COLORECTAL QUIZ: December 20, 2021

Ron Reeder • December 20, 2021

For the last two weeks we have been discussing a 12 year old female with lifelong constipation managed with a stool softener who presented with massive abdominal distension, peritoneal findings, and the below xray. She was taken urgently to the operating room and was found to have a sigmoid volvulus. 



The surgeons who cared for her untwisted the volvulus, the sigmoid was viable, and decided to perform a sigmoid resection with primary anastomosis. On POD #5 the patient had a leak from that anastomosis, a tiny hole at the staple line, and she underwent re-exploration, and they performed a colostomy with a Hartman’s pouch. I asked you for your plan now.

Below are the contrast studies with colostomy in place, showing the proximal colon and the Hartman’s.

The patient was ruled out for HD by rectal biopsy. An anorectal manometry was normal – but this test was vitally important to inform you whether botox would be needed to treat internal sphincter achalasia. The stoma had been functioning well, so Hartman’s closure can proceed. I would be inclined to check the motility of the proximal segment (CMAN, sitzmark, scintigraphy) to be sure no additional colon should be removed at the time of the colostomy closure. And, based on the constipation history prior to the volvulus would decide whether a Malone should be added to the procedure. Her constipation was not bad, easily managed by medication so a Malone was not felt to be needed here.

 

For this week, what would be your plan for this male patient with an ARM and the following distal colostogram. Was this a well-placed initial colostomy?

What would your plan now be?

There’s a new podcast!


Here is the current list of the Colorectal Quiz podcasts, best viewed via the StayCurrent app:

Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula - https://staycurrentapp.app.link/wK2FhonUEhb  

 

Colorectal Quiz Episode 2: When to redo a PSARP - https://staycurrentapp.app.link/RX2eeDqUEhb

 

Colorectal Quiz Episode 3: Hirschprung Disease - https://staycurrentapp.app.link/UnFRkprUEhb

 

The Colorectal Quiz Episode 3.5 - Proximal Hirschsprung Disease - https://staycurrentapp.app.link/JiaWCGsUEhb

 

The Colorectal Quiz Episode 4: Classic Hirschsprung disease - Surgical Technique - https://staycurrentapp.app.link/qGWLoGtUEhb

 

The Colorectal Quiz Episode 4: Classic Hirschsprung disease - Surgical Technique - https://staycurrentapp.app.link/qGWLoGtUEhb

 

The Colorectal Quiz Episode 5: Proximal Hirschsprung Disease Surgical Technique - https://staycurrentapp.app.link/AiGHjcvUEhb

 

The Colorectal Quiz Episode 6: Bowel Management Part 1 - https://staycurrentapp.app.link/SVuVYWvUEhb

 

The Colorectal Quiz Episode 7: Bowel Management Part 2 - https://staycurrentapp.app.link/b8IhkKwUEhb

 

The Colorectal Quiz Episode 8 - Motility Disorders Part 1 - https://staycurrentapp.app.link/NRerIoxUEhb

 

The Colorectal Quiz Episode 9: Motility Disorders Part 2 - https://staycurrentapp.app.link/s2cVlbyUEhb

 

The Colorectal Quiz Episode 10: Total Colonic Hirschsprung Disease Part 1 - https://staycurrentapp.app.link/fEtTMRyUEhb

 

The Colorectal Quiz Episode 11: Total Colonic Hirschsprung's Part 2 - https://staycurrentapp.app.link/MNqS9yzUEhb

 

Colorectal Quiz episode 12 Newborn ARM Part 1 - https://staycurrentapp.app.link/x5UL6DBUEhb

 

Colorectal Quiz Episode 13 Newborn ARM Part 2 - https://staycurrentapp.app.link/YqVpTmCUEhb

 

Colorectal Quiz Episode 14: ARM Newborn Part 3 - https://staycurrentapp.app.link/x9mUY7CUEhb

 

Colorectal Quiz Episode 15: Bowel Management in Spinal Patients - Need for a urologist - https://staycurrentapp.app.link/etX3mPDUEhb

