Jason Fisher

Jason's statements about Anorectal Malformation 56 statements

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Bowel Management Updates & Innovations with Live Q&A: April 2018

Statement The Colorectal Center patient population includes anorectal malformations (imperforate anus), Hirschsprung's disease, spina bifida, sacrococcygeal teratomas, trauma patients, and refractory constipation. Open

Statement Appendicostomy (Malone/MAC/ACE procedure) involves bringing the appendix to the belly button with a valve mechanism to prevent reflux, allowing patients to independently administer flushes through the colon over 10–15 minutes, then sit on toilet for approximately 45 minutes to empty. Open

Statement Sacral nerve stimulator is not FDA approved for children under 18, but is performed off-label; it acts like a heart pacemaker, stimulating the third sacral nerve to improve bowel and urinary continence outcomes. Open

Statement Sacral nerve stimulator is a two-stage procedure (test phase and permanent phase) and has been performed at Cincinnati Children's for almost 3 years. Open

Statement Solesta is an injection of hyaluronic acid polymer that fills space in the anal canal, used in patients with patulous (more open) anuses to help gain control. Open

Statement Patients with deformed sacrums have lower likelihood of success with bowel management using medication alone (not on enema program). Open

Statement Malone procedure requires prior success with enemas because it only changes the route of administration; surgical procedure should not be performed on patients unsuccessful with enema program. Open

Statement Malone procedure is typically performed starting at age 5 years and older, most commonly between ages 5 and 10–12 years. Open

Statement Vomiting after enema can be caused by high-volume enema with irritant causing colon distention and discomfort. Open

Statement Sacral nerve stimulator indication per manufacturer requires 50% improvement on symptoms; patient must have tried non-surgical bowel management first. Open

Statement Sacral nerve stimulator requires normal sacrum; it is the least invasive option compared to Malone or Solesta when bowel management is working or needs improvement. Open

Statement Using hybrid OR with 3D imaging, sacral nerve stimulator can be placed in patients with very abnormal sacrums by identifying anatomy in real-time. Open

Statement For failed redo Hirschsprung's pull-through, redo surgery can almost always create a channel for stool evacuation via rectum/anus, even after 1–3 prior redos; very few patients end up with ileostomy if goal is rectal evacuation. Open

Statement The large intestine (colon) primarily absorbs water; in adults it can absorb up to 1 liter of water per day. When colon is removed, stool becomes softer/looser because less water is absorbed. Open

Statement Bowel management sometimes requires using Imodium to constipate/harden stool, then using enema to empty it—thickening stool first, then mechanically emptying. Open

Quotation There is no perfect surgery for constipation. If we had it, we would all recommend it and do it. Open

Statement There is no perfect surgery for constipation; if there were, all surgeons would recommend and perform it. Open

Statement Transanal colon/rectum resection is minimally invasive but carries risk of post-surgical incontinence in some patients. Open

Statement Colon resection for constipation may lessen treatment burden (e.g., reduce laxative dose from 10 to 5 squares of Ex-Lax) but this outcome is not guaranteed. Open

Statement Before colon resection, offer sacral nerve stimulator and perform manometry (colonic and anorectal) to identify non-functioning colon segments or outlet problems (sphincter dysfunction). Open

Statement Anorectal manometry can reveal paradoxical sphincter function where child squeezes when trying to relax and vice versa; Botox works in younger children, physical therapy and biofeedback in older children for this. Open

Statement Colon resection is a big surgery requiring bowel anastomosis with associated risks; once colon is resected, it cannot be replaced. All other treatments (sacral nerve, enemas, laxatives) are reversible. Open

Statement Senna laxative is like insulin for a diabetic—a necessary medication to help move bowels in severe constipation; dose may change over time but patients are not 'addicted' to it. Open

Quotation I sort of say it's like insulin for a diabetic. A diabetic needs insulin to lower their blood blood glucose levels. A patient who has severe constipation needs a laxative stimulant to help move their bowels. Open

Statement Stimulant laxatives (Senna, Dulcolax) make the colon squeeze/push stool forward and reduce water absorption time, resulting in softer stool—two mechanisms that benefit the patient population. Open

Statement Only two stimulant laxatives are available in the United States: Senna (Ex-Lax chocolate squares, tablet, liquid forms) and Dulcolax. Open

Statement MiraLax is not a stimulant laxative; it prevents colon from absorbing water, keeping water in colon and making stool softer. Open

Statement MiraLax is avoided in patients without full continence mechanisms because very loose stool is hard to control when nerves and muscle are partially impaired. Open

Statement In spinal cord patients (tethered cord, spina bifida), stool is often so formed that MiraLax-type agent is needed to soften stool along with motility agents. Open

Statement Bowel rest with colostomy is typically used in patients with anorectal malformation or Hirschsprung's pull-through complications (narrowing, stenosis, tightness) causing dilated colon/rectum upstream. Open

Statement If colostomy is not working due to constipation, consider ileostomy to totally exclude colon and divert stool before it reaches colon. Open

Statement Michael Helmrath at Cincinnati Children's is growing colons in the lab from single cells, able to lengthen colon in mice and expanding to larger primates. Open

Statement Anal sphincter tissue regeneration has been attempted by many researchers (using muscles from other areas, other sphincters from esophagus/stomach) but none have been proven to work; no successful procedure is currently offered. Open

Statement Cincinnati Children's has nearly 3 years of experience with sacral nerve stimulators in children; it works in refractory constipation and combined urinary/stool issues, but pediatric patient heterogeneity makes outcome prediction difficult. Open

Statement Sacral nerve stimulator was initially designed for urinary incontinence in postpartum women; during testing it was found to also help fecal constipation and incontinence, leading to later FDA approval for fecal symptoms. Open

