sagittal anorectoplasty is a reasonable option based on imaging — Jason Frischer (opinion) [Ep 29 · 8:25](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=505)
- The key to deciding whether to approach perineally via posterior sagittal is knowing where the rectum is—must be confident the first structure encountered will be rectum, not urethra, bladder neck, or bladder — Marc Levitt (clinical) [Ep 29 · 9:11](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=551)
- Colostomies are done to know exactly where the rectum is via distal colostogram and to determine whether to approach perineally or laparoscopically — Marc Levitt (clinical) [Ep 29 · 9:11](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=551)
- Should never try to go in blind—must know what structure will be encountered before making posterior sagittal incision — Jason Frischer (guideline) [Ep 29 · 9:57](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=597)
- Colostomy is the safe choice and was the right decision in this case, though it carries its own complications including those from colostomy closure — Marc Levitt (opinion) [Ep 29 · 10:16](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=616)
- The anal repair is made safer by having a colostomy, though everything in medicine is a balance — Marc Levitt (opinion) [Ep 29 · 10:16](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=616)
- Very good surgeons have done beautiful anoplasties but ignored fistulas, resulting in children urinating out their anus postoperatively — Marc Levitt (clinical) [Ep 29 · 10:54](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=654)
- During primary posterior sagittal approach, open the posterior wall of rectum and inspect the anterior wall to rule out fistula — Marc Levitt (clinical) [Ep 29 · 12:00](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=720)
- Bulbar fistula nomenclature refers to anatomic location at the elbow of the urethra — Jason Frischer (clinical) [Ep 29 · 12:34](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=754)
- Fistula can be very close to rectum, making proper plane dissection along urethra important — Jason Frischer (clinical) [Ep 29 · 12:34](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=754)
- 95% of Down syndrome patients with imperforate anus have no fistula, but 5% do have a fistula — Marc Levitt (epidemiological) [Ep 29 · 13:15](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=795)
- Distal colostogram should still be performed in Down syndrome patients with imperforate anus despite 95% having no fistula — Marc Levitt (guideline) [Ep 29 · 13:15](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=795)
- Prenatal imaging clues for cloacal exstrophy include small bladder and sacral dysgenesis on ultrasound and MRI. — Payam Saadai (clinical) [Ep 11 · 1:10](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=70)
- Cloacal exstrophy is the most complicated condition managed in the colorectal world and requires collaboration with urology and gynecology. — Marc Levitt (opinion) [Ep 11 · 1:52](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=112)
- Patients with cloacal exstrophy almost always need a neurosurgeon in addition to colorectal surgery, urology, gynecology, and orthopedics. — Marc Levitt (clinical) [Ep 11 · 2:52](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=172)
- Like any anorectal malformation, cloacal exstrophy is not an emergency; surgeons have 24 to 48 hours to complete workup and decide on operative plan. — Payam Saadai (clinical) [Ep 11 · 4:24](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=264)
- Preoperative workup for cloacal exstrophy includes echocardiogram to rule out congenital cardiac anomalies, spinal ultrasound, and abdominal ultrasound to assess kidneys. — Payam Saadai (clinical) [Ep 11 · 4:42](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=282)
- Stool can often be seen coming out from the fecal plate or ileum in cloacal exstrophy, so there is not always a component of obstruction or dilated bowel loops. — Payam Saadai (clinical) [Ep 11 · 5:12](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=312)
- NICU management priorities for cloacal exstrophy include preventing fluid losses and dehydration by using plastic covering (such as saran wrap) over the hemi-bladders and exposed tissues. — Payam Saadai (clinical) [Ep 11 · 5:36](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=336)
- Antibiotics are not indicated for cloacal exstrophy unless there is a maternal-neonatal indication. — Payam Saadai (clinical) [Ep 11 · 6:03](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=363)
- The best time to bring the pelvis together in cloacal exstrophy is within the first 2 to 3 days because there is enough maternal relaxin on board. — Payam Saadai (clinical) [Ep 11 · 6:50](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=410)
- Two major surgical decision points in cloacal exstrophy are: (1) whether the omphalocele is large or small enough to close the abdominal wall, and (2) the staging of the exstrophy procedure—whether to just bring bladder plates together in a multi-stage approach or to close the bladder and bring the symphysis pubis together. — Jason Frischer (clinical) [Ep 11 · 7:05](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=425)
- Placing catheters into every orifice helps delineate the anatomy intraoperatively in cloacal exstrophy. — Payam Saadai (clinical) [Ep 11 · 7:43](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=463)
- The fecal plate in cloacal exstrophy contains more colon downstream from the cecum; it is not the end of the bowel. — Marc Levitt (clinical) [Ep 11 · 8:57](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=537)
- Performing an ileostomy and leaving behind a blind-ending fecal plate and hindgut creates a situation similar to a colonic atresia in the deep pelvis, which is a surgical error. — Marc Levitt (clinical) [Ep 11 · 9:21](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=561)
- The traditional approach to cloacal exstrophy is to extract the fecal plate from within the two hemi-bladders, tubularize it, and bring out the end of the hindgut as an end colostomy. — Marc Levitt (clinical) [Ep 11 · 10:28](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=628)
- The overriding principle in cloacal exstrophy management is bowel preservation, as small intestine can be shortened and some patients have long-term nutritional concerns. — Jason Frischer (clinical) [Ep 11 · 10:46](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=646)
- The traditional reason for separating the fecal plate from hemi-bladders was to avoid absorption of urine into the fecal plate and resulting acidosis. — Marc Levitt (clinical) [Ep 11 · 11:49](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=709)
- Patients with colonic mucosa absorbing urine (e.g., bladder augmentation situations) often do not develop acidosis, making this concern less relevant. — Marc Levitt (clinical) [Ep 11 · 12:11](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=731)
- Tubularized fecal plate can be a boggy, fairly useless piece of bowel where stool sits before emptying through the hindgut, and can contribute to recurrent bacteremia. — Marc Levitt (clinical) [Ep 11 · 12:21](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=741)
- A newer approach leaves the fecal plate between the hemi-bladders as an auto-augmentation for the bladder, connects the distal ileum to the hindgut as a primary anastomosis, and either creates an end stoma or performs an early pull-through to the anus with ileostomy diversion. — Marc Levitt (clinical) [Ep 11 · 13:13](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=793)
- When separating the ileum from the fecal plate to perform ileal-hindgut anastomosis, the hole in the fecal plate is oversewn. — Marc Levitt (clinical) [Ep 11 · 14:08](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=848)
- One reason for not performing early pull-through in cloacal exstrophy is concern about rash and managing a perineal stoma. — Jason Frischer (clinical) [Ep 11 · 14:42](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=882)
- The decision to perform early pull-through should be based on the amount of hindgut present; patients with enough hindgut (e.g., entire right colon) can develop thick enough stool for pull-through. — Marc Levitt (clinical) [Ep 11 · 15:18](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=918)
- If a patient cannot develop thickened stool, they should never have a pull-through. — Marc Levitt (clinical) [Ep 11 · 15:27](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=927)
- The mesentery in cloacal exstrophy can be confusing and problematic; mobilizing the hindgut up and out of the pelvis risks losing the hindgut, which would result in a permanent ileostomy. — Marc Levitt (clinical) [Ep 11 · 15:50](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=950)
- If the hindgut can be mobilized easily without compromising the mesentery, an end stoma in the right or left lower quadrant is the preferred approach. — Marc Levitt (clinical) [Ep 11 · 16:17](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=977)
- In the presented case, posterior and anterior osteotomies were performed to bring the pubic symphysis together, which influenced the decision to proceed with abdominal closure. — Payam Saadai (clinical) [Ep 11 · 17:10](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1030)
- Performing the hindgut pull-through to the anus in the newborn period avoids having to re-enter the pelvis later in life, which is a difficult surgical experience. — Payam Saadai (opinion) [Ep 11 · 17:31](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1051)
- When performing a pull-through with proximal diversion, a loop ileostomy can be created to allow some passage across and refeeding of the distal segment. — Marc Levitt (clinical) [Ep 11 · 17:58](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1078)
