# Perineal Fistula — GCMD Library living collection

Everything in the library about perineal fistula — built automatically from dossiers that name it.

Updated: n/a · 12 episodes · 340 cited statements

## Episodes
### Diagnosis & Workup
- [Colorectal Quiz Episode 13: Newborn ARM Part 2](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142) — podcast · 15:48 · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142.md)

### Surgical Management
- [Surgical Management Of Female Anorectal Malformation Patients Including...](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741) — video · 57:59 · [machine version](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741.md)
- [Anorectal Malformation Management of Female Patients Part I: Pediatric...](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091) — video · 26:39 · [machine version](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091.md)
- [ARMs in Female Patients: Pediatric Colorectal Controversies 2014](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101) — video · 55:00 · [machine version](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101.md)
- [Colorectal Quiz Episode 29: Female ARM-Post Op Management](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181) — podcast · 25:09 · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181.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
- [Complications of Anorectal Malformations with Dr. Marc Levitt](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951) — podcast · 48:09 · [machine version](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951.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)
- [Anorectal Malformations Complications](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872) — podcast · 48:08 · [machine version](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872.md)

### Case-Based Learning
- [Pediatric Colorectal Contraversies Part I: Pediatric Colorectal Contraversies...](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417) — video · 25:43 · [machine version](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417.md)
- [Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115) — podcast · 19:59 · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115.md)

### Long-Term Care
- [Gynecologic care in patients with anorectal malformations: A primer and call to action](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990) — podcast · 18:47 · [machine version](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990.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 6)
- [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 6)
- [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 6)
- [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 6)
- [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 6)
- [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 6)
- [23:17](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1397) Distal Colostogram Interpretation (Ep 6)
- [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 6)
- [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 6)
- [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 6)
- [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 6)
- [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 6)
- [0:00](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=0) Introduction and Initial Case Presentation: Low Malformations (Ep 1)
- [4:50](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=290) Intraoperative Complications and Anatomic Variants (Ep 1)
- [8:04](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=484) Surgical Indications and Presacral Mass Association (Ep 1)
- [11:56](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=716) Surgical Technique Debate: Cutback vs. Formal Repair (Ep 1)
- [16:46](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=1006) Electrical Stimulation and Sphincter Identification (Ep 1)
- [19:43](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=1183) Primary Repair vs. Colostomy in Males (Ep 1)
- [0:00](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=0) Introduction and Diagnostic Cases (Ep 2)
- [2:59](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=179) Mobilization Technique and Debate (Ep 2)
- [8:36](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=516) Primary Repair Without Colostomy (Ep 2)
- [16:45](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1005) Perioperative Management and Research Gaps (Ep 2)
- [24:44](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1484) Vaginal Anomalies: Septum and Absent Vagina (Ep 2)
- [33:56](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2036) Vaginal Reconstruction Techniques (Ep 2)
- [44:56](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2696) Cloaca and Hydrocolpos Management (Ep 2)
- [0:01](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1) Introduction and Missed Diagnoses in the Newborn Period (Ep 3)
- [2:57](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=177) Perineal Fistula in Males: Diagnosis and Management (Ep 3)
- [7:33](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=453) Perineal Fistula in Females: Diagnostic Criteria and Overdiagnosis (Ep 3)
- [10:11](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=611) Examination Under Anesthesia and Muscle Stimulation Techniques (Ep 3)
- [12:11](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=731) Rectourethral Fistula and Cloaca: Diagnosis and Initial Management (Ep 3)
- [15:12](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=912) Colostomy Technique: Common Errors and Best Practices (Ep 3)
- [20:53](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1253) Anoplasty Site Selection and Marking (Ep 3)
- [23:40](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1420) Distal Colostogram: Technique and Interpretation (Ep 3)
- [26:35](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1595) Intraoperative Identification of Distal Rectum (Ep 3)
- [29:48](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1788) Operative Approach Selection: PSARP versus Laparoscopy (Ep 3)
- [33:50](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2030) Rectal Prolapse: Prevention and Management (Ep 3)
- [38:30](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2310) Complications of Laparoscopic Approach (Ep 3)
- [40:46](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2446) Complications of Posterior Sagittal Approach (Ep 3)
- [41:47](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2507) Postoperative Soiling and Continence Assessment (Ep 3)
- [0:00](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=0) Diagnostic classification of perineal and vestibular fistulas (Ep 4)

## 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 46:25](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2785)
- "Anorectal malformations (ARMs) represent a spectrum of gastrointestinal anomalies present at birth, ranging from perineal fistula to persistent cloaca." (host_summary) [Ep 12 · 1:42](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=102)
- "In a perineal fistula, the rectum ends at an abnormal connection (fistula) that opens near the perineum instead of at a normal anal opening." (host_summary) [Ep 12 · 2:09](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=129)
- "In persistent cloaca, the urinary tract, reproductive tract, and gastrointestinal tract fail to separate in the womb and merge into one single common channel." (host_summary) [Ep 12 · 2:40](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=160)
- "During fetal development, the cloaca (lower intestines) and urogenital sinus (urinary and reproductive systems) develop in extremely close quarters, sharing the same microscopic real estate." (host_summary) [Ep 12 · 3:49](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=229)
- "Because the GI and genitourinary systems share developmental origin, an anomaly in the gastrointestinal tract almost inherently means the genitourinary system might be atypical as well." (host_summary) [Ep 12 · 4:36](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=276)
- "Gynecologic anomalies occur in 17% to 67% of all ARM cases." (host_summary) [Ep 12 · 4:51](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=291)
- "In non-cloaca ARMs, Müllerian anomalies (anomalies of the uterus, fallopian tubes, and upper vagina) occur in about 7% to 35% of patients." (host_summary) [Ep 12 · 5:19](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=319)
- "For patients with persistent cloaca, especially those with a common channel longer than 3 centimeters, up to 80% have co-occurring gynecologic anomalies." (host_summary) [Ep 12 · 5:49](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=349)
- "VACTERL is an acronym for a non-random association of birth defects: vertebrae, anus, cardiovascular tree, trachea, esophagus, renal system, and limbs." (host_summary) [Ep 12 · 6:12](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=372)
- "25% to 39% of patients with VACTERL also have a concomitant gynecologic anomaly." (host_summary) [Ep 12 · 6:30](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=390)
- "There is a movement to update the VACTERL acronym to VACTERL-G, adding a G to represent the gynecologic component." (host_summary) [Ep 12 · 6:40](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=400)
- "Historically, the reproductive system was pushed to the back burner during neonatal ARM surgery because it wasn't actively threatening the child's life, and was treated as a problem to address at puberty." (host_summary) [Ep 12 · 7:48](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=468)
- "Gynecologic evaluation should not wait for puberty and needs to begin at the time of the initial ARM diagnosis." (host_summary) [Ep 12 · 8:44](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=524)
- "Families desire to discuss long-term gynecologic anatomy and function immediately at the time of ARM diagnosis." (host_summary) [Ep 12 · 8:57](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=537)
- "Peripuberty and the transition to adult care represent a crucial vulnerability period for ARM patients." (host_summary) [Ep 12 · 9:24](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=564)
- "If a patient has an undiagnosed Müllerian anomaly such as a structural blockage in the reproductive tract or obstructed uterine horn and begins to menstruate, the menstrual blood has nowhere to go." (host_summary) [Ep 12 · 9:42](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=582)
- "Retrograde menstruation, where menstrual fluid flows backward into the pelvic cavity, can cause excruciatingly painful menstruation, endometriosis, and scar tissue that impacts future fertility." (host_summary) [Ep 12 · 9:59](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=599)
- "Because ARM patients' anatomy was surgically altered in infancy, standard gynecological exams might be physically impossible or incredibly traumatizing." (host_summary) [Ep 12 · 10:18](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=618)
- "Surveys indicate that patients with ARMs routinely lack access to specialized gynecologic care as adults because it is not a major part of standard OBGYN training." (host_summary) [Ep 12 · 11:35](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=695)
