Colorectal Quiz: December 5, 2022

Ron Reeder • December 5, 2022

Last week I asked how you about the case below, sent to us by our friend Dr. Mansur Nasirov from National Children's Medical CenterTashkent, Uzbekistan. This is a one-year-old male patient with anal stenosis presented and had these radiologic images.

There are several very important considerations here. First – how to treat the anal stenosis. Dilations alone sometimes work, but depending on how long is the narrowed length, a plasty may be required. See these videos for the anal stenosis and rectal atresia scenarios:

Anal stenosis: https://www.expertsinsurgery.com/programs/rectal-stenosismp4-d51c4a?categoryId=49506

Rectal atresia: https://www.expertsinsurgery.com/programs/rectal-atresia-nch-apple-devices-hd-most-compatiblemp4-ee0548?categoryId=49506

Also, the presacral mass must be excised. But is that a teratoma? Or is that a meningocele? You need a spinal MRI to figure out if the mass is connected to the dura. If so, the neurosurgical part should be done independently. 

Does this patient need diversion first – yes I think so, and would advocate for either an ileostomy or a proximal sigmoid colostomy.

What to do about the massive rectum and sigmoid? Will that decrease in size over time? I tend to doubt it and might do a pull-through of the normal caliber sigmoid at the time of the anal repair, which is why I like the ileostomy idea. And the mass could also be removed at that time if there is no dural component.

So for me, I would do an ileostomy and then in a few months an anal repair plus pull-through of the healthy sigmoid and removal of the rectum and distal sigmoid, and thereafter ileostomy closure.

I am curious if others have additional thoughts.


For this week, consider this finding in a three-month-old. There is a pit that goes in about 4 cm and parallels the posteriorly rectal lumen. What is it? What would you do about it?


How would you handle this case?

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!

Mark your calendars for:

October 26-29, 2023, the 14th Annual Pediatric Colorectal Congress in Milan, Italy.

And

November 16-18, 2023 the Pediatric Colorectal Pelvic Learning Consortium in Scottsdale, Arizona - scientific and didactic programming, for trainees, pediatric surgeons, urologists, gynecologist, gastroenterologists, nurses, APPs, stoma therapists, etc.


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

All of our operative videos can be found at www.expertsinsurgery.com and also on the StayCurrent app, the colorectal channel.


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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