- A purse-string closure of the distal segment can be used temporarily and removed in the future when everything has healed. — Marc Levitt (clinical) [Ep 11 · 18:27](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1107)
- Refeeding the distal segment helps the skin tolerate stool until the ileostomy can be closed. — Marc Levitt (clinical) [Ep 11 · 18:36](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1116)
- It is important that urology does not manage the bladder independent of the decision to pull through the colon; sequential procedures (bladder augmentation, Mitrofanoff, bladder neck closure at age 5 without considering colonic pull-through) make future reconstruction very difficult. — Marc Levitt (clinical) [Ep 11 · 19:40](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1180)
- Leaving the cecal plate on the bladder makes later Mitrofanoff creation easier because the appendix is already connected and easy to bring up. — Payam Saadai (clinical) [Ep 11 · 20:59](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1259)
- Spending extra time in the newborn period to reconstruct the hindgut and vagina can save significant work later, especially in patients whose anatomy allows for comprehensive reconstruction. — Payam Saadai (opinion) [Ep 11 · 20:37](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-33-cloaca-exstrophy-13819?t=1237)
- Hypospadias prenatal diagnosis has become part of routine prenatal care, whereas up to 5-7 years ago pediatric surgeons were never called for such counseling. — Paola Midrio (epidemiological) [Ep 6 · 1:32](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=92)
- The combination of urologic defects (bladder atrophy, penoscrotal transposition, severe hypospadias) and anatomic changes in the pelvic region is commonly associated with perineal fistula. — Marc Levitt (clinical) [Ep 6 · 3:53](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=233)
- In a newborn with severe hypospadias, penoscrotal transposition, and unclear connection between rectum and urinary tract, diverting colostomy is appropriate rather than primary repair. — Paola Midrio (clinical) [Ep 6 · 4:44](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=284)
- Performing colostomy in the newborn period makes the subsequent rectal dissection easier. — Marc Levitt (clinical) [Ep 6 · 5:19](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=319)
- Laparoscopic colostomy with three trocars allows precise selection of sigmoid location, external meconium evacuation, and creation of two separate stomas with no skin opening between them, which facilitates ostomy bag attachment. — Paola Midrio (clinical) [Ep 6 · 6:10](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=370)
- Irrigating the distal colostomy segment by passing a large Foley catheter under laparoscopic visualization allows confirmation of meconium removal and distal segment decompression. — Marc Levitt (clinical) [Ep 6 · 6:51](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=411)
- In this case, colostogram showed 2.5 cm distance from the perineal fistula to the bulging rectal lumen and urethral length of almost 3 cm. — Paola Midrio (clinical) [Ep 6 · 7:38](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=458)
- A healthy, normally developed sacrum is not surprising in a patient with a perineal fistula, given that the rectum is so low. — Marc Levitt (clinical) [Ep 6 · 8:42](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=522)
- For urologists, 5 months of age is quite early for hypospadias repair; they would ideally perform two-stage reconstruction closer to 1 year of age. — Paola Midrio (clinical) [Ep 6 · 9:37](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=577)
- In most male perineal fistulas, the fistula is within the anteriormost portion of the sphincteric ellipse, allowing posterior rectal wall mobilization only with no anterior dissection and no possibility of urethral injury. — Marc Levitt (clinical) [Ep 6 · 10:08](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=608)
- The perineal fistula opening can be located anywhere along the anterior midline raphe from within the sphincter ellipse all the way to the base of the scrotum, center of the scrotum, or even higher at the exit of the hypospadias. — Marc Levitt (clinical) [Ep 6 · 10:30](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=630)
- In this case with a 3 cm long, 1 mm diameter fistula, the surgical approach is to leave the fistula undissected close to the urethra and work on the bulging rectal lumen without starting from the perineal fistula, because there is basically no wall between the urethra, the spongiosis, and the fistula. — Paola Midrio (clinical) [Ep 6 · 10:46](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=646)
- The surgical goal is to achieve enough rectal mobilization that the anastomosis is not under tension, but less dissection is better because significant damage can occur with anterior dissection. — Jason Fisher (clinical) [Ep 6 · 11:31](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=691)
- In perineal fistulas with long anterior tracts, the repair is essentially a glorified cutback with no need to dissect the anterior rectal wall at all; only posterior rectal wall mobilization is needed to fill the space. — Marc Levitt (clinical) [Ep 6 · 11:44](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=704)
- The surgical approach is to mobilize the lip of anterior rectal wall and leave the fistula floating as it attaches adjacent to the urethra, to be addressed later by the urologist during urethral dissection. — Marc Levitt (clinical) [Ep 6 · 12:10](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=730)
- The fistula tissue is mucosally lined and might potentially be used by urologists for hypospadias repair. — Jason Fisher (opinion) [Ep 6 · 12:28](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=748)
- The anterior rectal wall must be adequately dissected so it is completely separated, creating a healthy anterior edge of the anoplasty with no tension so it does not pull back or retract. — Marc Levitt (clinical) [Ep 6 · 12:50](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=770)
- In a typical newborn perineal fistula, if you can avoid a posterior sagittal incision, the rectum is usually right below the surface, and by the end of the case you can have no incision anterior or posterior to the anoplasty. — Marc Levitt (clinical) [Ep 6 · 13:07](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=787)
- This case will need a posterior sagittal incision, probably fairly close to the level of the coccyx, to achieve full rectal mobilization. — Marc Levitt (clinical) [Ep 6 · 13:44](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=824)
- The same approach of leaving a long narrow fistula undissected applies to perineal fistulas without hypospadias when the meconium opening is at the base or middle of the scrotum; there is no need to chase the fistula, it will disappear. — Marc Levitt (clinical) [Ep 6 · 14:21](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=861)
- Pathologists will report 'no ganglia' on transitional tissue from perineal fistulas, which can cause panic and lead to a confusing diagnostic pathway ending in wrong decisions, especially in bulbar perineal fistula patients who are often constipated. — Paola Midrio (clinical) [Ep 6 · 15:11](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=911)
- The planned timeline is to perform at least the first-stage hypospadias repair (the most complicated step) with the colostomy still in place between 6 to 9 months of age, then close the colostomy, with final urologic repair 6 months after colostomy closure. — Paola Midrio (clinical) [Ep 6 · 15:53](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=953)
- VACTERL workup for anorectal malformation includes vertebral abnormalities (plain X-ray), cardiac defects (exam and echo), esophageal atresia (NG tube passage), renal abnormalities (kidney ultrasound), and limb abnormalities (physical exam). — Marc Levitt (guideline) [Ep 27 · 3:01](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=181)
- Spinal ultrasound should include evaluation of the presacral space to look for presacral masses. — Marc Levitt (clinical) [Ep 27 · 4:22](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=262)
- In anal stenosis or rectal atresia defects, presacral masses are found almost half the time, and those patients require MRI. — Marc Levitt (epidemiological) [Ep 27 · 4:33](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=273)
- Cross-table lateral X-ray should be obtained at approximately 24 hours of life to assess the air column position relative to the perineal skin. — Jason Frischer (clinical) [Ep 27 · 5:08](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=308)
- Cross-table lateral is performed with the baby prone, positioning the buttock at the highest point where air will rise. — Jason Frischer (clinical) [Ep 27 · 6:10](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=370)
- Cross-table lateral can be obtained at bedside in the neonatal unit by placing the baby on a bump under the buttocks. — Marc Levitt (clinical) [Ep 27 · 6:20](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=380)
- A marker should be placed where the anus is thought to be appropriate on the cross-table lateral to allow measurements and inform operative approach. — Jason Frischer (clinical) [Ep 27 · 6:29](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=389)
- True sacral ratio measurements should wait until the child is 3 months of age, though early imaging gives a sense of pelvic development. — Marc Levitt (clinical) [Ep 27 · 3:55](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=235)
- A sacral ratio greater than 0.7 connotes very good prognosis for bowel control. — Marc Levitt (clinical) [Ep 27 · 7:20](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=440)