- "The PCPLC Gynecology Committee developed five consensus statements to bridge the communication void between pediatric surgeons and adult gynecologists." (host_summary) [Ep 12 · 12:11](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=731)
- "The PCPLC created a standardized term dictionary (Appendix 1) and advocates utilizing the American Society of Reproductive Medicine (ASRM) Classification System for Müllerian Anomalies (Appendix 2)." (host_summary) [Ep 12 · 13:00](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=780)
- "There is a distinct lack of Level 1 and Level 2 evidence for gynecologic care in ARMs." (host_summary) [Ep 12 · 13:37](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=817)
- "Level 1 and 2 evidence comes from massive randomized controlled trials, which cannot be ethically conducted on life-threatening birth defects in infants." (host_summary) [Ep 12 · 13:55](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=835)
- "The medical community relies heavily on Level 3 evidence for ARMs, which consists of case series, retrospective reviews, and expert consensus, translating to Level B and C recommendations." (host_summary) [Ep 12 · 14:32](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=872)
- "The only way to turn today's expert opinions into tomorrow's Level 1 evidence is through exhaustive long-term cross-institutional data repositories that track patients from infancy through reproductive years." (host_summary) [Ep 12 · 15:47](https://qa.library.globalcastmd.com/watch/gynecologic-care-in-patients-with-anorectal-malformations-a-primer-and-call-to-action-13990?t=947)
- "Perineal fistulas in males are commonly missed in the newborn period because the baby passes meconium through the small fistulous opening, and no one notices the abnormal anal anatomy. These patients typically present in the first year of life with severe constipation." — Marc Levitt (clinical) [Ep 11 · 2:55](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=175)
- "By the time a missed perineal fistula is diagnosed, the rectum and sigmoid have dilated because stool has been passing through a very tiny fistulous orifice which is not normal anal or rectal mucosa." — Marc Levitt (clinical) [Ep 11 · 3:43](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=223)
- "The current standard is to check temperature on the forehead or in the ear rather than rectally, so if you don't look at the anus, you might not know there is a malformation." — Marc Levitt (clinical) [Ep 11 · 4:03](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=243)
- "Relocating a perineal fistula into the sphincters does not completely fix the constipation, though it improves the anatomy by making the hole adequately sized and lined by mucosa." — Marc Levitt (clinical) [Ep 11 · 4:53](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=293)
- "Patients with uncorrected perineal fistulas can have some semblance of continence with formed stool, but with loose stool or athletic activity they will soil because they cannot completely close the anteriorly located hole when squeezing their sphincters." — Marc Levitt (clinical) [Ep 11 · 5:23](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=323)
- "A newborn anus should accept a size 12 Hagar dilator, and a one-year-old should accept a size 15." — Marc Levitt (clinical) [Ep 11 · 6:05](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=365)
- "A bucket handle (a lifted skin tag that you can pass a probe underneath) is consistent with a perineal fistula even if you cannot see the fistula itself." — Marc Levitt (clinical) [Ep 11 · 6:41](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=401)
- "Perineal fistula in females is probably the most confounding diagnosis in pediatric colorectal surgery, with many patients either being missed or overdiagnosed." — Marc Levitt (opinion) [Ep 11 · 7:28](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=448)
- "Diagnostic criteria for perineal fistula in females: inadequate perineal body (hole too close to vagina), inadequate hole size, and hole not centered in the sphincter." — Marc Levitt (clinical) [Ep 11 · 7:50](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=470)
- "If the anal opening in a female is adequate size and centered in the sphincter, even if it appears slightly anterior with a short perineal body, that patient does not need surgery. The perineal body will lengthen with growth." — Marc Levitt (clinical) [Ep 11 · 8:25](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=505)
- "An anesthesia nerve stimulator ($150) with appropriate needle probes works as well as a dedicated Pena stimulator ($15,000) for intraoperative sphincter mapping." — Marc Levitt (clinical) [Ep 11 · 10:50](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=650)
- "The vast majority of male ARM patients have a rectourethral fistula. It is important not to approach these primarily because you don't know where the rectum is—it could be at bladder neck, prostatic, or bulbar level." — Marc Levitt (clinical) [Ep 11 · 12:38](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=758)
- "If you open posterior sagittal looking for a rectourethral fistula without knowing the location, you will find something midline, white, and shiny that might be the urinary tract, not the rectum." — Marc Levitt (clinical) [Ep 11 · 13:20](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=800)
- "Cloacas can be missed in the newborn period. Dr. Levitt saw a six-month-old who presented with constipation and was found to have an undiagnosed cloaca with no hint of an anal opening." — Marc Levitt (clinical) [Ep 11 · 14:04](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=844)
- "Ambiguous genitalia (clitoromegaly from endocrine stimulation) presents with a urogenital sinus but a completely normal anus. This is different from a cloaca, which has no anus and no endocrine problem." — Marc Levitt (clinical) [Ep 11 · 15:49](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=949)
- "The most common colostomy error is opening too distal in the sigmoid, which restricts the ultimate pull-through by the location of the colostomy or mucous fistula." — Marc Levitt (clinical) [Ep 11 · 16:44](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1004)
- "Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections." — Marc Levitt (clinical) [Ep 11 · 17:20](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1040)
- "Transverse colostomies are problematic because they can prolapse, and if there is a large rectourethral fistula, the left colon absorbs all the urine (which doesn't come out the mucous fistula), causing acidosis." — Marc Levitt (clinical) [Ep 11 · 17:50](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1070)
- "Dr. Levitt's preference is a very proximal sigmoid colostomy with separated stomas, leaving the entire sigmoid loop for the pull-through. He makes the mucous fistula very tiny and flat." — Marc Levitt (clinical) [Ep 11 · 18:35](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1115)
- "Prolapse is related to where in the colon you choose to do the colostomy. Mid-transverse: both sides can prolapse. Hepatic flexure: only distal can prolapse. Proximal sigmoid: only distal (mucous fistula) can prolapse because left colon is fixed to retroperitoneum." — Marc Levitt (clinical) [Ep 11 · 19:58](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1198)
- "Dr. Levitt marks the anoplasty location by drawing a circle around the pinkish ellipse where it stimulates on the skin surface BEFORE making the incision, to avoid getting lost when looking at jumping muscles from the stimulator." — Marc Levitt (clinical) [Ep 11 · 21:10](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1270)
- "Really good surgeons have put anuses in crazy places because they don't have a sense of what's the center once everything is disrupted and open." — Marc Levitt (clinical) [Ep 11 · 22:36](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1356)
- "The distal colostogram is an absolutely vital study. Many mistakes are made because of a poorly done study and misinterpretation." — Marc Levitt (clinical) [Ep 11 · 23:29](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1409)
- "The basic questions the distal colostogram must answer: Where is the rectum? How low is it? Is it reachable posterior sagittally or better approached laparoscopically? What is its relationship to the urinary tract?" — Marc Levitt (clinical) [Ep 11 · 23:55](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1435)
- "The common colostogram mistake is not giving enough contrast and pressure into the distal segment, giving a false impression that the rectum is high or that there is no fistula." — Marc Levitt (clinical) [Ep 11 · 24:30](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1470)
- "If you see a straight line flattening of the rectum corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure. You need to overcome the PC line (the sphincters compressing the distal rectum) to see the bulging rectum and fistula." — Marc Levitt (clinical) [Ep 11 · 25:00](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1500)
- "Fistula classification: if the fistula is at the urethral 'elbow' or below, it's bulbar. Above the elbow is prostatic. At the bladder neck is bladder neck fistula." — Marc Levitt (clinical) [Ep 11 · 25:55](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1555)
- "If the rectum is bulbous, it might be reachable posterior sagittally and hard to do laparoscopically because of the girth. If it's tapered, you're better off laparoscopically." — Marc Levitt (clinical) [Ep 11 · 25:55](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1555)
- "If you don't know where the rectum is and open posterior sagittal, you will find a whitish, shiny structure and may think it's the rectum. Often it's the bladder neck." — Marc Levitt (clinical) [Ep 11 · 26:52](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1612)
- "You avoid bladder neck injury by knowing exactly where the rectum is from a properly done distal colostogram. When you open posterior sagittal, you know the rectum is right under the coccyx (prostatic) or distal to the coccyx (bulbar), or it isn't posterior sagittal at all (bladder neck—do laparoscopy)." — Marc Levitt (clinical) [Ep 11 · 27:30](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1650)
- "Dr. Levitt will do posterior sagittal for bulbar fistulas and low prostatic fistulas with a bulge. High prostatic with tapered rectum and bladder neck fistulas are best served by laparoscopy." — Marc Levitt (clinical) [Ep 11 · 30:03](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1803)
- "If you try laparoscopy for a rectum bulging below the peritoneal reflection at low prostatic or bulbar level, you may leave behind a remnant of the original fistula (ROOF)—the distal rectum left behind that causes trouble later." — Marc Levitt (clinical) [Ep 11 · 30:50](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1850)
- "Laparoscopy replaces laparotomy, not PSARP. Dr. Levitt does a mini-PSARP when doing laparoscopy to safely enter the pelvis and tack the rectum to the posterior edge of the muscle complex to avoid prolapse." — Marc Levitt (clinical) [Ep 11 · 31:38](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1898)
- "Dr. Levitt calls his approach 'laparoscopic-assisted PSARP' rather than pure laparoscopy." — Marc Levitt (clinical) [Ep 11 · 32:30](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1950)