Statement Sacral nerve stimulator in adults is used in patients with normal anatomy/development, but in pediatrics it is used in patients with prior pelvic operations, malformations, or disease processes, making study difficult because every patient is different. Open

Statement Sacral nerve stimulator has a temporary trial stage (1–2 weeks); if it doesn't work, the device is removed without implanting permanent battery. Open

Statement Constipation or fecal impaction puts pressure on urinary tract, causing urinary infections, improper emptying, urgency, and other symptoms; treating stool issues is often first step before urologic investigation. Open

Statement All anorectal malformation patients should be followed by urology long-term; more complex malformations have more associated urinary tract malformations, but even minor malformations require periodic follow-up to ensure kidney function and proper urinary tract emptying. Open

Statement Urinary tract problems in anorectal malformation patients can cause diminished health with late-appearing signs/symptoms; regular urology checkups (exam, renal ultrasound, possibly further testing) are important even without visible problems. Open

Statement Cincinnati Children's has weekly meeting with colorectal, urology, and gynecology teams reviewing all patients to ensure comprehensive (not just focused) evaluation. Open

Statement Long-term MiraLax literature is scant; many patients do fine on it. A class action lawsuit against MiraLax occurred 1–2 years ago but has not been heard about recently. Open

Statement A couple of studies suggested MiraLax may have less-than-ideal neurodevelopmental outcomes, but these have not been reproduced; it is something to be thoughtful about when prescribing. Open

Statement Fleet phosphate enema causes the most irritation with long-term use, making colon look like a 'lead pipe' (very stiff, lacking mobility and pliability); it is used intermittently as rescue enema, not for long-term maintenance. Open

Statement Solesta is not FDA approved for children; it is used in patients with patulous (open) anus as a filler to close the anal canal and help with fecal incontinence. Open

Statement Solesta can be used in any age patient; Cincinnati has used it in patients 3–4 years old and older, with mixed results but little side effect (small infection risk). Open

Statement Solesta or sacral nerve stimulator may help patients transition from enemas to laxatives when prior attempts have failed, depending on individual anal canal anatomy and situation. Open

Statement Sacral nerve stimulator results in spina bifida patients are mixed; some respond positively, others do not. Literature and research exist on this. Open

Statement Sacral nerve stimulator in spina bifida requires adequate sacrum anatomy and presence of third sacral foramina (opening where third sacral nerve exits sacrum to innervate pelvis). Open

Statement Botox is a muscle relaxant that relaxes the anal sphincter; it is used in Hirschsprung's disease patients with high anal resting pressures. Open

Statement Solesta is hyaluronic acid polymer, a gel filling agent that closes a wide-open (patulous) anal canal; it acts very differently from Botox. Open

Statement Hirschsprung's patients can potty train around the same age as other children; some will have harder time with continence depending on post-surgical anal canal anatomy and development. Open

Statement Hirschsprung's evaluation requires contrast enema to assess surgical anatomy of anal canal and entire colon, plus repeat biopsy because initial frozen section may show adequate nerve cells but later those cells may be less abundant (transition zone). Open

Statement Anorectal malformation is abnormal development of where colon/rectum ends up (where it 'lands' in development); there is a wide spectrum in males and females. Open

Statement In anorectal malformation, rectum can land outside anal canal/sphincter complex on skin just above that area, outside vagina in girls, anywhere along urinary tract in boys (with fistula causing stool to come out urinary tract), or connected to bladder in more complex cases. Open

Statement Anorectal malformation diagnosis requires good physical exam and sometimes imaging. Open

Jason's statements about Anorectal Malformations & Cloacal Reconstruction 3 statements

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Colorectal Quiz: Episode 41 - Perineal Hypospadias

Quotation It's that delicate balance of getting enough mobilization that your anastomosis is not under any tension. But less is more in this case, because there's a lot of damage that can happen on that anterior dissection. Open

Statement The surgical goal is to achieve enough rectal mobilization that the anastomosis is not under tension, but less dissection is better because significant damage can occur with anterior dissection. Open

Statement The fistula tissue is mucosally lined and might potentially be used by urologists for hypospadias repair. Open

Jason's statements about Cloaca 10 statements

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Colorectal Quiz Episode 18: Cloaca Part 2

Statement Definitive diagnostic workup for cloaca is usually performed at about 5-6 months of age Open

Quotation Yeah, so we usually do it at about five to six months. Open

Statement During cystoscopy it is important to look for cervices to determine if there is one or two vaginas and assess Müllerian development Open

Quotation I think it's also important to look for cervices and see if you have one vagina, two vaginas. Do you have a cervix, which will sort of be the front door? Is there a uterus behind there? Open

Statement Surgeons should look for ureteral orifices during cystoscopy because in complex malformations there can be anomalous ureteral attachments to the bladder or bladder neck that come in very low and could be treacherous Open

Statement Endoscopy performed by general pediatric surgeons has value in determining whether a cloaca is straightforward or complex, helping surgeons decide whether to refer to a specialized center Open

Quotation I can tell you, as recently as 10 or 15 years ago, there was a lot more redoing of cloacas that was required because I think surgeons attempted a repair and then realized that it was much more complicated than they had imagined. Open

Statement As recently as 10-15 years ago, there was much more redoing of cloacas required because surgeons attempted repairs without adequate evaluation and realized the cases were more complicated than imagined Open

Statement Lower confluence cloacas are elegant operations if the surgeon knows how to perform them, while higher confluence cases with vaginal replacements and ectopic ureters should be done at specialized centers Open

Quotation The definition is of urethral length because I think some people may consider that from the single orifice all the way to the bladder neck and I don't think that's what you're alluding to. Open

Jason's statements about Colorectal / ARM & Hirschsprung 72 statements

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