- Well-formed buttocks, visible sphincter mechanism location, and well-developed sacrum together indicate likely good prognosis for continence. — Jason Frischer (clinical) [Ep 27 · 7:46](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=466)
- The key to deciding whether to perform posterior sagittal anorectoplasty is knowing where the rectum is located. — Marc Levitt (clinical) [Ep 27 · 9:06](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=546)
- The danger of blind posterior sagittal approach is finding a midline white structure like the urethra, bladder neck, or bladder itself instead of the rectum. — Marc Levitt (clinical) [Ep 27 · 9:25](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=565)
- Colostomies and distal colostograms are performed to know exactly where the rectum is and whether to approach it perineally or laparoscopically. — Marc Levitt (clinical) [Ep 27 · 9:42](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=582)
- Colostomy is the safe choice for anorectal malformation repair, though it carries risks of complications from both the colostomy creation and the subsequent closure. — Marc Levitt (clinical) [Ep 27 · 10:24](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=624)
- If primary anorectoplasty is performed without recognizing a fistula, the child may later urinate through the anus. — Marc Levitt (clinical) [Ep 27 · 11:20](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=680)
- During primary posterior sagittal repair, the posterior wall of the rectum should be opened and the anterior wall inspected to rule out fistula. — Marc Levitt (clinical) [Ep 27 · 12:09](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=729)
- A bulbar fistula is located at the elbow of the urethra, using anatomic nomenclature. — Jason Frischer (clinical) [Ep 27 · 13:00](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=780)
- When a fistula is very close to the rectum, it is important to identify the proper dissection plane between the two structures. — Jason Frischer (clinical) [Ep 27 · 12:34](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=754)
- 95% of patients with Down syndrome and imperforate anus have no fistula, but 5% do have a fistula. — Marc Levitt (epidemiological) [Ep 27 · 13:48](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=828)
- Distal colostogram should still be performed in Down syndrome patients with imperforate anus because some may have a fistula despite the lower prevalence. — Marc Levitt (clinical) [Ep 27 · 13:44](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=824)
- The multidisciplinary approach with multiple disciplines represented to help complicated ARM patients was conceived during Levitt's medical school elective with Alberto Pena. — Marc Levitt (opinion) [Ep 34 · 3:58](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=238)
- The first ever colorectal center was launched in Cincinnati in 2005 by Levitt and Pena. — Marc Levitt (clinical) [Ep 34 · 4:48](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=288)
- Training surgeons in ARM specialty provides greater impact than individual patient care because trained surgeons help hundreds or thousands more patients. — Marc Levitt (opinion) [Ep 34 · 6:50](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=410)
- The bowel management program with focused nursing attention for 4-5 days plus long-term follow-up is a major advance in ARM care. — Marc Levitt (clinical) [Ep 34 · 8:40](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=520)
- Integration of urology and bladder management has revolutionized ARM care, with kidney transplant now exceedingly rare compared to previously being not uncommon. — Marc Levitt (clinical) [Ep 34 · 9:12](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=552)
- Better urologic care has dramatically reduced renal disease in ARM patients. — Marc Levitt (clinical) [Ep 34 · 9:31](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=571)
- The standard PSARP incision has gotten smaller and understanding of anatomy has improved since 2005. — Marc Levitt (clinical) [Ep 34 · 10:14](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=614)
- Laparoscopy has been added to many kinds of ARM cases as a technical innovation. — Marc Levitt (clinical) [Ep 34 · 10:29](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=629)
- Transition programs for ARM patients moving to adult care are the most behind aspect of the field compared to other areas like congenital heart disease and cystic fibrosis. — Marc Levitt (opinion) [Ep 34 · 11:06](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=666)
- There are only 3 surgeons in the entire world trained in both pediatric and adult colorectal surgery: Ali Gisher in Columbus Ohio, Erin Teeple in Wilmington Delaware, and a surgeon named Mark in Munich Germany. — Marc Levitt (clinical) [Ep 34 · 12:12](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=732)
- Paris at Necker Children's Hospital has done an amazing job with formal transition to adult programs, with teenagers meeting pediatric and adult providers together before transitioning to adult facility visits. — Marc Levitt (clinical) [Ep 34 · 13:16](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=796)
- No parent has ever known anything about ARM when their baby is born, creating shock when a colorectal problem is announced. — Marc Levitt (opinion) [Ep 34 · 15:51](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=951)
- ARM surgery typically requires 3 surgeries within the first year of life: colostomy, reconstructive operation, and colostomy closure. — Marc Levitt (clinical) [Ep 34 · 16:41](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1001)
- ARM surgery requires months to years of tinkering and may require lifelong adjustments, unlike typical surgery where the problem is immediately solved. — Marc Levitt (opinion) [Ep 34 · 17:57](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1077)
- Parents care more about functional results than anatomic reconstruction, but surgeons are often very proud of their anatomic creations. — Marc Levitt (opinion) [Ep 34 · 18:20](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1100)
- A complex colorectal operation takes about 4 hours, but delivering a good result requires 96 more hours of tinkering, almost all of which is nursing care. — Marc Levitt (opinion) [Ep 34 · 19:27](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1167)
- If a proper colostomy is made, most families would agree they'd rather change a colostomy bag than a diaper. — Marc Levitt (opinion) [Ep 34 · 20:01](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1201)
- If the anus is misaligned with sphincters due to surgical error, the problem won't be discovered until potty training fails 4 years later, making it difficult for surgeons to improve their technique. — Marc Levitt (clinical) [Ep 34 · 20:44](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1244)
- Studies have shown cardiac surgery in adults gets better results with higher surgical volume. — Marc Levitt (epidemiological) [Ep 34 · 22:20](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1340)
- In typical US pediatric surgery training, fellows do approximately 12 ARM cases over 2 years of training. — Marc Levitt (epidemiological) [Ep 34 · 22:30](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1350)
- The average finished pediatric surgeon performs 1 ARM case per year. — Marc Levitt (epidemiological) [Ep 34 · 22:57](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1377)
- Levitt advocates strongly for pull-through surgery and colostomy closure rather than permanent colostomy, stating he wants every kid to be typical and normal without a colostomy. — Marc Levitt (opinion) [Ep 34 · 24:25](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1465)
- With proper bowel management and good nursing care, Levitt is very confident patients can be gotten clean mechanically. — Marc Levitt (opinion) [Ep 34 · 24:40](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1480)
- The Malone appendicostomy is an advance that allows patients without innate anatomy or sphincters to be cleaned mechanically by emptying the colon once daily. — Marc Levitt (clinical) [Ep 34 · 24:56](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1496)
- Most patients would prefer being cleaned through the Malone route than having a permanent stoma. — Marc Levitt (opinion) [Ep 34 · 25:20](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1520)
- Permanent colostomy may be more practical for rare patients who don't ambulate. — Marc Levitt (clinical) [Ep 34 · 25:29](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1529)
- The vast majority of ARM patients can be perfectly clean with stool flowing through the normal anal route via bowel management. — Marc Levitt (clinical) [Ep 34 · 25:31](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1531)
- Many patients actually develop bowel control even if predicted they would never achieve it, with proper nursing care and medical regimen tinkering. — Marc Levitt (clinical) [Ep 34 · 25:54](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1554)
- Levitt and Richard Wood conducted a randomized controlled trial comparing standard dilation protocol versus no dilation after primary PSARP. — Marc Levitt (clinical) [Ep 34 · 26:39](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1599)
- The dilation study found that whether dilations were done or not, there was a similar 15% risk of developing a stricture. — Marc Levitt (clinical) [Ep 34 · 32:26](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1946)
- Strictures can be treated straightforwardly with a minor Heineke-Mikulicz anoplasty to enlarge the stricture at the time of colostomy closure. — Marc Levitt (clinical) [Ep 34 · 32:49](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=1969)