- "Prolapse prevention: put the rectum in the right location, close the levators properly, close the posterior wall to the posterior edge of the muscle complex for 3-4 stitches, don't dissect the rectum more than necessary." — Marc Levitt (clinical) [Ep 11 · 32:55](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1975)
- "Prolapse occurs in about 3% of cases, particularly in those without great muscles." — Marc Levitt (epidemiological) [Ep 11 · 33:49](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2029)
- "Rectal prolapse causes bleeding, mucus, and for patients with good continence potential, it inhibits bowel control because they can't close the opening with prolapsed tissue through it." — Marc Levitt (clinical) [Ep 11 · 33:54](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2034)
- "Dr. Levitt trims prolapse of more than about 3mm. For circumferential prolapse, he does half the circumference in two different ambulatory settings so families don't need hospitalization and the patient doesn't need dilation (half the circumference is untouched so they won't stricture)." — Marc Levitt (clinical) [Ep 11 · 34:30](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2070)
- "Perineal body dehiscence is the most common cause of reoperation Dr. Levitt performs in female ARM repairs." — Marc Levitt (clinical) [Ep 11 · 35:27](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2127)
- "The key to preventing perineal body dehiscence is mobilizing the rectum well—you must get the anterior rectal wall completely separated from the posterior vaginal wall to the areolar plane. If you don't, the anoplasty will be under tension and can pull back, leak into the perineal body space, and dehisce." — Marc Levitt (clinical) [Ep 11 · 35:55](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2155)
- "Dr. Levitt uses 3-0 suture for perineal body closure in a baby and 4-0 Vicryl on the perineal skin, then watches the perineum very closely." — Marc Levitt (clinical) [Ep 11 · 36:50](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2210)
- "Traditionally Dr. Levitt kept patients NPO for 7 days on 10% dextrose after female ARM repair. Recently he has been trialing clear liquids only for a week because the major problem is hard stool—clear liquids won't make hard stool." — Marc Levitt (clinical) [Ep 11 · 37:15](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2235)
- "If perineal body dehiscence is detected on days 5-8, Dr. Levitt will take the patient back to the OR and re-suture the perineal body, which can salvage the situation. This happens in maybe 1-2 cases out of about 200." — Marc Levitt (clinical) [Ep 11 · 37:47](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2267)
- "Laparoscopy causes trouble if you try to dissect a rectum that's too low—you get too close to the urinary tract or you're too timid and leave behind the distal rectum (remnant of original fistula)." — Marc Levitt (clinical) [Ep 11 · 38:31](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2311)
- "For high rectums, particularly bladder neck fistulas, the dissection of the distal rectum is quite challenging to make it reach with good blood supply. You must preserve the IMA because the colostomy may have disrupted collaterals down the left colic, making the rectum completely dependent on the IMA." — Marc Levitt (clinical) [Ep 11 · 39:10](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2350)
- "The rectum has an excellent intramural blood supply from the IMA. If you take the IMA or take branches too close to the aorta, the rectum will die because there's no collateralization down the left colic." — Marc Levitt (clinical) [Ep 11 · 39:40](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2380)
- "The biggest problem with posterior sagittal incision is going after a rectum when you don't know where it is. You open and find the bladder neck, urethra, seminal vesicles, vas deferens, ectopic ureter—everything but the distal rectum." — Marc Levitt (clinical) [Ep 11 · 40:12](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2412)
- "There are famous cases of pull-through of bladder neck made into beautiful anoplasties, and post-op the patient was draining liquid out their anoplasty—it was the bladder neck." — Marc Levitt (clinical) [Ep 11 · 40:50](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2450)
- "To determine if an ARM patient has potential for bowel control, Dr. Levitt looks at three factors: original type of malformation, quality of sacrum and calculated sacral ratio, and quality of spine. He calls this the ARM continence index." — Marc Levitt (clinical) [Ep 11 · 42:09](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2529)
- "Three A's (excellent malformation type, sacrum, and spine) predicts a continent patient. Three C's predicts an incontinent patient. Dr. Levitt's group is working on quantifying the in-between grades." — Marc Levitt (clinical) [Ep 11 · 43:10](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2590)
- "A bulbar fistula with a good sacrum (sacral ratio of 1) and normal spine should absolutely have bowel control. A bladder neck fistula with poor sacrum (sacral ratio 0.4) and tethered cord or myelomeningocele has no real chance of good bowel control." — Marc Levitt (clinical) [Ep 11 · 43:45](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2625)
- "For a soiling 4-year-old ARM patient, Dr. Levitt's first step is to get them clean mechanically with bowel management using enemas. For those with continence potential, when they're older and more mature, he tries to switch them to laxatives to achieve voluntary bowel movements." — Marc Levitt (clinical) [Ep 11 · 44:30](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2670)
- "Indications for redo pull-through: any patient with potential for bowel control whose anatomy is not perfect—improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum)." — Marc Levitt (clinical) [Ep 11 · 45:20](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2720)
- "One of the biggest problems with ARM is that if you don't get it right, you don't know for a few years. Most surgical problems become obvious immediately, but with ARM, patients may not present with soiling until age 4, making it hard for surgeons to learn what to fix about their technique." — Marc Levitt (opinion) [Ep 11 · 46:05](https://qa.library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2765)
- "In every single redo of a female anorectal malformation, areolar tissue is found that had never been dissected by the original surgeon, suggesting inadequate anterior rectal wall mobilization led to perineal body disruption." — Mark (clinical) [Ep 2 · 6:38](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=398)
- "The rectal blood supply is intramural, so injuring the rectal wall during dissection hurts its blood supply." — Mark (clinical) [Ep 2 · 14:12](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=852)
- "Starting lateral dissection before attempting to separate the common anterior wall is key; the lateral plane defines the anterior plane." — Mark (host_summary) [Ep 2 · 14:34](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=874)
- "Coming in from lateral to anterior and starting more proximally (where structures are easier to separate) rather than at the perineum improves the dissection plane." — Mark (host_summary) [Ep 2 · 15:25](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=925)
- "A systematic review found that early enteral nutrition appears better than later nutrition in anorectal malformation repair, but all studies were retrospective and poor quality." — Mark (host_summary) [Ep 2 · 19:54](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1194)
- "About 2 to 5% of vestibular fistulas have a vaginal septum that should be identified at the time of rectal repair." — Mark (epidemiological) [Ep 2 · 27:40](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1660)
- "Women with longitudinal vaginal septum often learn to work around it for intercourse and may be asymptomatic, but menstrual hygiene (tampon use) is a major reason for resection." — Mark (host_summary) [Ep 2 · 30:32](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1832)
- "Vaginal septum resection in adolescents is not a difficult operation and can be done with electrocautery, getting as close to the cervix as possible without damaging it." — Mark (host_summary) [Ep 2 · 31:29](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1889)
- "If a vaginal septum is found in a 6-year-old after anorectal malformation repair, there is no rush to remove it before puberty unless another operation is planned." — Mark (host_summary) [Ep 2 · 42:29](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2549)
- "Of 33 patients with vestibular fistula and absent vagina, 75% had urologic problems including neurogenic bladder, and 50% had CKD stage 3 or greater." (epidemiological) [Ep 2 · 37:17](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2237)
- "Vestibular fistula with absent vagina requires aggressive urologic screening due to high rates of solitary kidneys, reflux, hydronephrosis, neurogenic bladder, and urinary tract infections." (clinical) [Ep 2 · 37:31](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2251)
- "For absent vagina with vestibular fistula, sigmoid neovagina is preferred, using sigmoid colon mobilized laparoscopically and brought to the perineum, with backup colostomy." — Mark (host_summary) [Ep 2 · 34:56](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2096)
- "The ideal time to create a neovagina is when fixing the rectum, because the perineal body is open and the sigmoid pedicle reaches more easily in younger children with shorter pelvis." — Mark (opinion) [Ep 2 · 39:35](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2375)
- "About 50% of cloacas have a bifid gynecologic system." — Mark (epidemiological) [Ep 2 · 45:50](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2750)
- "For newborn cloaca with hydrocolpos, an open divided colostomy should be performed, and the vagina decompressed with a pigtail catheter rather than formal vaginostomy." — Mark (host_summary) [Ep 2 · 46:12](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2772)
- "Cystoscopy at the time of colostomy creation in cloaca makes the colostomy creation very difficult and should be avoided; scope at 2–3 months instead." — Mark (host_summary) [Ep 2 · 46:48](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2808)
- "Intermittent catheterization of the cloaca 2–3 times daily can drain urine from the vagina and avoid the need for vaginostomy tube in many cases." — Mark (host_summary) [Ep 2 · 51:09](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=3069)
- "Catheterization of cloaca should be done under ultrasound guidance initially to ensure the catheter enters the correct structure (right vagina, left vagina, bladder, or rectum)." — Mark (clinical) [Ep 2 · 52:02](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=3122)
- "In hydrocolpos compressing the ureters, once the hydrocolpos is drained, the bladder fills beautifully, demonstrating the physiology of ureteral compression." — Mark (host_summary) [Ep 2 · 53:50](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=3230)
