Postoperation Care After Pull-Through / PSARP Surgery for Anorectal Malformations / Imperforate Anus
Two weeks after the Pull-Through / PSARP surgery, the stitches are removed and the antibiotic ointment is discontinued.
At this time, the process of anal dilations is initiated. The dilations prevent anal structures from forming because of the scar tissue around the anus.
It is imperative for the family to adhere to the guidelines given to them. The surgeon generally passes the first dilator and then the surgeon or pediatric surgical nurse teaches the parents the dilation process.
Position the child with the knees flexed close to the chest. Lubricate the tip of the anal dilator and insert it three to four centimeters into the rectum.
Repeat this procedure twice a day for approximately 30 seconds each time. Every week advance to the next size dilator. After six to eight weeks the "desired size" is reached. Then, colostomy closure is planned.
Patients who undergo a posterior sagittal operation generally have a smooth post operative course. The incision is relatively painless considering the extent of surgery that was done.
We attribute this to the fact that the operation is done through a midline incision and most probably no nerve endings are divided.
Foley catheters in those cases with urinary fistula must remain in place between five and 14 days. Five days will be adequate for a typical rectourethral bulbar fistula, and up to two weeks are needed for a complicated or complex cloaca.
In service cloacas, a formal suprapubic cystostomy is recommended rather than inserting a Foley catheter. We believe that the presence of a foreign body in the urethra for longer periods of time will not only fail to prevent strictures, but may act as a foreign body, causing irritation and increasing the inflammatory rectourethral fistulas in males.
If the catheter comes out before five days, it is better to leave it out rather than risk tearing the sutures in the posterior urethra by trying to recatheterize the child. Most patients will void spontaneously without further consequences.
On a few occasions, when the patient cannot void, then a percutaneous suprapubic tube can be inserted and left in place for three to five days.
Bacitracin ointment is used three times a day on the wound site. Antibiotics, including ampicillin and gentamicin, should be administered intravenously, usually 24 to 72 hours.
After that period, provided the patient is doing well and no manifestation of infection is seen, we suggest stopping the intravenous antibiotics and continuing with ampicillin by mouth.
In specific cases in which the colostomy was not completely diverting and therefore gross fecal contamination occurred during the operation, we give a more aggressive treatment with ampicillin, gentamicin and clindamycin for one week postop.
Those patients whose abdomen was also opened in order to repair a very high defect, in addition to the postop care already described, may need a nasogastric tube for a variable period, usually 48 to 96 hours, until there is evidence that the bowel is working well.
A child who underwent a posterior sagittal operation without having had the abdomen opened, may receive oral feedings on the day of surgery. They can be discharged after 48 hours, whereas the patients with laparotomy may spend a few more days in the hospital.
For more information or to request an appointment, please contact the Colorectal Center at Cincinnati Children's.