- Levitt's center no longer performs routine dilations, allowing families to avoid daily dilation burden and accept the 10-15% stricture risk manageable at colostomy closure. — Marc Levitt (clinical) [Ep 34 · 33:29](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2009)
- Doing a good anoplasty with no tension and good blood supply affects the likelihood of getting a stricture. — Marc Levitt (clinical) [Ep 34 · 33:52](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2032)
- Skin irritation after colostomy closure is a short-term problem lasting about 2 weeks because the skin has never seen stool. — Marc Levitt (clinical) [Ep 34 · 35:09](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2109)
- The distal unused bowel segment needs to learn to adapt and absorb water to thicken stool after colostomy closure. — Marc Levitt (clinical) [Ep 34 · 35:15](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2115)
- Post-closure skin irritation is managed with good perineal creams, frequent diaper changes, and preventing stool from sitting on skin, typically resolving by 3 weeks. — Marc Levitt (clinical) [Ep 34 · 35:33](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2133)
- At 3 weeks post-closure, the problem switches to constipation, which many surgeons fail to manage aggressively. — Marc Levitt (clinical) [Ep 34 · 35:56](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2156)
- Unrecognized constipation causes colonic dilation over time, making the colon harder to empty by age 4 when potty training begins. — Marc Levitt (clinical) [Ep 34 · 36:14](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2174)
- Almost all of Levitt's patients are on laxatives about 3-4 weeks after colostomy closure to keep them flowing. — Marc Levitt (clinical) [Ep 34 · 36:31](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2191)
- Starting at about age 2.5 years, the goal is achieving a good bowel movement pattern of 1-2 well-formed stools per day. — Marc Levitt (clinical) [Ep 34 · 36:50](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2210)
- Achieving good bowel pattern requires diet with bulk fiber, water-soluble fiber, and a laxative with senna or bisacodyl that provokes stool. — Marc Levitt (clinical) [Ep 34 · 37:08](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2228)
- Stool softeners do not help ARM children and actually make them worse because they prevent sensation development needed for potty training. — Marc Levitt (clinical) [Ep 34 · 37:33](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2253)
- ARM children have a surgically created anal canal without typical sensation and somewhat good or not-so-good sphincters, missing two key continence components. — Marc Levitt (clinical) [Ep 34 · 37:47](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2267)
- ARM patients are dependent on feeling rectal stretch from stool filling to develop bowel control. — Marc Levitt (clinical) [Ep 34 · 38:17](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2297)
- Loose stool from stool softeners prevents feeling stretch, preventing development of bowel control. — Marc Levitt (clinical) [Ep 34 · 38:26](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2306)
- Bulky stool (not constipated but with enough bulk to feel stretch) allows most patients to translate into successful potty training with one stool per day. — Marc Levitt (clinical) [Ep 34 · 38:35](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2315)
- If potty training doesn't succeed, bowel management should begin at age 3-4 to get children clean and in normal underwear. — Marc Levitt (clinical) [Ep 34 · 38:51](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2331)
- Enemas should be introduced when the child should be in normal underwear according to family choice, which varies but should be by age 4-5 for all children. — Marc Levitt (clinical) [Ep 34 · 39:09](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2349)
- Bowel management is nursing-run by nurse practitioners or advanced practice providers. — Marc Levitt (clinical) [Ep 34 · 40:10](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2410)
- The first responsibility in bowel management is assessing patient anatomy, which should be fixed first if there are anatomic issues. — Marc Levitt (clinical) [Ep 34 · 40:25](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2425)
- Bowel management with enemas can still be done even without perfect anatomy, with anatomic correction performed later. — Marc Levitt (clinical) [Ep 34 · 40:39](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2439)
- Bowel management involves mechanical emptying of the colon with an enema containing saline plus an additive that provokes stool emptying. — Marc Levitt (clinical) [Ep 34 · 41:17](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2477)
- The Malone procedure connects the appendix to the umbilicus for more comfortable and independent enema administration. — Marc Levitt (clinical) [Ep 34 · 41:31](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2491)
- The goal of bowel management is to empty the colon with a flush, then have nothing pass for the next 24 hours, achieving a clean child in normal underwear for 23.5 hours. — Marc Levitt (clinical) [Ep 34 · 42:01](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2521)
- Bowel management program typically lasts about a week, with 4-5 days of X-rays. — Marc Levitt (clinical) [Ep 34 · 42:24](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2544)
- An early Cincinnati study claimed 95% bowel management success at one week, but this short-term result is misleading. — Marc Levitt (clinical) [Ep 34 · 42:32](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2552)
- Levitt and Wood's follow-up study documented bowel management results at 1 year, showing over 80% success for ARM patients. — Marc Levitt (clinical) [Ep 34 · 43:12](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2592)
- Among the 4 patient categories (ARM, Hirschsprung's, spinal disorders, functional constipation), Hirschsprung's patients are the hardest for bowel management because they don't have good functioning sphincters or their sphincters are sometimes too good. — Marc Levitt (clinical) [Ep 34 · 43:33](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2613)
- A lot of tinkering is required during the year after bowel management initiation, with X-rays and flush adjustments when accidents occur. — Marc Levitt (clinical) [Ep 34 · 44:02](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2642)
- About 75% of ARM patients should be able to develop their own bowel control and have voluntary bowel movements based on good operation, good quality sacrum, and good quality spine. — Marc Levitt (clinical) [Ep 34 · 44:29](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2669)
- About 25% of ARM patients will not achieve their own bowel control even with perfect operation because they don't have the best sphincters or have spinal issues affecting bowel function. — Marc Levitt (clinical) [Ep 34 · 44:47](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2687)
- Many patients choose the Malone appendicostomy route to the umbilicus rather than rectal enemas for bowel management. — Marc Levitt (clinical) [Ep 34 · 45:04](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2704)
- In Europe, many patients use Peristeen for enema administration. — Marc Levitt (clinical) [Ep 34 · 45:18](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2718)
- Levitt performs over 100 Malone procedures per year laparoscopically as a one-hour procedure with most patients staying one night in hospital. — Marc Levitt (clinical) [Ep 34 · 45:31](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2731)
- The Malone procedure is very low investment of patient time and surgical morbidity, and is straightforward if done frequently. — Marc Levitt (opinion) [Ep 34 · 45:41](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2741)
- The Malone makes it much easier for older children to administer their own enema without parental help. — Marc Levitt (clinical) [Ep 34 · 45:54](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2754)
- A full-fledged colorectal center requires integrated psychology, child life services, and social work rather than surgeons calling them only when help is needed. — Marc Levitt (opinion) [Ep 34 · 46:30](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2790)
- An integrated psychologist should meet every patient and decide whether they can be of use rather than waiting for surgeon referral. — Marc Levitt (opinion) [Ep 34 · 46:37](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2797)
- The burden of therapy has been ignored but is an enormous component of ARM care that every collaborative center should recognize. — Marc Levitt (opinion) [Ep 34 · 47:19](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2839)
- The dilation study was prompted by investigating burden of therapy and recognizing the cost to families of achieving correct anus size. — Marc Levitt (clinical) [Ep 34 · 47:31](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2851)
- Many ARM problems are physiologic rather than psychologic, requiring anatomic correction and bowel management first before psychological intervention. — Marc Levitt (opinion) [Ep 34 · 48:22](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2902)
- Many patients who received significant psychological help actually needed re-operation and good bowel management, after which psychological and emotional problems resolved. — Marc Levitt (clinical) [Ep 34 · 48:39](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2919)
- One week of proper bowel management can transform an entire family's emotional state. — Marc Levitt (clinical) [Ep 34 · 49:01](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2941)