- "Most patients with hydrocolpos can be successfully drained by draining the hydrocolpos only, without needing to drain the bladder separately." — Mark (clinical) [Ep 2 · 54:04](https://qa.library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=3244)
- "Perineal fistula is diagnosed when the fistula opening is at or anterior to the fourchette, with normal urethra and vagina visible" — Marc Levitt (clinical) [Ep 5 · 0:23](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=23)
- "Vestibular fistula is diagnosed when the fistula opens posterior to the fourchette within the vestibule" — Marc Levitt (clinical) [Ep 5 · 1:53](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=113)
- "For perineal fistula mobilization, the goal is to mobilize just enough to reach perineal skin with a little bit of tension" — Don (opinion) [Ep 5 · 2:27](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=147)
- "Complete separation from vagina is preferred because incomplete mobilization may lead to retraction and wound problems" — Marc Levitt (opinion) [Ep 5 · 2:50](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=170)
- "In every redo of a female ARM, areolar tissue is found that had never been dissected by the original surgeon" — Marc Levitt (clinical) [Ep 5 · 5:40](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=340)
- "Inadequate anterior rectal wall mobilization can lead to perineal body disruption as the anterior wall pulls back" — Marc Levitt (clinical) [Ep 5 · 6:10](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=370)
- "Many newborn female vestibular fistula redos were done without a colostomy" — Don (clinical) [Ep 5 · 6:52](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=412)
- "The rectal blood supply is intramural, so injuring the rectal wall hurts its blood supply" — Marc Levitt (clinical) [Ep 5 · 13:09](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=789)
- "Starting laterally before attempting anterior separation is key to avoiding injury when separating rectum from vagina" — Marc Levitt (clinical) [Ep 5 · 13:35](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=815)
- "Coming in from lateral to anterior and starting more proximally makes separation easier than starting at the perineum" — Don (clinical) [Ep 5 · 14:25](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=865)
- "Primary vestibular repair without colostomy can be done in newborn or within 3-4 months depending on child's condition" — Marc Levitt (opinion) [Ep 5 · 15:00](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=900)
- "Waiting until perineal body is healed (day 6-7) before feeding allows intervention if dehiscence is developing" — Marc Levitt (opinion) [Ep 5 · 16:28](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=988)
- "10% dextrose can be used for NPO periods up to 7 days in well-nourished children, avoiding need for hyperalimentation" — Marc Levitt (clinical) [Ep 5 · 17:18](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1038)
- "Systematic review shows early enteral nutrition appears better than later nutrition in ARM patients, but all studies are retrospective and poor quality" — Marc Levitt (epidemiological) [Ep 5 · 18:48](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1128)
- "About 2-5% of vestibular fistulas have a vaginal septum" — Marc Levitt (epidemiological) [Ep 5 · 26:39](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1599)
- "The ideal time to remove a vaginal septum is when the rectum is being mobilized and the perineal body is open" — Marc Levitt (opinion) [Ep 5 · 26:58](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1618)
- "Women with longitudinal vaginal septum often learn to work around it for intercourse but have problems with tampon use" — Marc Levitt (clinical) [Ep 5 · 29:17](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1757)
- "Vaginal septum resection in adolescents is not a difficult operation and can be done with electrocautery" — Marc Levitt (clinical) [Ep 5 · 30:30](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1830)
- "True vaginal fistula (within introitus) is rare and requires slightly more rectal mobilization than vestibular fistula" — Marc Levitt (clinical) [Ep 5 · 32:28](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1948)
- "In vestibular fistula with absent vagina, 75% have urologic problems including neurogenic bladder" — Don (epidemiological) [Ep 5 · 36:15](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2175)
- "Of patients with vestibular fistula and absent vagina, 50% have CKD stage 3 or greater" — Don (epidemiological) [Ep 5 · 36:27](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2187)
- "Sigmoid colon can be used as neovagina in vestibular fistula with absent vagina" — Don (clinical) [Ep 5 · 34:12](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2052)
- "Using rectum as vagina and mobilizing proximal bowel as neo-rectum should only be done if patient unlikely to be continent (spinal anomaly, absent sacrum)" — Marc Levitt (opinion) [Ep 5 · 35:33](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2133)
- "Rectum separates from urethra more easily than from vagina in absent vagina cases, with thick fibrous tissue rather than adherent common wall" — Marc Levitt (clinical) [Ep 5 · 37:18](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2238)
- "Neovagina is technically easier in younger children because the pedicle reaches more easily in a shorter pelvis" — Marc Levitt (clinical) [Ep 5 · 38:42](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2322)
- "There are two types of cloacas: lower ones (common channel ≤3 cm) and complicated ones (>3 cm)" — Marc Levitt (clinical) [Ep 5 · 44:12](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2652)
- "About 50% of cloacas have a duplicated gynecologic system" — Marc Levitt (epidemiological) [Ep 5 · 44:51](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2691)
- "Hydrocolpos in cloaca may obstruct distal ureters and cause bilateral hydronephrosis" — Marc Levitt (clinical) [Ep 5 · 44:40](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2680)
- "For newborn cloaca with hydrocolpos, open divided colostomy with pigtail catheter decompression of vagina is preferred over formal vaginostomy" — Marc Levitt (opinion) [Ep 5 · 45:10](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2710)
- "Attempting cystoscopy at time of colostomy creation in cloaca makes the colostomy very difficult" — Marc Levitt (clinical) [Ep 5 · 45:49](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2749)
- "Laparoscopic approach for cloaca colostomy allows visualization of pelvic structures and percutaneous vaginostomy tube placement" — Marc Levitt (clinical) [Ep 5 · 47:53](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2873)
- "Curled tube is preferred over straight tube for vaginostomy because straight tubes fall out at 2 months when inflammation resolves" — Marc Levitt (clinical) [Ep 5 · 48:50](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2930)
- "Much of hydrocolpos fluid is urine refluxing up, not just vaginal secretions" — Don (clinical) [Ep 5 · 49:30](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2970)
- "Intermittent catheterization of cloaca 2-3 times daily can drain urine and avoid need for vaginostomy tube in many cases" — Marc Levitt (clinical) [Ep 5 · 50:11](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=3011)
- "Catheterization teaching should be done under ultrasound guidance because tube can go into right vagina, left vagina, bladder, or rectum" — Marc Levitt (clinical) [Ep 5 · 51:00](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=3060)
- "Once hydrocolpos is drained, the bladder can fill, demonstrating that hydrocolpos compresses ureters and prevents bladder filling" — Marc Levitt (clinical) [Ep 5 · 52:45](https://qa.library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=3165)
- "Low anorectal malformations (bucket-handle and perineal fistula) are typically managed with local perineal procedures (anoplasty) at birth in stable patients." — Alp (clinical) [Ep 1 · 1:31](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=91)
- "Urethral injury is the most feared and common intraoperative complication when repairing low anorectal malformations, even in seemingly simple cases." — Mark (host_summary) [Ep 1 · 5:58](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=358)
- "When a perineal fistula is visible, the rectum is usually located low, but anatomic variants exist where following the narrow track leads to finding the rectum located much higher than expected." — Pena (clinical) [Ep 1 · 6:37](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=397)
- "When an unexpected high rectal location is encountered during attempted perineal repair, the surgeon must use clinical judgment to decide whether to continue or convert to colostomy." — Pena (clinical) [Ep 1 · 7:23](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=443)
- "Perineal fistula is the anorectal malformation most commonly associated with presacral masses." — Pena (clinical) [Ep 1 · 10:22](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=622)
- "All patients with perineal fistulas must have an AP film of the sacrum (not only lateral) to detect sacral defects that indicate presacral masses." — Pena (guideline) [Ep 1 · 10:02](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=602)
- "Presacral masses cause a very narrow fibrotic anus that interferes with dilation, and patients subjected to dilations may fail only because the presacral mass diagnosis was missed." — Pena (clinical) [Ep 1 · 10:32](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=632)
- "Perineal fistula with presacral mass and sacral defect runs more frequently in families than other anorectal malformations, warranting screening of all family members for sacral defects." — Pena (clinical) [Ep 1 · 10:55](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=655)
- "100% of patients with perineal fistula operated without presacral mass have bowel control, but presence of presacral mass and sacral defect changes the prognosis." — Pena (clinical) [Ep 1 · 11:24](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=684)
- "In females with anterior fistula and adequately sized anal opening (12 Hegar dilator), observation without surgery is an acceptable approach, with one series following 21 girls (median age 7 years) without surgical intervention." — Sabine (clinical) [Ep 1 · 12:07](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=727)
- "Surgical indications for female perineal fistula include: hole too small, distal aspect is fistula tissue (not mucosa) that remains stenotic, and malposition outside the sphincter center, which leads to dilated rectosigmoid and severe constipation." — Mark (clinical) [Ep 1 · 13:01](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=781)
- "Patients with untreated perineal fistula have good bowel control but may have imperfect control as adults, with problems during loose stools or athletic activity." — Mark (clinical) [Ep 1 · 13:29](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=809)
- "Surgical goals for perineal fistula repair are: adequately sized hole, centered within the sphincter, and adequate length perineal body." — Mark (clinical) [Ep 1 · 13:54](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=834)
