Colorectal Quiz: December 19, 2022

Ron Reeder • December 19, 2022


Happy Monday! We will take a bit of a break from these quizzes, after this one today, until after the new year. I want to take this opportunity to wish everyone a happy holiday season and new year!


Starting soon these quizzes will go directly to the StayCurrent app, and will be more interactive – I think you are going to really like the new format.

 

Last week I asked you about a one-year-old boy who was treated for neonatal obstruction with an ileostomy. At that time, a biopsy of the sigmoid showed ganglion cells, but a rectal biopsy showed no ganglion cells but also no hypertrophic nerves. Below is the contrast study.

So many of you asked for a repeat rectal biopsy which I was happy to hear – because we all should know that no HD operation should be done with only the absence of ganglion cells.


To my frustration that repeat biopsy showed the same thing, no ganglion cells but also no hypertrophic nerves, which was quite confounding. Calretinin staining was negative which helped me confirm my suspicion that we were dealing with Hirschsprung’s and we planned a pulled through. In the operating room, the mid-sigmoid colon showed no ganglion cells and hypertrophic nerves. The proximal sigmoid/distal left colon showed good ganglion cells and normal nerves. We did the pull-through to that level and also closed the ileostomy.

 

For this week, another Hirschsprung’s challenge:

A patient with total colonic HD has been living their life with an ileostomy, but they are short gut – requiring 12 hours of TPN plus enteral feeds via a G tube. They are being evaluated for a possible small bowel transplant. Is there anything to be done for this patient to improve their nutrition?

 

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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