 

Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a urologist - https://staycurrentapp.app.link/5C7GsJIDEhb

 

Colorectal Quiz Episode 17: Cloaca Part I - https://staycurrentapp.app.link/YGPmYZPEPhb

 

Colorectal Quiz Episode 18: Cloaca Part II - https://staycurrentapp.app.link/vUEzQxG80hb 

 

Colorectal Quiz Episode 19: Hirschsprung Disease - The Obstructed Patient Part 1 - https://staycurrentapp.app.link/gBzrAtLKLib

 

Colorectal Quiz: Episode 20:- Hirschsprung Disease – The Obstructed Patient Part 2 - https://staycurrentapp.app.link/W7kEcqB6vjb


Colorectal Quiz Episode 21: The History of Hirschsprung Disease - https://staycurrentapp.app.link/QXtFg2UlTjb


The Colorectal Quiz Episode 22: Hirschsprung Disease - the Soiling Patient Part 1 - https://staycurrentapp.app.link/OII38hVhQkb



The Colorectal Quiz Episode 23: Hirschsprung Disease The Soiling Patient Part 2 - https://staycurrentapp.app.link/DA4WEDIcXlb

Colorectal Conundrum: January 29, 2024

By Ron Reeder • January 29, 2024
Colorectal Conundrum for January 29: A male with a rectoperineal fistula undergoes a PSARP with mobilization of the rectum, both anterior and posterior rectal walls. In the days following surgery he starts to drain urine around the anoplasty consistent with a urethral injury. He is also voiding via the penis. A cystogram is shown below. How would you manage this situation? Answer: This patient has suffered from a urethral injury, and urine is draining out the posterior urethra into the perineum around the anoplasty. The key first step is to divert the urine with a suprapubic tube. A colostomy is not necessarily needed. The fistula might heal with diversion. If after a month or so a cystogram shows the persistence of the fistula, then a redo is needed with re-mobilization of the rectum, fully lifting the anterior rectal wall off of the urinary tract, and repair the urethra, with coverage of the posterior urethra with an ischiorectal fat pad. Then a voiding trial a month later with ultimate removal of the SP tube.

Colorectal Conundrum: January 22, 2024

By Ron Reeder • January 22, 2024
Colorectal Conundrum for January 22nd: In the previous week’s case, of an imperforate hymen, the MRI showed dilation all the way down to the perineum. Management involved a perineal – introital – incision to drain the fluid. If that were not the case and you had a dilated vagina but the distal extent was far away from the introital area, how might you handle that hydrocolpos? Answer: If this were a case of hydrolpos with normal anus and normal urethra, and the vagina cannot be drained by the introitus like an imperforate hymen, then drainage needs to be from above. IR or laparoscopy is an ideal approach to get a drain in the dilated structure (remember this could be bilateral, so both sides may need to be drained. Drainage is to relieve distension and most concerning its potential cause of distal ureteral obstruction causing hydronephrosis. Once the material hormones have dissipated the hydrocolpos will resolve and can be dealt with later in life via a laparoscopic distal vaginal pull-through, after the onset of puberty. In such a patient, I would follow closely with ultrasound 6 months after thelarche (breast budding).

Colorectal Conundrum: January 16, 2024

By Ron Reeder • January 16, 2024
Colorectal Conundrum for January 16: A newborn female is noted to have abdominal distension. On exam the uretha and anus are normal, and there appears to be a bulge in the hymen. The has an MRI with the image shown below. What would be your treatment plan? What are the variations in such a case and how would you manage each? Answer: This could be a case of imperforate hymen, but the MRI is key – how high up is the obstruction? How large is the hydrocolpos? In this case, it appears that a perineal incision might all that is needed as the dilation extends all the way down to the perineum. That is the most common scenario. An incision at the level of the hymen should drain out the fluid and no further intervention should be needed. Of course a careful exam needs to check to be certain you see a urethra – sometimes such a bulge could be a paraurethral cyst. For the next week’s question – what would you do if the perineal approach was inadequate – i.e. could not reach the dilated lumen.
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