- "Cutback procedure is an operation for bad surgeons or good surgeons working under very difficult circumstances with very sick babies; it is a temporary procedure but patients subjected to it also have bowel control." — Pena (opinion) [Ep 1 · 14:53](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=893)
- "The most important message about perineal fistula is that patients will suffer the worst constipation in the spectrum of anorectal malformations, requiring aggressive management with laxatives at doses 2, 3, 5, or 10 times more than standard recommendations." — Pena (clinical) [Ep 1 · 15:49](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=949)
- "In the spectrum of anorectal malformations, the lower the malformation, the more severe the constipation; the higher the malformation, the less constipation (with exceptions)." — Pena (clinical) [Ep 1 · 15:49](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=949)
- "Constipation in perineal fistula patients is lifelong and does not follow standard dosing guidelines from textbooks." — Pena (clinical) [Ep 1 · 16:18](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=978)
- "In China, surgeons prefer cutback procedure for male perineal fistula because functional results are good and the procedure is easy to perform." — Long Lee (clinical) [Ep 1 · 17:40](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=1060)
- "The sphincter center can be identified visually as an ellipse of red, pink tissue on the perineum." — Mark (clinical) [Ep 1 · 18:16](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=1096)
- "Adult women with uncorrected perineal fistula may be upset for psychological reasons about having the anal opening very close to the vagina, and there is potential risk of serious rectal injury during vaginal delivery." — Pena (clinical) [Ep 1 · 23:41](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=1421)
- "For male newborns with flat buttocks and no visible fistula at 24 hours of life with abdominal distension, colostomy is the appropriate first procedure rather than primary repair." — Alp (clinical) [Ep 1 · 24:59](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=1499)
- "Since 1948, surgeons have attempted primary repair of anorectal malformations; if lucky enough to find the rectum immediately, successful operation is possible, but this should not be generalized as standard practice." — Pena (clinical) [Ep 1 · 21:45](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=1305)
- "Cross-table lateral film (replacing the invertogram) is performed by placing the baby in posterior sagittal position, placing the film on the lateral side, with the x-ray beam entering the other side, producing the same image as an invertogram." — Pena (clinical) [Ep 1 · 22:13](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=1333)
- "If cross-table lateral film shows gas below the coccyx, an experienced, meticulous surgeon can be sure of finding the rectum via posterior sagittal approach and may successfully repair the malformation primarily." — Pena (clinical) [Ep 1 · 22:39](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=1359)
- "Attempting primary repair without finding the rectum causes serious problems for the baby; such attempts are 'adventures that may become misadventures with serious consequences.'" — Pena (clinical) [Ep 1 · 23:01](https://qa.library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=1381)
- "Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period." — Marc Levitt (clinical) [Ep 3 · 2:57](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=177)
- "Male babies with perineal fistula may pass meconium and have the malformation go unnoticed, typically presenting in the first year of life with severe constipation." — Marc Levitt (clinical) [Ep 3 · 3:06](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=186)
- "In perineal fistula, the hole is too small and anterior to the center of the sphincters, causing the rectum and sigmoid to dilate as stool passes through a tiny fistulous orifice." — Marc Levitt (clinical) [Ep 3 · 3:26](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=206)
- "The standard practice of checking temperature on the forehead or ear rather than rectally means the anus may not be examined, potentially missing malformations." — Marc Levitt (clinical) [Ep 3 · 4:25](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=265)
- "Relocating a perineal fistula into the sphincters does not completely fix constipation, though it improves anatomy by making the hole adequately sized and lined by mucosa." — Marc Levitt (clinical) [Ep 3 · 4:54](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=294)
- "Patients with uncorrected perineal fistula may have some continence with formed stool but will soil with loose stool or athletic activity because sphincter contraction cannot completely close the anteriorly located hole." — Marc Levitt (clinical) [Ep 3 · 5:25](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=325)
- "A newborn anus should accept a size 12 Hagar dilator and a one-year-old should accept size 15." — Marc Levitt (clinical) [Ep 3 · 6:16](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=376)
- "A bucket handle skin tag is consistent with perineal fistula; a probe can be passed underneath it even when the fistula itself is not visible." — Marc Levitt (clinical) [Ep 3 · 6:42](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=402)
- "Diagnosing perineal fistula in females is probably the most confounding thing in pediatric colorectal surgery, with many patients either missed or overdiagnosed." — Marc Levitt (opinion) [Ep 3 · 7:33](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=453)
- "Criteria for perineal fistula in females: hole too close to vagina (inadequate perineal body), inadequate hole size by Hagar dilators, and hole not centered in sphincter." — Marc Levitt (clinical) [Ep 3 · 8:02](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=482)
- "If the hole is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, the patient does not need surgery; the perineal body will lengthen with growth." — Marc Levitt (clinical) [Ep 3 · 8:47](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=527)
- "Examination under anesthesia with stimulation can confirm whether a questionable hole is properly centered within the sphincter." — Marc Levitt (clinical) [Ep 3 · 9:51](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=591)
- "An anesthesia nerve stimulator costing $150 with appropriate needle probes works as well as commercial $15,000 sphincter stimulators." — Marc Levitt (clinical) [Ep 3 · 11:06](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=666)
- "In rectourethral fistula, there is no anal opening and no hope for a hole; some babies pee meconium, making the diagnosis obvious." — Marc Levitt (clinical) [Ep 3 · 12:18](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=738)
- "Rectourethral fistulas should not be approached primarily because the rectum location (bladder neck, prostatic, or bulbar level) is unknown; attempting posterior sagittal incision may find urinary tract structures instead of rectum." — Marc Levitt (clinical) [Ep 3 · 12:45](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=765)
- "Rectourethral fistula patients should be managed with colostomy and distal colostogram, except in exceedingly rare cases where cross-table lateral at 20 hours shows very low rectum allowing safe primary posterior sagittal approach." — Marc Levitt (clinical) [Ep 3 · 13:20](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=800)
- "Cloaca can be missed in the newborn period; a recent case presented at 6 months with constipation when someone finally noticed no anus." — Marc Levitt (clinical) [Ep 3 · 14:07](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=847)
- "Ambiguous genitalia (clitoromegaly from endocrine stimulation) with urogenital sinus has a completely normal anus, distinguishing it from cloaca which has no anus." — Marc Levitt (clinical) [Ep 3 · 15:54](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=954)
- "Cloaca patients have no endocrine problem and two completely normal ovaries, unlike urogenital sinus with virilization." — Marc Levitt (clinical) [Ep 3 · 16:24](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=984)
- "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 3 · 17:18](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?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 3 · 17:39](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1059)
- "Transverse colostomies can prolapse and, with large rectourethral fistula, the left colon absorbs urine causing acidosis; they also make distal colostogram difficult." — Marc Levitt (clinical) [Ep 3 · 18:30](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1110)
- "Preferred technique is very proximal sigmoid colostomy leaving entire sigmoid for pull-through, with tiny flat mucous fistula separated from proximal stoma." — Marc Levitt (clinical) [Ep 3 · 19:14](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1154)
- "Prolapse is related to colon mobility: mid-transverse colostomy both sides can prolapse, hepatic flexure only distal prolapses, proximal sigmoid only distal can prolapse because left colon is fixed to retroperitoneum." — Marc Levitt (clinical) [Ep 3 · 19:58](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1198)
- "Ileostomies prolapse frequently because they are free-floating unless tacked to anterior abdominal wall." — Marc Levitt (clinical) [Ep 3 · 20:37](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1237)
- "The anoplasty site should be marked before making the incision by drawing a circle around the pinkish ellipse where it stimulates on the skin surface, preventing confusion when anatomy is disrupted." — Marc Levitt (clinical) [Ep 3 · 21:30](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1290)
- "Without pre-marking, surgeons can choose the wrong place when seeing muscles jumping with stimulator after opening posterior sagittal incision, requiring re-operation despite good muscle potential." — Marc Levitt (clinical) [Ep 3 · 22:04](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1324)
- "The distal colostogram is an absolutely vital study; many mistakes result from poorly done studies and misinterpretation." — Marc Levitt (clinical) [Ep 3 · 23:29](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1409)
- "The colostogram must answer: where is the rectum, how low is it, is it reachable posterior sagittally or better laparoscopically, and what is its relationship to the urinary tract." — Marc Levitt (clinical) [Ep 3 · 23:55](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1435)
- "Common colostogram error is insufficient contrast and pressure, giving false impression of high rectum and no fistula." — Marc Levitt (clinical) [Ep 3 · 24:11](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1451)
- "If the distal rectum shows a straight line corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure; more pressure will show bulging rectum and fistula." — Marc Levitt (clinical) [Ep 3 · 24:26](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1466)
- "Fistula classification using urethra as reverse C or elbow: fistula at or below elbow is bulbar, above elbow is prostatic, at bladder neck is bladder neck fistula." — Marc Levitt (clinical) [Ep 3 · 25:23](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1523)