- Fecal incontinence is a physiologic problem, not a psychologic problem, though psychology still needs to be managed. — Marc Levitt (opinion) [Ep 34 · 49:17](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=2957)
- Patient engagement through family networks and social media has dramatically improved ARM care worldwide. — Marc Levitt (opinion) [Ep 34 · 50:11](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=3011)
- Greg Ryan did not meet another ARM patient until his adult life, 52 years after his surgery. — Marc Levitt (clinical) [Ep 34 · 51:16](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=3076)
- The origin of modern ARM care began in Melbourne Australia with Dr. Kelly, who learned from Dr. Stevens and taught Dr. Pena, who revised and improved the operation and launched it in 1980. — Marc Levitt (clinical) [Ep 34 · 52:56](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=3176)
- Dr. Stevens operated on Greg Ryan when he was a baby. — Greg Tiao (clinical) [Ep 34 · 53:30](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=3210)
- In medicine, the colorectal surgeon may take care of a colorectal problem and not really worry about the bladder issue, and 6 months later the urologist meets the patient and realizes they have to do some intervention after the patient already had a laparotomy for their colon problem—completely uncoordinated care. — Marc Levitt (opinion) [Ep 35 · 1:18](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=78)
- There are about 600 newborns with an anorectal malformation born per year in the United States. — Marc Levitt (epidemiological) [Ep 35 · 8:05](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=485)
- A pediatric surgery fellow does about 14 anorectal malformation cases in 2 years, and a graduate does about 1 case per year. — Marc Levitt (epidemiological) [Ep 35 · 8:05](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=485)
- Complications of anorectal malformations include fecal incontinence, urinary incontinence, renal dysfunction and the need for renal transplant, sexual dysfunction, and infertility. — Marc Levitt (clinical) [Ep 35 · 8:20](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=500)
- In colorectal surgery, if you do an operation as a 6 month old and put the anus outside of the sphincters, the 6 month old won't know that until they are 4 years old and trying to potty train—the surgeon will never figure out they didn't do a great job and will keep doing the same mistake over and over again. — Marc Levitt (clinical) [Ep 35 · 8:47](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=527)
- The speaker's current practice is about 60% reoperative surgery. — Marc Levitt (clinical) [Ep 35 · 11:13](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=673)
- Patients with anorectal malformations many times have associated spinal problems, and if you don't collaborate upfront with neurosurgery, you may discover a neurologic problem 5 years later when the patient already has renal damage. — Marc Levitt (clinical) [Ep 35 · 22:04](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=1324)
- Patients with cloacal malformations many times have Mullerian anomalies and hemisystems—if you don't think about gynecology when they're 6 months old during cloacal reconstruction, you're setting yourself up for a very difficult problem 13 years down the road when they have pelvic pain because their Mullerian structure is not draining menstrual blood. — Marc Levitt (clinical) [Ep 35 · 22:40](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=1360)
- Knowing the associated sacral and spinal problems allows us to predict continence and have a conversation with a family in the neonatal unit about whether their child will very likely be continent with proper management, or whether there's not really a lot of chance for continence because of the associated spinal problem. — Marc Levitt (clinical) [Ep 35 · 23:07](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=1387)
- Rectourethral fistulas are classified as bladder neck fistula (at the deltoid level), prostatic fistula (at the tricep level), or bulbar fistula (at the elbow level)—each diagnosis has a different surgical approach and a different potential outcome. — Marc Levitt (clinical) [Ep 35 · 24:24](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=1464)
- Common technical errors in anorectal malformation repair include anus placed too far posterior (outside the sphincter), stricture, remnant of the original fistula left behind, and rectal prolapse—these are solvable with better technique. — Marc Levitt (clinical) [Ep 35 · 25:23](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=1523)
- Redoing patients with misplaced anus can dramatically improve their functional outcome and quality of life—we were able to convert a good number of these patients to continence by making them have better anatomy. — Marc Levitt (clinical) [Ep 35 · 25:55](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=1555)
- The surgeon's responsibility is to get good anatomy, but after achieving that goal there's a functional outcome that's relevant—you can do a perfectly good Nissen but it requires some tinkering over time to try to get the best possible result for that patient. — Marc Levitt (opinion) [Ep 35 · 26:16](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=1576)
- The colostomy and ileostomy closure surgical site infection rate was 22.4%, which is pretty standard in the literature. — Marc Levitt (clinical) [Ep 35 · 27:03](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=1623)
- Implementing a GI bundle—most importantly changing instruments and gloves before closing the fascia—reduced the wound infection rate to 7.9%. — Marc Levitt (clinical) [Ep 35 · 27:11](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=1631)
- The organism that ultimately grew in the wounds was resistant to the preoperative antibiotic (cefoxitin) given within an hour of incision in every circumstance. — Marc Levitt (clinical) [Ep 35 · 27:22](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=1642)
- Changing the preoperative antibiotic from cefoxitin to Unasyn (chosen with infectious disease collaboration based on wound culture data) reduced the wound infection rate to 2.2%. — Marc Levitt (clinical) [Ep 35 · 27:53](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=1673)
- In cloacal malformation repair, you have to measure both the common channel length and the urethral length and make a plan accordingly—if the urethra is going to ultimately be shorter than 1.5 centimeters, bringing the bladder neck down to the perineum makes a wet (incontinent) patient. — Marc Levitt (clinical) [Ep 35 · 29:45](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=1785)
- If you leave enough of the urethra behind at the end of cloacal reconstruction (>1.5 cm), you could have a dry patient 4 years hence. — Marc Levitt (clinical) [Ep 35 · 30:03](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=1803)
- In a 6 year old with myelomeningocele who has urinary and fecal incontinence, you can take out the sigmoid to improve bowel care but keep it on its mesentery and roll it over to use for bladder augmentation, and share the appendix between Malone (antegrade enema) and Mitrofanoff (catheterizable channel)—the only way to do that is with coordinated care between urology and colorectal surgery. — Marc Levitt (clinical) [Ep 35 · 32:09](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=1929)
- The proximal appendix becomes the antegrade access for enemas for patients that are fecally incontinent but can be made clean by a flush every single day, and the distal piece stays on its blood supply and can be implanted into the bladder for intermittent catheterization for urine—they can be rendered dry and clean for urine and stool in a single operation. — Marc Levitt (clinical) [Ep 35 · 33:39](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=2019)
- There are certain patients with severe functional constipation that need surgical solutions—in the adult world that's a subtotal colectomy ileorectal anastomosis, but in the pediatric world before the entire colon has dilated up we may be able to get away with just a segmental resection of the sigmoid. — Marc Levitt (clinical) [Ep 35 · 34:42](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=2082)
- In medicine, complex problems are often approached without coordinated planning, analogous to building a bridge by having cement layers arrive Monday, steel workers Tuesday, architect Wednesday, and engineers Thursday. — Marc Levitt (opinion) [Ep 36 · 0:22](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=22)
- Some children are born without an opening for stool (anorectal malformation). — Marc Levitt (clinical) [Ep 36 · 1:32](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=92)
- A cloacal malformation is a condition where the bladder, gynecologic system, and colon all converge into one opening. — Marc Levitt (clinical) [Ep 36 · 2:00](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=120)
- Cloacal malformation is not compatible with life without surgical intervention. — Marc Levitt (clinical) [Ep 36 · 2:20](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=140)
- Once surgically corrected, cloacal malformation has unique implications on the child's quality of life. — Marc Levitt (clinical) [Ep 36 · 2:28](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=148)
- In cloacal malformation, the bladder, gynecologic, and colorectal structures are anatomically adjacent to each other, and each is handled by a different type of doctor. — Marc Levitt (clinical) [Ep 36 · 2:39](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=159)
- Effective management of cloacal malformation requires doctors from different specialties to work together. — Marc Levitt (opinion) [Ep 36 · 2:42](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=162)
