COLORECTAL QUIZ: October 17, 2022

Ron Reeder • October 17, 2022

Happy Monday! 


Last week I asked you about a patient with a cloaca, whose anatomy is shown below. I pointed out some highlights: massively dilated left ureter (but MAG III scan showed no distal ureteral obstruction), rectum entering the common channel high, above the PC line, and no evidence of any vaginal connection to the common channel.



Many aspects to this case – the rectum is attached to the common channel and can be mobilized laparoscopically. The common channel will become the urethra. There is no visible vagina, and during the laparoscopy the Mullerian structures need to be inspected. In this case there were none, just normal ovaries and tiny Fallopian tubes on either side. So in the future she will need a vagina, perhaps created with buccal graft or maybe tissue engineered will be available then! I have stopped doing vaginal replacement with colon, unless I need that to bridge the gap to the perineum after a UG separation, but then would have the plan to excise the neovagina in the future and to pull-through the native vagina. If in this case we had found a blind ending but present vagina with a lumen, I would have waited until puberty and then done a laparoscopic mobilization of the distal vagina.

So for this week, we had a patient with HD who initially underwent colonic mapping and an ileostomy. The transition zone was found to be at the splenic flexure. The pull-thru of the splenic flexure went very well, it was pulled down the left side of the abdomen, and we performed a simultaneous closure of the ileostomy. In the postop period the patient had a prolonged ileus, but interestingly passed stool and gas but remained with high volume NG output which was bilious, for 7 days. The abdomen remained flat and the patient was clinically well otherwise. What do you think may be going on, and what would you do about it?


Please note, our weekly quiz is also posted on the Pediatric Colorectal and Pelvic Learning Consortium, (PCPLC) website, www.pcplc.org

https://www.pcplc.org/educational_courses/quizzes

Access code is: pcplc-2022!

How would you handle this case?

Looking forward to seeing many of you soon at the upcoming PCPLC meeting in Cincinnati, November 2-4, 2022:   Information for registration found at www.pcplc.org

Pediatric Colorectal Surgery Tips and Tricks is now out. You can order it using this link: https://bit.ly/Levitt-CRCBooks and this discount code: MAL22.

All proceeds from the sale of the book benefit Colorectal Team Overseas, www.ctoverseas.org

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

The newest Colorectal Quiz Episode # 34 "Newborn Perforation in ARM" is at the bottom of the list.

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             Hirschsprung 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 III

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


Colorectal Quiz Episode 27          Delayed Hirschsprung Disease

https://staycurrentapp.app.link/v37xYPDSDnb


Colorectal Quiz Episode 28          Female ARM Management - Perineal Fistula 

https://staycurrentapp.app.link/lLH7KQr20nb


Colorectal Quiz Episode 30          Tethered Cord

https://staycurrentapp.app.link/sE57H6IPzob


Colorectal Quiz Episode 31          Müllerian Anomalies in patients with ARM

https://staycurrentapp.app.link/FuQyrjuC8ob


Colorectal Quiz Episode 32          Anorectal Malformations and Cardiac Anomalies

https://staycurrentapp.app.link/3yJWt3t1rqb


Colorectal Quiz Episode 33          Cloacal exstrophy 

https://staycurrentapp.app.link/H4l85Pe2isb


Colorectal Quiz Episode 34          Newborn Perforation in ARM

https://staycurrentapp.app.link/EgIRTe14wtb

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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