- "Bulbous rectum may be reachable posterior sagittally and hard laparoscopically due to girth; tapered rectum is better approached laparoscopically." — Marc Levitt (clinical) [Ep 3 · 25:55](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1555)
- "Opening posterior sagittally without knowing rectum location will find a whitish shiny structure that may be bladder neck, not rectum." — Marc Levitt (clinical) [Ep 3 · 27:00](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1620)
- "Adjunct techniques to locate rectum include balloon catheter in mucous fistula inflated with fluid or gastroscope to look for light, though the speaker has not used these." — Marc Levitt (clinical) [Ep 3 · 28:42](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1722)
- "Never go to the operating room without knowing exactly what anatomy to expect from a proper distal colostogram; the key question is where is the rectum and is it the most posterior structure." — Marc Levitt (clinical) [Ep 3 · 29:28](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1768)
- "Bulbar or low prostatic rectum with bulge is more easily approached posterior sagittally; high prostatic tapered rectum is best served by laparoscopy; bladder neck fistulas are certainly best by laparoscopy." — Marc Levitt (clinical) [Ep 3 · 30:09](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1809)
- "Laparoscopy for bulging rectum below peritoneal reflection at low prostatic or bulbar level requires unnecessary extra work and risks leaving remnant of original fistula (roof) if surgeon is timid." — Marc Levitt (clinical) [Ep 3 · 30:43](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1843)
- "Posterior sagittal approach for high rectum is very difficult to mobilize and risks urinary tract injury." — Marc Levitt (clinical) [Ep 3 · 31:16](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1876)
- "Laparoscopy replaces laparotomy as elegant dissection from above but should not give away advantages of PSARP; a mini-PSARP during laparoscopy allows safe pelvic entry and rectal tacking to prevent prolapse." — Marc Levitt (clinical) [Ep 3 · 31:48](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1908)
- "Preferred terminology is laparoscopic-assisted PSARP rather than laparoscopy versus PSARP." — Marc Levitt (opinion) [Ep 3 · 32:44](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1964)
- "Prolapse prevention: proper levator closure, tacking rectum to posterior edge of muscle complex for 3-4 stitches, not dissecting rectum more than necessary, avoiding excessive trimming." — Marc Levitt (clinical) [Ep 3 · 33:04](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1984)
- "Prolapse occurs in about 3% of cases, particularly in those without great muscles." — Marc Levitt (epidemiological) [Ep 3 · 33:35](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2015)
- "Rectal prolapse causes bleeding, mucus, and can inhibit bowel control in patients with good muscle potential because they cannot close the opening with prolapsed tissue through it." — Marc Levitt (clinical) [Ep 3 · 33:54](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2034)
- "Prolapse more than 3 millimeters should be treated; ideal time is when colostomy is still present." — Marc Levitt (clinical) [Ep 3 · 34:18](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2058)
- "For circumferential prolapse, performing half the circumference in two different ambulatory settings is preferred by families over hospitalization and avoids need for dilation since half is untouched." — Marc Levitt (clinical) [Ep 3 · 34:48](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2088)
- "Perineal body dehiscence prevention requires complete anterior rectal wall separation from posterior vaginal wall to reach areolar plane, avoiding tension on anoplasty." — Marc Levitt (clinical) [Ep 3 · 35:41](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2141)
- "Perineal body dehiscence is the most common cause of reoperation in female ARM repairs." — Marc Levitt (clinical) [Ep 3 · 36:03](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2163)
- "Traditional postoperative management is NPO for 7 days on 10% dextrose (hyperalimentation only if longer than 7 days); recently trialing clear liquids only for a week to avoid hard stool while allowing some oral intake." — Marc Levitt (clinical) [Ep 3 · 36:35](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2195)
- "Daily perineal examination during the first week is critical; if dehiscence is detected on day 5-8, taking the patient back to OR to re-suture can salvage the repair, but by 3-4 weeks later nothing can be done." — Marc Levitt (clinical) [Ep 3 · 37:32](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2252)
- "Laparoscopy causes trouble if dissecting a rectum that is too low, getting too close to urinary tract or being too timid and leaving remnant of original fistula (distal rectum)." — Marc Levitt (clinical) [Ep 3 · 38:36](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2316)
- "For high rectums, particularly bladder neck fistulas, dissection to make the rectum reach with good blood supply is challenging; the IMA must be preserved because prior colostomy may have disrupted left colic collaterals." — Marc Levitt (clinical) [Ep 3 · 39:20](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2360)
- "The rectum has excellent intramural blood supply from the IMA; taking tiny distal vessels along the rectal wall preserves this, but taking IMA or branches too close to aorta will cause rectal necrosis." — Marc Levitt (clinical) [Ep 3 · 39:47](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2387)
- "The biggest PSARP problem is exploring without knowing rectum location and finding bladder neck, urethra, seminal vesicles, vas deferens, or ectopic ureter instead of distal rectum." — Marc Levitt (clinical) [Ep 3 · 40:18](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2418)
- "Famous cases exist of bladder neck being pulled through and made into beautiful anoplasties, with the patient postoperatively draining liquid (urine) from the anoplasty." — Marc Levitt (clinical) [Ep 3 · 41:02](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2462)
- "To determine continence potential, assess three factors: original malformation type, sacral quality and calculated sacral ratio, and spine quality (ARM continence index)." — Marc Levitt (clinical) [Ep 3 · 42:14](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2534)
- "Three A's in continence index (malformation type, sacrum, spine) predicts continence; three C's predicts incontinence; intermediate grades are being quantified through data collection." — Marc Levitt (clinical) [Ep 3 · 42:57](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2577)
- "Bulbar fistula with sacral ratio of 1 and normal spine should absolutely have bowel control; bladder neck fistula with sacral ratio 0.4 and tethered cord or myelomeningocele has no chance of good bowel control." — Marc Levitt (clinical) [Ep 3 · 43:19](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2599)
- "For 4-year-old with soiling and continence potential, first step is mechanical cleaning with bowel management enemas to gain confidence, then when older try switching to laxatives for voluntary bowel movements." — Marc Levitt (clinical) [Ep 3 · 43:52](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2632)
- "If patient cannot be weaned from enemas, consider antegrade option like Malone procedure." — Marc Levitt (clinical) [Ep 3 · 44:25](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2665)
- "Indications for redo pull-through: any continence potential with imperfect anatomy including improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum)." — Marc Levitt (clinical) [Ep 3 · 44:39](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2679)
- "Redoing anoplasty to center rectum in sphincter can change a patient to have continence potential; success is very good when the right patient is selected." — Marc Levitt (clinical) [Ep 3 · 45:08](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2708)
- "One of the biggest problems with anorectal malformations is that surgical errors do not become apparent for years, unlike most surgical complications which are evident immediately." — Marc Levitt (opinion) [Ep 3 · 46:25](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2785)
- "A perineal fistula opens at or anterior to the fourchette, while a vestibular fistula opens posterior to the hymen in the vestibule." (clinical) [Ep 4 · 0:23](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=23)
- "Don's mobilization goal is to mobilize the rectum just enough to reach the perineal skin with a little bit of tension, not necessarily achieving complete separation from the vagina." — Don (clinical) [Ep 4 · 2:27](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=147)
- "Ivo advocates complete separation of rectum from vagina because incomplete separation may lead to retraction and wound problems, and redo cases often show an undissected plane between rectum and vagina." — Ivo (clinical) [Ep 4 · 2:46](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=166)
- "Complete rectal mobilization results in loss of some rudimentary internal sphincter tissue." — Ivo (clinical) [Ep 4 · 3:43](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=223)
- "Michael agrees with more mobilization to bring the rectum down without tension, and warns that dissecting too far from the rectal wall risks entering the posterior vagina even though there is a separate plane (compared to vestibular fistulas with a common wall)." — Michael (clinical) [Ep 4 · 4:10](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=250)
- "In every redo of a female anorectal malformation, the host finds areolar tissue that had never been dissected by the original surgeon, suggesting inadequate anterior rectal wall mobilization." (clinical) [Ep 4 · 5:30](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=330)
- "The host believes that inadequate anterior rectal wall mobilization creates tension that disrupts the perineal body, leading to reoperations." (opinion) [Ep 4 · 6:10](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=370)
- "Don suggests that many redo cases may have been done in the newborn period without a backup colostomy, which could contribute to complications." — Don (opinion) [Ep 4 · 6:49](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=409)
- "Many female redo cases were done with colostomy under all perfect conditions, but the surgeon did not dissect the anterior wall to the areolar plane." (clinical) [Ep 4 · 7:06](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=426)
- "Common perineal groove is a mucosal-lined channel between vagina and anus, associated with anorectal malformation, where the anus itself is normal in size and position." — Jonathan (clinical) [Ep 4 · 7:51](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=471)
- "Jonathan has not found patients with common perineal groove becoming symptomatic from the groove itself." — Jonathan (clinical) [Ep 4 · 8:06](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=486)
- "The vast majority of common perineal grooves, if observed, will become normal skin over time." (clinical) [Ep 4 · 10:36](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=636)
- "For common perineal grooves that produce mucus and do not resolve, a simple fix is to unroof the mucosa and suture it up." (clinical) [Ep 4 · 10:43](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=643)