- Twenty-five years ago, the speaker's mentor attempted to provide colorectal surgery, urology, and gynecology care for these patients as a single provider. — Marc Levitt (clinical) [Ep 36 · 2:53](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=173)
- As medicine became more complicated, a single provider became incapable of solving all problems in complex malformation cases without gathering a multidisciplinary team. — Marc Levitt (opinion) [Ep 36 · 3:15](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=195)
- The speaker's vision was to unite GI motility specialists, colorectal surgeons, gynecologic surgeons, and urologic surgeons to work together in a unified approach for complex children. — Marc Levitt (opinion) [Ep 36 · 3:50](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=230)
- Surgeons, particularly, like to be in charge and do not like to share patients or be told they cannot go first in an operation when another team needs to go first for the patient's benefit. — Marc Levitt (opinion) [Ep 36 · 5:47](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=347)
- Hospitals face logistical challenges with collaborative care including billing, clinic scheduling with all doctors present on the same day, and managing surgeon productivity when a 10-hour operation requires a specialist for only 2 hours. — Marc Levitt (opinion) [Ep 36 · 6:12](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=372)
- When a surgeon is needed for a portion of a long operation, they cannot leave to do other work because they must be available when needed while the patient is under anesthesia. — Marc Levitt (clinical) [Ep 36 · 6:33](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=393)
- Patients with complex malformations face significant burdens when specialists are in different cities, including scheduling multiple appointments at different times and dates, travel costs, and sibling care logistics. — Marc Levitt (opinion) [Ep 36 · 6:45](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=405)
- There are clinical circumstances where a child benefits from one operation where tissues can be shared between surgical teams. — Marc Levitt (clinical) [Ep 36 · 7:06](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=426)
- In a case where a segment of colon was not working and the bladder was too small, a section of colon could be removed from the fecal stream and added to the bladder to augment it, performed simultaneously in one operation. — Marc Levitt (clinical) [Ep 36 · 7:20](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=440)
- Typically, bladder augmentation would be performed first, and 6 months later someone would perform the colonic work as a separate operation. — Marc Levitt (clinical) [Ep 36 · 7:46](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=466)
- Implementing collaborative care requires deep infrastructure including coordinators, administrative assistants, schedulers, and multiple types of specialized nurses (floor, operating room, clinic). — Marc Levitt (opinion) [Ep 36 · 8:00](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=480)
- Nationwide Children's Hospital provided institutional support for the collaborative care model, whereas other institutions where the speaker had attempted this approach did not successfully adopt it. — Marc Levitt (opinion) [Ep 36 · 8:36](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=516)
- The siloed approach to subspecialty care was the traditional way of practicing medicine. — Marc Levitt (opinion) [Ep 36 · 8:46](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=526)
- In the collaborative model, 1 + 1 equals 3, meaning the sum is greater than the individual parts. — Marc Levitt (opinion) [Ep 36 · 8:55](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=535)
- The collaborative care model could be applied to other hospital programs, such as a limb program requiring orthopedic surgery and rehabilitation medicine, where teams meet before the patient arrives and see the patient together on the same day. — Marc Levitt (opinion) [Ep 36 · 9:06](https://qa.library.globalcastmd.com/watch/time-for-some-patient-driven-change-marc-levitt-tedxcolumbus-13828?t=546)
- Dr. Alberto Peña is the director of the Colorectal Center at Cincinnati Children's Hospital. — Alberto Peña (clinical) [Ep 37 · 0:26](https://qa.library.globalcastmd.com/watch/tell-me-a-story-pediatric-surgeons-putting-colorectal-center-on-the-map-13829?t=26)
- Dr. Peña developed a new surgical procedure in the 1970s. (clinical) [Ep 37 · 0:34](https://qa.library.globalcastmd.com/watch/tell-me-a-story-pediatric-surgeons-putting-colorectal-center-on-the-map-13829?t=34)
- In most institutions, the operation is called the Peña procedure, but at Cincinnati Children's it is called the posterior sagittal anorectoplasty due to Dr. Peña's humility. (clinical) [Ep 37 · 0:43](https://qa.library.globalcastmd.com/watch/tell-me-a-story-pediatric-surgeons-putting-colorectal-center-on-the-map-13829?t=43)
- The posterior sagittal anorectoplasty put colorectal surgery on the map and particularly Dr. Peña's name on the map. (opinion) [Ep 37 · 0:54](https://qa.library.globalcastmd.com/watch/tell-me-a-story-pediatric-surgeons-putting-colorectal-center-on-the-map-13829?t=54)
- Over approximately 20 years following the procedure's development, patients came to have the procedure and surgeons came to learn it. (clinical) [Ep 37 · 0:59](https://qa.library.globalcastmd.com/watch/tell-me-a-story-pediatric-surgeons-putting-colorectal-center-on-the-map-13829?t=59)
- The expansion of the colorectal center's work to all other fields has occurred in the last 6 to 10 years. (clinical) [Ep 37 · 1:07](https://qa.library.globalcastmd.com/watch/tell-me-a-story-pediatric-surgeons-putting-colorectal-center-on-the-map-13829?t=67)
- The center's expansion came from hard work, dedication, passion about the patient, commitment to writing about results, careful patient follow-up, and communicating their work to the world. (opinion) [Ep 37 · 1:16](https://qa.library.globalcastmd.com/watch/tell-me-a-story-pediatric-surgeons-putting-colorectal-center-on-the-map-13829?t=76)
- The Colorectal Center has seen patients from 80 countries. (epidemiological) [Ep 37 · 1:38](https://qa.library.globalcastmd.com/watch/tell-me-a-story-pediatric-surgeons-putting-colorectal-center-on-the-map-13829?t=98)
- Dr. Peña advises young surgeons asking about the key to success to focus on doing the best version of whatever operation they are performing, even routine procedures like hernias. — Alberto Peña (opinion) [Ep 37 · 1:45](https://qa.library.globalcastmd.com/watch/tell-me-a-story-pediatric-surgeons-putting-colorectal-center-on-the-map-13829?t=105)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- A single institution prospective randomized controlled trial found that anal dilations after PSARP may not be needed. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 1:10](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=70)
- There is literature suggesting a component of psychosocial, psychological dissociation in children on later testing related to anal dilations. — Ellen Encisco summarizing the discussion [Ep 32 · 1:31](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=91)
- In the dilation study, length of follow-up was 12 months, PSARP had to be performed in a child under 24 months of age, it was primary surgery, and excluded cloaca as a diagnosis. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 1:37](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=97)
- The average PSARP was performed at 5 months in the study. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 1:50](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=110)
- A stricture was defined as a Hagar dilator size of less than 10. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 1:52](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=112)
- The standard Hagar dilator size for a newborn is about size 12, so a size 10 is 2 deviations less. — Todd Ponsky summarizing the discussion [Ep 32 · 1:57](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=117)
- In the dilation study with 25 children, the types of malformations were evenly distributed and complexity was about equal. — Todd Ponsky summarizing the discussion [Ep 32 · 2:16](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=136)
- Strictures were non-significant between both groups (dilation vs no dilation), and a Heineke-Mikulicz anoplasty (longitudinal incision closed transversely to widen diameter) was able to be performed for stricture management. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 2:26](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=146)
- The number of strictures, number needing anoplasties, and number of redo operations were the same between dilation and no-dilation groups. — Ellen Encisco summarizing the discussion [Ep 32 · 2:55](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=175)
- The number of patients who had rectal prolapse is consistent with the literature. — Ellen Encisco summarizing the discussion [Ep 32 · 3:04](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=184)
- A study of 30-day outcomes for ARM with perineal or rectovaginal fistulas divided patients into early repair (before 6 days old) and late repair (6-8 weeks), with 66 early and 231 late repairs among 291 patients. — Ellen Encisco summarizing the discussion [Ep 32 · 5:20](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=320)
- 30-day complications are not statistically different between early and late repair groups for perineal and rectovaginal fistulas. — Caitlin Smith summarizes what Dr. Rebecca Rentea said [Ep 32 · 5:40](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=340)
- A second study defined early repair as 14 days or younger and late as after 14 days, with 31 early and 133 late repairs among 164 patients, also showing no difference in 30-day complications. — Caitlin Smith summarizes what Dr. Rebecca Rentea said [Ep 32 · 5:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=345)
