Colorectal Conundrum: November 13, 2023

Ron Reeder • Nov 15, 2023

For the Quiz & Answers to last weeks Conundrum - see the blog post here.


Colorectal Conundrum for November 13th:

What would you do in this male patient with ARM, newborn colostomy, and now with distal colostogram showing the below finding?

Answer for November 13th:  There is much more to this case than meets the eye and several options. The key item to recognize is the very high rectum and short distal piece of bowel given the location of the colostomy. One choice would be to take down the fistula laparoscopically and pull it through, but I caution against leaving a Hartman’s pouch in – the colostomy closure will be super difficult. So one could close the colostomy and then divert above with a more proximal colostomy or with an ileostomy. However, given the potentially poor blood supply of this piece of rectum and to avoid two anastomoses (anoplasty and colo-colonic), plus the new diversion and the stoma closure that goes along with it, and seeing how poor is the sacrum, my choice here would be to pull through the colostomy and remove this distal piece. I know how important is the rectum to provide a reservoir and allow for continence but I am balancing all of that surgery with a likely incontinent child here that would do fine with a sigmoid pulled through and antegrade flushes via the Malone.


How would you handle this case?

Colorectal Conundrum: January 29, 2024

By Ron Reeder • 29 Jan, 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 • 22 Jan, 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 • 16 Jan, 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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