- "Common perineal groove is often associated with a perineal fistula." (clinical) [Ep 4 · 10:51](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=651)
- "If a hole must be made during dissection, it is preferable to make it in the vagina rather than the rectum because the vagina heals very well with few complications." — Ivo (clinical) [Ep 4 · 12:47](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=767)
- "Rectal blood supply is intramural, so injuring the rectal wall hurts its blood supply." (clinical) [Ep 4 · 13:14](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=794)
- "Michael's key technique is to start laterally and find the lateral plane before attempting to separate or create two structures out of the common wall anteriorly." — Michael (clinical) [Ep 4 · 13:34](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=814)
- "The lateral plane defines the anterior plane during dissection." (clinical) [Ep 4 · 13:51](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=831)
- "Don's technique is to come in from lateral to anterior, and to start more proximally where the structures are easier to separate, then work from proximal to distal." — Don (clinical) [Ep 4 · 14:26](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=866)
- "The host performs vestibular fistula repair primarily without a colostomy, either in the newborn period or as a repair in the next 3-4 months depending on the child's condition." (clinical) [Ep 4 · 15:00](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=900)
- "The host does not believe these patients need a colostomy in the newborn period followed by repair and then colostomy closure (three stages)." (opinion) [Ep 4 · 15:30](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=930)
- "For primary vestibular repair without colostomy, the host waits until the perineal body is healed (around day 6 or 7) before feeding." (clinical) [Ep 4 · 16:27](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=987)
- "The host's practice of delayed feeding is based on experience doing many redo cases, many of which were in patients fed early." (opinion) [Ep 4 · 16:39](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=999)
- "By watching the perineal body carefully during the NPO period, the surgeon can intervene without a dehiscence by taking the patient back to the OR on day 6 or 7 to re-suture the perineal body if needed." (clinical) [Ep 4 · 16:50](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1010)
- "In patients who are fed early and sent home, perineal body disruption may go unnoticed until clinic follow-up at 3-4 weeks or later, or may not be noticed until potty training failure at age 4." (opinion) [Ep 4 · 17:09](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1029)
- "In settings without hyperalimentation, 10% dextrose can be used for NPO periods up to 7 days in healthy, robust children (not in undernourished or very young infants)." (clinical) [Ep 4 · 17:22](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1042)
- "Ivo performed a systematic review on perioperative nutrition showing that early enteral nutrition appears better than later nutrition in retrospective studies, similar to findings in adult surgery, but all studies are poor quality." — Ivo (epidemiological) [Ep 4 · 18:48](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1128)
- "Kate Deans describes rapid learning healthcare systems as a 10-year-old concept that allows continuous accrual of experience with rapid statistical modeling to provide real-time point-of-care results for rare diseases." — Kate (clinical) [Ep 4 · 22:13](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1333)
- "For delayed vestibular repairs (not newborns), the host performs a full GoLYTELY bowel prep until effluent is clear, plus or minus oral antibiotics." (clinical) [Ep 4 · 23:04](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1384)
- "The host's practice for primary vestibular repair includes PICC line placement, hyperalimentation for 7 days, and careful daily inspection of the perineum, with feeding and discharge on day 7 (Tuesday afternoon) if the perineal body is well healed." (clinical) [Ep 4 · 23:55](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1435)
- "About once or twice a year, the host observes early perineal body separation and returns the patient to the OR for reinforcing sutures." (clinical) [Ep 4 · 24:25](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1465)
- "The host does not use a Foley catheter for vestibular or perineal fistula repairs, believing that urine leaking on the perineum is not a big deal." (clinical) [Ep 4 · 25:31](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1531)
- "Jonathan uses a Foley catheter to keep alkaline urine away from the fresh wound." — Jonathan (clinical) [Ep 4 · 26:15](https://qa.library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1575)
- "Indications for surgery in female ARM include: hole too small, hole not in center of sphincter, and inadequate perineal body" — Marc Levitt (clinical) [Ep 7 · 2:34](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=154)
- "Perineal groove with mucosal lining will keratinize and look like normal perineal body over time" — Jason Frischer (clinical) [Ep 7 · 4:45](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=285)
- "Surgical intervention for perineal groove is indicated only if secreting mucus, causing irritation, or developing ulcers" — Jason Frischer (clinical) [Ep 7 · 5:00](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=300)
- "Congenital perineal groove usually epithelializes on its own by age two" — Amanda Jensen (host_summary) [Ep 7 · 6:10](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=370)
- "Perineal groove can be misdiagnosed as contact dermatitis, trauma, or sexual abuse" — Amanda Jensen (host_summary) [Ep 7 · 6:10](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=370)
- "If anal opening is adequately sized, surrounded by sphincter, and has a perineal body (albeit short), no surgery is indicated" — Marc Levitt (clinical) [Ep 7 · 7:14](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=434)
- "Short perineal body will grow over time and there is nothing to do about it surgically" — Marc Levitt (clinical) [Ep 7 · 8:01](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=481)
- "If half the fistula is within sphincter complex and half outside, patient will leak stool because they cannot close the hole, making surgery worthy" — Marc Levitt (clinical) [Ep 7 · 8:39](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=519)
- "Three qualities to assess in anal location are: anal size, location (whether surrounded by sphincter), and perineal body size" — Amanda Jensen (host_summary) [Ep 7 · 9:11](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=551)
- "Vestibular fistula is very common in females and needs formal repair with hole transposed to center of sphincter" — Jason Frischer (clinical) [Ep 7 · 9:35](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=575)
- "For vestibular fistula diagnosed in newborn period, options are primary repair if baby is well, or allow stooling through fistula for couple months then elective repair without stoma" — Jason Frischer (clinical) [Ep 7 · 10:22](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=622)
- "Patients diagnosed with vestibular fistula at 6-12 months who have dilated rectosigmoid need diversion as first step, then repair" — Jason Frischer (clinical) [Ep 7 · 10:22](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=622)
- "Purpose of diversion in ARM repair is to avoid perineal body dehiscence" — Jason Frischer (clinical) [Ep 7 · 10:22](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=622)
- "Cloaca presents with single perineal orifice and hypertrophied area around clitoral hood is typical, not ambiguous genitalia" — Marc Levitt (clinical) [Ep 7 · 11:25](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=685)
- "Cloaca patients do not need endocrine workup or steroids and there is no question of gender assignment - they are female" — Marc Levitt (clinical) [Ep 7 · 11:25](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=685)
- "Cloaca patients are still being misdiagnosed as ambiguous genitalia, with some babies not having proper gender assignment for one to two weeks" — Marc Levitt (clinical) [Ep 7 · 11:25](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=685)
- "Urogenital sinus plus normal anus is an endocrine problem, but no anus and urogenital sinus is a cloaca" — Amanda Jensen (host_summary) [Ep 7 · 12:22](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=742)
- "Key to perineal exam is to push down and flatten the perineal body to assess if it is normal" — Marc Levitt (clinical) [Ep 7 · 13:26](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=806)
- "Use Hagar dilators starting low and working up for accurate anal size measurement; do not use fingers because every surgeon has different size glove" — Rod Gerardo (host_summary) [Ep 7 · 13:38](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=818)
- "Normal anus is centered within sphincter, of adequate size, and perineal body is of normal length properly distanced from vestibule" — Marc Levitt (clinical) [Ep 7 · 13:47](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=827)
- "To evaluate for vestibular fistula, pull labia towards examiner with both hands to visualize vaginal opening and urethra" — Jason Frischer (clinical) [Ep 7 · 14:11](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=851)
- "Female ARM exam requires determining number of perineal orifices: three orifices means perineal or vestibular fistula; two orifices raises question of fistula presence, vaginal atresia, or rectovaginal fistula; one orifice is cloaca" — Amanda Jensen (host_summary) [Ep 7 · 15:03](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=903)
- "A normal anus must meet three criteria: appropriate size, centered in the sphincter, and presence of a perineal body." — Amanda Jensen (host_summary) [Ep 8 · 3:02](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=182)
- "If the hole is in the center of the sphincter with adequate lumen and a perineal body is present, the patient does not need surgery." — Marc Levitt (clinical) [Ep 8 · 3:12](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=192)
- "If the hole is too small or outside of the sphincter, surgery is required." — Marc Levitt (clinical) [Ep 8 · 3:24](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=204)
- "Conversations about female perineal fistula management are more time-consuming than those about cloaca, and patients seek multiple opinions for this relatively benign malformation." — Marc Levitt (opinion) [Ep 8 · 2:25](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=145)
- "There are five valid management options for perineal fistula: colostomy then repair, primary repair, dilation then repair, simultaneous colostomy and repair, and dilation alone." — Marc Levitt (clinical) [Ep 8 · 4:20](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=260)
- "Diverting with a colostomy does not necessarily prevent perineal body dehiscence, and colostomy carries significant morbidity including closure complications." — Marc Levitt (clinical) [Ep 8 · 5:23](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=323)