- Long segment Hirschsprung disease is defined as any disease proximal to the rectosigmoid colon for the majority of reviewed articles. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 7:27](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=447)
- A contrast study itself is very inaccurate for Hirschsprung disease, and colonic mapping needs to be performed to determine the level of the transition zone. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 7:42](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=462)
- There was no superior or more common operation for long segment Hirschsprung, although Duhamel and Swenson-Soave were the top operations. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 7:51](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=471)
- There are no new novel surgical techniques for Hirschsprung disease over the past several years, though there is potential for stem cell therapy which is still in its infancy. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 8:13](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=493)
- A hypermotility and skin rash protocol for total colonic Hirschsprung disease outlines why an early operation (around 5 months old) is possible. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 8:31](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=511)
- If a child with an ileostomy is adequately prepared and the family can learn to thicken stool, they can have a pull-through that does not result in complete perineal skin breakdown and learn techniques helpful for this difficult-to-toilet-train group. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 8:49](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=529)
- A PCPLC study on bowel management strategies in children with anorectal malformations looked at 624 patients in the 5-12 year old age group. — Caitlin Smith summarizes what Dr. Rebecca Rentea said [Ep 32 · 10:36](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=636)
- Even mild and moderate anorectal malformation patients in the 5-12 year old group need to rely on enemas and other bowel management strategies to stay clean when heading into school age. — Caitlin Smith summarizes what Dr. Rebecca Rentea said [Ep 32 · 10:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=645)
- The majority of ARM patients had constipation as their primary complaint, and only 40% were toilet trained. — Caitlin Smith summarizes what Dr. Rebecca Rentea said [Ep 32 · 11:14](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=674)
- A study on timing of pull-through for Hirschsprung disease required all infants to be diagnosed under 1 month of age, with primary pull-throughs performed either less than or greater than 31 days. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 11:38](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=698)
- Preoperative enterocolitis was the same between both timing groups (before and after 31 days), postoperative enterocolitis was the same, and transition zone was the marker if a child needed treatment for constipation. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 11:46](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=706)
- A PCPLC consortium study of 525 ARM patients found that public insurance was associated with decreased rates of urinary incontinence. — Caitlin Smith summarizes what Dr. Rebecca Rentea said [Ep 32 · 12:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=735)
- Urethral length of about 2.5 centimeters has been measured in VCUGs of normal females, and about 1.5 centimeters is needed for cloacal reconstruction. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 13:26](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=806)
- If a urethra that is too short is pulled past the bladder neck, there is a risk for incontinence. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 13:44](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=824)
- A short vagina, even in an otherwise shorter common channel operation, may require a vaginal replacement. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 13:55](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=835)
- Rotational fluoroscopy and 3D reconstructions are key to being able to make reliable measurements for cloacal anatomy. — Rebecca Rentea summarizes what Dr. Caitlin Smith said [Ep 32 · 14:03](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=843)
- Enterocolitis remains a risk for Hirschsprung patients even after pull-through, at about a rate of 20% of all patients. — The host summarizing the discussion [Ep 30 · 2:13](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=133)
- Regular irrigations minimize enterocolitis risk in Hirschsprung patients. — The host summarizing the discussion [Ep 30 · 2:21](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=141)
- Most centers still do some kind of stool crusting—putting stool on the patient's bottom while they have a stoma for small periods of time—to help get their bottom used to it. — Meghan Mesa summarizing the discussion [Ep 30 · 3:35](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=215)
- Betel leaf was used in Bangladesh as a barrier for peristomal skin with excellent results, showing pristine skin underneath. — Marc Levitt summarizing the discussion [Ep 30 · 3:59](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=239)
- There have been advances in robotic-assisted Hirschsprung repair and the use of ICG (indocyanine green fluorescence imaging) to check blood supply of pull-throughs. — Felipe Gli summarizing the discussion [Ep 30 · 5:23](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=323)
- ICG fluorescence imaging is used to assess real-time tissue perfusion and vascularity during pull-throughs and can reduce the risk of leaks and ischemia. — The host summarizing the discussion [Ep 30 · 5:36](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=336)
- High-frequency ultrasound measurement of internal muscle thickness can help determine the segment of aganglionic bowel in Hirschsprung disease, potentially avoiding biopsy. — Felipe Gli summarizing the discussion [Ep 30 · 5:49](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=349)
- Robotic colorectal surgery is becoming feasible in children less than 10 kg because equipment is improving. — Marc Levitt summarizing the discussion [Ep 30 · 6:40](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=400)
- Robotic surgery is not as expensive anymore as it used to be; expenses are almost equivalent to other techniques. — Felipe Gli summarizing the discussion [Ep 30 · 6:51](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=411)
- Single-incision laparoscopic Malone procedures were presented with really great results and better post-operative recovery. — Felipe Gli summarizing the discussion [Ep 30 · 7:21](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=441)
- Goblet cells increase from proximal to distal colon, and the mucosal mucus layer has a protective role; more proximal resection may increase enterocolitis risk because proximal segments produce less mucus. — Marc Levitt summarizing the discussion [Ep 30 · 7:40](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=460)
- Mechanical stress and distension on the bowel wall leads to increased gut microbial dysbiosis and breakdown of the mucosal lining and barrier, with upregulation of pro-inflammatory factors affecting immune response. — Marc Levitt summarizing the discussion [Ep 30 · 8:37](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=517)
- Transition programs for pediatric colorectal patients often fail or are lacking in many parts of the world; patients need sexologists, gynecologists, and urologists more than adult colorectal surgeons. — Felipe Gli summarizing the discussion [Ep 30 · 13:49](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=829)
- The Ready Steady Go program uses patient questionnaires to assess knowledge of disease, symptoms, and readiness for transition to adult care. — The host summarizing the discussion [Ep 30 · 14:40](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=880)
- The perineal-preserving PSARP (PPP) avoids perineal body dissection and the risk of dehiscence, potentially eliminating the need for colostomies in some patients. — Marc Levitt summarizing the discussion [Ep 30 · 16:25](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=985)
- The posterectal advancement anoplasty (PRAA) mobilizes only the posterior rectal wall in males with perineal fistula and some females when the fistula is in the anteriormost extent of the sphincteric ellipse. — Marc Levitt summarizing the discussion [Ep 30 · 16:57](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=1017)
- Delaying vaginal reconstruction in cloaca may allow for other surgical options with less morbidity and avoid bowel vaginoplasty. — Felipe Gli summarizing the discussion [Ep 30 · 18:07](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=1087)
- A bowel neovagina can hold the spot in cloaca patients and be resected later in life when the patient is older. — Felipe Gli summarizing the discussion [Ep 30 · 18:27](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=1107)
- Cloaca patients need long-term follow-up during puberty to avoid menstrual obstruction, incapacity for egress, and risk of endometriosis and damage to uterus and fallopian tubes. — Felipe Gli summarizing the discussion [Ep 30 · 18:44](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=1124)
- Removal of the skin tag in chronic anal fissure can lead to better long-term healing, along with injection of 20 to 50 units of Botox. — Felipe Gli summarizing the discussion [Ep 30 · 21:04](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=1264)
