COLORECTAL QUIZ: February 14, 2022

Ron Reeder • February 14, 2022

Hello all and happy Monday. It’s that time again.


Last week I asked you about a case of a 3 year old girl who underwent a laparoscopic pull-through in the newborn period. Over the last year she has had four episodes of enterocolitis, has been given botox several times, but these episodes of enterocolitis have continued to occur. She is otherwise growing well, and is now fine, but on a daily irrigation. Exam under anesthesia shows no stricture, no twist, no cuff. Her dentate line and sphincters are intact. You do a rectal biopsy and we offered three possible scenarios.

What would you do in the following three scenarios, if the rectal biopsy showed:

  1. no ganglion cells, plus hypertrophic nerves – in this case I think we all agree, she needs a redo of the pull-through
  2. ganglion cells present, plus hypertrophic nerves – this is a tough call. I would like to know what the original pathology showed, and whether that biopsy showed transition zone. This could represent a transition zone, but also could represent decompensation of the pull-through with the subsequent development of hypertrophic nerves (that weren’t there at the original pull-through. This could result from her non-relaxing sphincters or inadequate medical management (i.e. laxatives). But these obstructive symptoms are significant, and therefore I would offer a redo.
  3. ganglion cells present, plus normal nerves – this patient needs medical management, to include botox, plus laxatives, or for the short term, enemas – either retrograde or antegrade (Malone).

I sent you this email prior to knowing what would happen with the case, and ultimately this biopsy showed scenario #1, and the patient underwent a redo, and so far is stooling very well, which I anticipate will continue.

For this week, let’s continue with another Hirschsprung conundrum.

I was asked to see a 1 year old boy who was ex-premature (32 weeker), with a VSD, weighing 1.5 kg, who had distension in the newborn period and a rectal biopsy showing HD. The contrast study had shown no obvious transition zone. He went to the OR for a planned pull-through but biopsy of the proximal sigmoid on frozen section showed no ganglion cells. The cecum and ileum were biopsied and showed ganglion cells. The surgeon then opened an ileostomy with no further biopsies. What would you do now?

  1. Laparoscopy with biopsy of left colon and if ganglion cells proceed with pull-through?
  2. Laparoscopy with mapping of the colon and wait for another time for definitive pull-through after final pathology has returned

And, if you do a pull-through

  1. Would you leave the ileostomy? Or
  2. Close the ileostomy at the same time



What would you do next?

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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 Pts. Need for a urologist Part 1               https://staycurrentapp.app.link/etX3mPDUEhb

 

Colorectal Quiz Episode 16          Bowel Management in Spinal Pts. Need for a urologist Part 2               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

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

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

Colorectal Quiz Episode 24          Cloaca Part 3                                                                                                    https://staycurrentapp.app.link/3uuEG49mkmb

Colorectal Quiz Episode 25          Perineal Groove                                                                                             https://staycurrentapp.app.link/PxlGWtfswmb

Colorectal Quiz Episode 26          Perianal Crohn's Disease                                                                            https://staycurrentapp.app.link/qQbadIDjTmb


Some announcements of future meetings – please join for these virtual offerings by the pcplc.





 

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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