- "Dilation alone is potentially acceptable but could be problematic if the fistulous distal end will not grow, leading to proximal distension." — Marc Levitt (clinical) [Ep 8 · 6:07](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=367)
- "A vestibular fistula is not a vaginal fistula because the posterior vaginal wall is intact with no fistula to it." — Marc Levitt (clinical) [Ep 8 · 9:14](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=554)
- "True vaginal fistulas are exceedingly rare in anorectal malformations." — Marc Levitt (epidemiological) [Ep 8 · 9:34](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=574)
- "Some perineal fistulas (position 4 on the classification) can be managed with posterior wall mobilization without touching the anterior wall." — Marc Levitt (clinical) [Ep 8 · 10:50](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=650)
- "Anal stenosis (position 5 on the classification) requires screening for Currarino syndrome." — Marc Levitt (clinical) [Ep 8 · 7:38](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=458)
- "Many children with anorectal malformations have associated genitourinary anomalies, which is well documented in the literature." — Kathleen Van Leeuwen (epidemiological) [Ep 8 · 12:12](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=732)
- "During vaginoscopy, seeing a single cervix does not definitively mean only one cervix is present; a second may be found later if there is a narrow side." — Kathleen Van Leeuwen (clinical) [Ep 8 · 12:48](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=768)
- "Surgeons performing vaginoscopy should look for single versus duplicated cervix, distal vaginal atresia, and vaginal septum." — Marc Levitt (clinical) [Ep 8 · 14:09](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=849)
- "The incidence of distal vaginal atresia is quite rare in anorectal malformations." — Marc Levitt (epidemiological) [Ep 8 · 14:21](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=861)
- "Vaginal septums occur in approximately 3 to 5% of vestibular fistulas." — Marc Levitt (epidemiological) [Ep 8 · 14:28](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=868)
- "Perineal fistulas can be associated with distal vaginal atresia, though less commonly than vestibular fistulas." — Marc Levitt (clinical) [Ep 8 · 14:36](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=876)
- "When neurologic anomalies are found in anorectal malformation patients, gynecological anomalies are more likely, especially on the same side." — Jason Frischer (clinical) [Ep 8 · 15:22](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=922)
- "For patients with anorectal malformations and ureteral abnormalities, differential renal function assessment (such as DMSA scan) is important to determine whether to reimplant the ureter or remove a non-functional kidney." — Marc Levitt (clinical) [Ep 8 · 16:36](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=996)
- "Absent kidneys in anorectal malformation patients are usually not truly absent but rather non-functional, often multicystic and dysplastic." — Marc Levitt (clinical) [Ep 8 · 17:20](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=1040)
- "Every surgeon caring for anorectal malformations should know the malformation type, spinal status (tethered cord, myelomeningocele, or normal), and sacral anatomy including sacral ratio." — Marc Levitt (guideline) [Ep 8 · 17:44](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=1064)
- "Sacral ratio calculation is valuable for informing family conversations about potential for bowel control in anorectal malformation patients." — Marc Levitt (clinical) [Ep 8 · 18:15](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=1095)
- "A patient with a low-type anorectal malformation (such as perineal fistula) but with associated spinal pathology has a different prognosis for bowel control than the same malformation with a normal spine." — Marc Levitt (clinical) [Ep 8 · 18:15](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=1095)
- "At Children's National, many surgeons start breast milk on post-op day 0 or 1 after primary perineal fistula repair, advance diet as tolerated, and discharge on post-op day 2-3." — Christine (clinical) [Ep 9 · 0:48](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=48)
- "Alberto Pena's original protocol mandated 7 days NPO with central line and hyperalimentation after ARM repair, feeding only on day 7 if healed." — Marc Levitt (clinical) [Ep 9 · 1:37](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=97)
- "A study by Carlos Reck (now in Vienna, Austria) compared NPO for 7 days versus clear liquids for 7 days and found the same amount of stool output in both groups." — Marc Levitt (clinical) [Ep 9 · 3:04](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=184)
- "The problem is not stool passage itself but hard stool passage that can disrupt the perineal body anastomosis." — Marc Levitt (clinical) [Ep 9 · 3:30](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=210)
- "Dr. Levitt's current protocol is regular IV (no PICC line), clear liquids or breast milk for 5 days, with very low dehiscence rate. Day 5 provides better healing than day 1-2." — Marc Levitt (clinical) [Ep 9 · 3:37](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=217)
- "There is no published article showing post-op day 1 regular diet (not breast milk, but actual food or formula) with a very low dehiscence rate." — Marc Levitt (opinion) [Ep 9 · 3:58](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=238)
- "Phoenix group (14 surgeons) performs most ARM repairs before children are on anything except breast milk or formula, does early repairs with early discharge home on ad lib PO intake, and reports very low dehiscence rate with close post-op follow-up." — Kathy (clinical) [Ep 9 · 4:32](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=272)
- "Perineal body dehiscence usually leads to no perineal body over several months, requiring redo surgery because the anterior anoplasty has no sphincter around it (it's split)." — Marc Levitt (clinical) [Ep 9 · 5:45](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=345)
- "Nearly every redo case Dr. Levitt sees for perineal body dehiscence involved patients who were fed right away and discharged home." — Marc Levitt (clinical) [Ep 9 · 5:59](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=359)
- "Dr. Fisher's protocol for perineal body primary repair (no stoma) is 5-7 days NPO on D10 via midline catheter (not PICC line) until the repair is confirmed healed." — Jason Frischer (clinical) [Ep 9 · 7:17](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=437)
- "A randomized controlled trial by Richard Wood and Dr. Levitt compared dilation versus non-dilation for primary PSARP (cloacas excluded). Families were randomized and knew the backup plan for stricture was dilation ± Heineke-Mikulicz anoplasty." — Marc Levitt (clinical) [Ep 9 · 9:06](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=546)
- "In the dilation trial, both groups (dilation and non-dilation) had stricture rates somewhere between 10 and 20%." — Marc Levitt (clinical) [Ep 9 · 9:33](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=573)
- "Many patients' anoplasties look absolutely fine 8 weeks later at colostomy closure if they were never touched with a dilator, provided the anoplasty was healthy with no tension and good blood supply." — Marc Levitt (clinical) [Ep 9 · 10:25](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=625)
- "The dilation study was prompted by asking families their biggest concern about ARM care, and by far number one was dilations. This was family-driven research, not doctor-driven problem-solving." — Marc Levitt (clinical) [Ep 9 · 10:45](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=645)
- "The non-dilation protocol offers families a choice: dilate twice daily for 4 months, or accept a 10-15% risk of stricture requiring Heineke-Mikulicz anoplasty, with the child already going under anesthesia in 8 weeks for colostomy closure." — Marc Levitt (clinical) [Ep 9 · 11:25](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=685)
- "Dilations can drive couples apart. Often one family member does the dilations and over time doesn't want to come to clinic anymore. Parents feel guilty and find it traumatic to hold their child down for dilations." — Kathy (opinion) [Ep 9 · 12:16](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=736)
- "Jack Langer's protocol is to see patients weekly in clinic and pass a dilator himself rather than having families do it at home." — Marc Levitt (clinical) [Ep 9 · 13:45](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=825)
- "In the dilation trial, 4 patients required redo operations for stricture: 2 in the dilation arm (who didn't actually dilate) and 2 in the non-dilation arm. Additional patients required Heineke-Mikulicz procedures (3 in one group, 47 total procedures mentioned)." — Jason Frischer (host_summary) [Ep 9 · 14:20](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=860)
- "Full continence can be restored with a redo operation for stricture, and data is available showing this. One indication for redo is stricture." — Marc Levitt (clinical) [Ep 9 · 16:38](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=998)
- "The vast majority of patients needing intervention for stricture in the non-dilation protocol are already undergoing surgery for colostomy closure, making the intervention relatively minor." — Marc Levitt (clinical) [Ep 9 · 17:12](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1032)
- "Dr. Levitt has yet to meet a family that has chosen dilation when presented with the non-dilation option and its risks/benefits." — Marc Levitt (clinical) [Ep 9 · 17:21](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1041)
- "Some families at Phoenix have chosen dilation after being presented with the study data and options, preferring the known approach since long-term continence outcomes of non-dilation are not yet established." — Kathy (clinical) [Ep 9 · 18:08](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1088)
- "In Ghana, a colleague makes anoplasties slightly bigger knowing patients won't return for follow-up, anticipating some contraction will occur." — Marc Levitt (clinical) [Ep 9 · 19:37](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1177)
- "For redo ARM cases, Dr. Levitt makes the anoplasty a little bigger knowing there will be contraction. Redos are not dilated at all, but are examined under anesthesia at one month to check for early stricture." — Marc Levitt (clinical) [Ep 9 · 20:18](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1218)
- "For primary repairs, Dr. Levitt makes the lumen match what the maximal rectal lumen can be. With good mobilization (not overdoing it, throwing away as little rectum as possible), the anoplasty is usually a good size, about Hegar 13 or 14 at the end." — Marc Levitt (clinical) [Ep 9 · 20:33](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1233)
- "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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 19:37](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=1177)

## Changelog
- Sep 12: 1 item added automatically
- Sep 9: 2 items no longer name perineal fistula
- Sep 7: 16 items added automatically

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