- There is a higher incidence of perianal disease in children with Crohn disease, and perianal disease can be the first hint that a patient will develop Crohn disease. — Marc Levitt summarizing the discussion [Ep 30 · 21:35](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=1295)
- Enteral nutrition is as effective as steroids in treating transmural inflammation or stenosis of the small bowel in Crohn disease. — Marc Levitt summarizing the discussion [Ep 30 · 21:53](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-11653?t=1313)
- Anorectal malformation is defined as a birth defect that occurs when a baby's anus and rectum don't develop normally during pregnancy, causing abnormalities in the anal opening, rectum, and occasionally surrounding structures. — Thomas Hsu summarizing the discussion [Ep 28 · 1:24](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=84)
- Performing colostomy laparoscopically has the advantage of potentially identifying incidental findings like malrotation that might remain undiagnosed with a standard left lower quadrant colostomy. — Thomas Hsu summarizing the discussion [Ep 28 · 4:53](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=293)
- A theoretical approach proposed by gynecologist Alison May for cloaca cases where native vagina doesn't reach is to provide a neovagina as a bridge so the patient can menstruate through it, then potentially remove it 20 years later. — Marc Levitt summarizing the discussion [Ep 28 · 12:46](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=766)
- Using the colon in this case for vaginal replacement would be very risky due to blood supply concerns from the original divided stoma procedure that already disrupted the blood supply once. — Thomas Hsu summarizing the discussion [Ep 28 · 13:21](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=801)
- Fred Reichman used to say 'you are judged by what you are willing to stop for'—surgeons must be willing to stop when uncertain, get more information or help, rather than plowing through. — Jason Frischer summarizing the discussion [Ep 28 · 15:57](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=957)
- The visualization of the bladder neck will not predict its competency and ability to hold back urine; urodynamics will be needed in the future. — Thomas Hsu summarizing the discussion [Ep 28 · 17:39](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=1059)
- If diversion were needed in this case, an ileostomy would be the preferred choice. — Thomas Hsu summarizing the discussion [Ep 28 · 10:28](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=628)
- In Hirschsprung's disease, there is concern about distal obstruction from non-relaxing sphincters causing backup pressure into the anastomosis and blowing it out, which is why diversion would be more important in that context than in anorectal malformation repair. — Thomas Hsu summarizing the discussion [Ep 28 · 10:28](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=628)
- The common channel takes a very significant turn as it gets behind the pubis, which is visible on lateral view imaging — Amanda Jensen summarizing the discussion [Ep 16 · 6:26](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=386)
- Cystoscopy significantly undermeasures anatomical structures compared to 3D reconstruction because the straight scope cannot measure the turn behind the pubis — Amanda Jensen summarizing the discussion [Ep 16 · 6:45](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=405)
- A study comparing endoscopy to 3D cloacogram showed that cystoscopy significantly under-reads the length of the common channel — Amanda Jensen summarizing the discussion [Ep 16 · 7:20](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=440)
- If urethral length is less than 1.5 cm, urogenital separation is advocated because performing TUM would result in the bladder neck sewn near the perineum, potentially rendering the patient incontinent — Amanda Jensen summarizing the discussion [Ep 16 · 11:57](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=717)
- The majority of 1-3 cm common channel cloacas have normal length urethra and are amenable to TUM and PSARP — Amanda Jensen summarizing the discussion [Ep 16 · 12:40](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=760)
- If the vagina or vaginas cannot reach the perineum after urogenital separation, the patient may need vaginal replacement to bridge the gap — Amanda Jensen summarizing the discussion [Ep 16 · 13:08](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=788)
- After anorectoplasty, your first shot might be your only shot to give the patient a good outcome — Rod Gerardo summarizing the discussion [Ep 19 · 0:00](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=0)
- In the JPS study, the vast majority of reoperations were for mislocation, followed by stricture — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 19 · 11:38](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=698)
- Less common reasons for redo included remnant of original fistula (roof), rectal prolapse, and others — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 19 · 11:38](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=698)
- Quality of life improved with redo operations — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 19 · 11:38](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=698)
- Patients had improved ability to achieve continence after redo — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 19 · 11:38](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=698)
- Twenty percent of patients with a poor sacrum or poor spine developed bowel control after their redo — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 19 · 11:38](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=698)
- Patients with good potential (good sacrum and spine) did extremely well after redo — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 19 · 11:38](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=698)
- Patients who did not develop voluntary bowel movements after redo were still able to be clean with bowel management program using enemas or antegrade Malone — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 19 · 11:38](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=698)
- The average age of patients in the JPS study was about three and a half years — Marc Levitt summarizes what Dr. Jason Frischer said [Ep 19 · 11:38](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=698)
- In the large majority of cloaca patients, diagnosis is made at birth rather than prenatally. — Hira Ahmad summarizing the discussion [Ep 17 · 5:41](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=341)
- Definitive imaging and reconstructive planning should wait until the patient is growing and thriving. — Hira Ahmad summarizing the discussion [Ep 17 · 25:43](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1543)
- For cross-table lateral, baby is positioned prone with buttocks at highest point where air will rise, can be done at bedside with bump under buttocks — Em Gootee summarizing the discussion [Ep 29 · 6:01](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=361)
- In patients with low rectum, inspecting anterior rectal wall by dissecting a little bit and carefully lifting it off the urinary tract will usually rule out fistula — Em Gootee summarizing the discussion [Ep 29 · 12:16](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=736)
- In perineal fistula repairs where anterior dissection is avoided, there is no posterior sagittal incision and no anoplasty; rather, the incision is the sphincter length. — Felipe Galdus summarizing the discussion [Ep 6 · 11:57](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=717)
- Most perineal fistulas do not require anterior rectal wall dissection. — Felipe Galdus summarizing the discussion [Ep 6 · 13:00](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=780)
- In perineal fistula repairs, the transitional tissue containing anal mucosa and urothelium cells should not be sent to pathology for ganglion cell evaluation, which is distinctly different from Hirschsprung cases. — Felipe Galdus summarizing the discussion [Ep 6 · 14:53](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-41-perineal-hypospadias-13882?t=893)
- In low rectal malformations, dissecting a small portion of the anterior rectal wall and lifting it off the urinary tract will usually rule out fistula. — Em Gootee summarizing the discussion [Ep 27 · 12:17](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-1-low-bulbar-fistua-13824?t=737)
- Dr. Marc Levitt has cared for children from 50 states and 76 countries and performed more than 10,000 pediatric colorectal procedures. — Greg Tiao summarizes what Dr. Marc Levitt said [Ep 34 · 0:51](https://qa.library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstructi-13825?t=51)
- In the UK, biliary atresia and bladder exstrophy can only be cared for at certain medical centers because they recognized that gaining experience was going to improve outcomes. — Marc Levitt summarizing a resource [Ep 35 · 6:30](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=390)
- Walmart sends employees anywhere in the United States to Cleveland Clinic for coronary surgery because they've decided that is their go-to place for open heart surgery. — Marc Levitt summarizing a resource [Ep 35 · 7:09](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=429)
- In adult rectal cancer, the American College of Surgeons has designated that you need center of excellence care—you can't just do rectal cancer surgery wherever you want because the colorectal surgeons made the argument that you need radiation therapy and oncology and a whole list of things in order to provide best outcomes. — Marc Levitt summarizing a resource [Ep 35 · 16:38](https://qa.library.globalcastmd.com/watch/2019-chandler-lecture-dr-marc-levitt-13827?t=998)

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