Update Course Rewind 2025: Timing of PSARP: Early vs. Delayed—Does It Really Matter?

Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. I'm Jill Knepprath with Stay Current MD. In this video series, we will be recapping some of the key highlights from our 13th annual update course in pediatric surgery. This is on timing of PSARP, early versus delayed. Does it really matter? for patients with rectal vestibular fistulas, some surgeons still insist on performing anal rectoplasties right away. Others say, wait till after discharge. So what's right? The data may surprise you. In this session. Doctor Jamie Harris presents a full-term newborn baby girl with rectal vestibular fistula. She weighs 3 kg, and they've done the workup in the NICU and her Vactral workup is completely negative. Let's see what the audience thinks the next step should be. So on the poll, it looks like dilations and then delayed PARP is leading by a substantial margin. Doing dilations alone is probably not the correct management of this for a number of different reasons, but certainly dilations initially will allow for decompression. I would recommend only dilating to a 7 Hagar to decrease the potential scarring along the track for future Parps. Jamie, you brought up a really important point about that if you're gonna just try to keep it open, you just have to keep it open enough for little soft, mustardy poop to be able to make it through there. There's no reason. To drive that dilation up big. This leads us to the next question. What is the ideal timing to do the PSAP? I would rather do it at one month of age so the baby could grow a little bit bigger. I think Nelson and I disagree a little bit on this. He likes doing them up front, but I like getting them a little bit older, let the babies go home. It doesn't have to be the next day, but I like to get it done on the neonatal admission. The panel agreed that it's safe to perform the PSARP either early before discharge or later around 1 to 3 months of age. There were two important studies that both came out in 2021. The first is a Nisquip study that defined early repair as 7 days. Delayed repair was between 6 weeks and 8 months. They found no difference in overall outcomes, including. Re-operations and readmissions. There was another study in 2021. This one looked at 30-day outcomes and it was neonatal versus delayed anoplasty and a multi-institutional retrospective study through the PCPLC. Their early repair was defined as 14 days versus a late after 14 days. Wound breakdown and dehiscence was the most common complication for both early and delayed repair groups. However, there was no significant difference in postoperative complications between the groups. So they concluded the same thing. This slide shows the discrepancy in terms of delayed repair from A couple of months to multiple months of age, so there's no right timing of delayed repair in the literature. What are the drawbacks to delayed repair in practice? One, that theoretical fibrosis of the fistula tract, making your dissection a little bit more difficult on the PSARP. The other is if you're not completely decompressing it, the rectum can get distended and make it technically more difficult to perform that PSARP. An early repair during the newborn period also Avoids an additional admission for the surgery. With some of the social determinants of health that have been looked at recently, it's not always easy for families to make that trip multiple times. It's a long distance and can also be expensive. Let's summarize. Both early and delayed PSR repairs are safe for patients with rectal vestibular fistulas. What matters most is the circumstances, family access to care, patient size, and importantly, your comfort and experience as a surgeon. Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.