Distal Colostogram Research Articles

Rectal Perforation Following High-Pressure Distal Colostogram: A Case Report

Rectal Perforation Following High-Pressure Distal Colostogram: A Case Report

Pneumatic Insufflation to Confirm Distal Stoma When in Doubt.

Background Distal colostogram and ileostogram are commonly performed radiological procedures in the pediatric population. It is sometimes difficult to identify the distal stoma while performing these procedures. Aim The aim of this study was to describe a technique for the confident identification of distal stoma. Methods Injection of a small quantity of air through the catheterized stoma and following it can help to identify the stoma, as proximal or distal, based on anatomy of the delineated bowel. Conclusion Pneumatic insufflation is a simple, quick procedure to confidently identify the distal stoma whenever in doubt.

Usefulness of 3D reconstruction of low dose pelvic CT as an innovative tool for surgical planning in definitive correction of cloacal malformations

PurposeTo describe the results of the use of a low dose pelvic CT protocol for preoperative imaging in cloacal anomalies at a referral center. MethodsWe reviewed 43 cases of cloacal anomalies treated at our institution from 2012 to 2022. The patients underwent a cystoscopy under general anesthesia, with measurement of the common channel and the urethra, and visualization of the Müllerian structures, and a Foley catheter was placed in the bladder. Then the patient was transferred to the CT suite for a low dose pelvic CT, filling the bladder, the vagina (by overflow) and the sigmoid/rectum (as in a distal colostogram) with diluted meglumine. Volume rendering was obtained at the CT station. Results43 girls with cloaca were treated our institution, 40 of them operated on for correction. The median effective radiation dose was of 2.19mSv (0.81 - 2.96 mSv). The measurement of the common channel had a Pearson coefficient of 0.96 when correlated with the actual measurement. The length was < 1 cm in 3, 1-3 cm in 18, 3-5 cm in 15, and >5 cm in 4. Total urogenital mobilization was possible in 28 patients. We found vaginal duplication in 16, and vaginal reconstruction was performed in 13 others. ConclusionThis technique provided the spatial anatomy of the urinary, vaginal, and colorectal components, with a higher fidelity than fluoroscopy. Since we do not have rotational fluoroscopy, we overcame that limitation with this modality, and found it to be an improvement for planning, allowing for better outcomes.

Intraoperative visualization of urethra using illuminating catheter in laparoscopy-assisted anorectoplasty for imperforated anus-A novel and safe technique for preventing urethral injury.

In this study, we used a near-infrared ray catheter (NIRC) to visualize the urethral line. We herein report our intraoperative visualization technique of the urethra using an illuminating catheter in laparoscopy-assisted anorectoplasty (LAARP) for imperforated anus. A 3.0-kg term male neonate with anorectal malformation was delivered. An invertogram revealed the type as intermediate. Transverse colostomy was performed at the left upper abdomen. A recto-bulbar urethral fistula (RBUF) was diagnosed via distal colostogram and voiding cystourethrogram. LAARP was planned at 6 months of age. We performed the operation with four trocars. A 45° 5-mm scope was used to clearly view the deep pelvic space. Before starting rectal dissection, a 6-Fr pig-tail-type NIRC was inserted through the external opening of the urethra to visualize the urethra during the laparoscopic procedure. The catheter tip was placed in the bladder, and excretion of urine was maintained through the NIRC during the procedures. While dissecting the deep pelvic space between the posterior wall of the urethra and anterior wall of the rectum, the exact line of the urethra was clearly confirmed by overlay images of the NIRC. The RBUF was dissected safely using this innovative image-guided technique. Anoplasty was performed between the rectal stump and perineal skin. The postoperative course was uneventful. Oral intake was started on postoperative day 1. Postoperative dynamic urography showed no complications. An NIRC is useful for detecting the urethra during LAARP.

Comparison of MRI with Distal Colostogram in Patients with Anorectal Malformations- A Cohort Study

Introduction: Anorectal Malformations (ARMs) are the second most common paediatric surgical emergencies with management strategy is restoration of near normal anatomy and physiology which require accurate and proper imaging diagnosis. Aim: To evaluate Magnetic Resonance Imaging (MRI) findings and its comparison with Distal Colostogram (DC) against surgical findings in anorectal malformation patients. Materials and Methods: A cohort study was done at two centers Jawaharlal Nehru Medical College, Aligarh (JNMC, Aligarh) and Vardhman Mahavir Medical College (VMMC) and Safdarjung Hospital, New Delhi involving 60 patients of ARMs. MRI was done in all patients and distal colostogram was done in 46 (74.4%) patients. All patients were evaluated for associated anomalies. Both the imaging modalities were compared for the type of ARM and fistula against the surgical findings and Chi-square and Fisher’s test were used to calculate statistical significance. Results: Out of total 60 patients included in this study, there were 37 (61.7%) males and 23 females (38.3%). High ARM was seen in 34 (56.7%) patients and low ARM was seen in 26 (43.3%). There was no significant difference between distal colostogram and MRI in differentiating the type of ARM (p-value 0.13). Spinal anomalies (52.5%) were the most common associated anomalies, followed by genitourinary (47.5%) and musculoskeletal (32.5%). Conclusion: From the results of present study no significant difference was found between DC and MRI findings regarding the type of ARM.

Image-guided confirmation of a precision pull-through procedure during laparoscopically assisted anorectoplasty in an open MRI operating theater: first application in an infantile case with anorectal malformation

BackgroundImage-guided surgery with an open magnetic resonance imaging (MRI) system is applied for brain tumors in the neurosurgery field, but has rarely been reported in pediatric surgery. We report our initial experience of intraoperative confirmation of precision rectal pull-through during laparoscopically assisted anorectoplasty (LAARP) in an open MRI operating theater for pediatric patients with anorectal malformation (ARM).Case presentationA 3.0 kg term male neonate was delivered with anorectal malformation. An invertogram revealed the intermediate type. Transverse colostomy was made on the left upper abdomen. The recto-bulbar urethral fistula (RBUF) was diagnosed by a distal colostogram and voiding cystourethrogram. LAARP was planned at 6 months of age. Because this was the first procedure in which the pediatric abdomen had been scanned in an open MRI operating theater in our institution, we scanned his pelvic floor under sedation 3 weeks before the operation using the open MRI system in our operation room. We performed the operation with 4 trocars. The peritoneal reflection was carefully incised and the rectum was dissected. The RBUF was resected. The center of the muscle complex was detected at the perineal skin with an electrical nerve stimulator, and a 7-mm longitudinal skin incision was made on the perineal lesion for anoplasty. The muscle complex and the pubo-rectal sling were confirmed laparoscopically using a 3.5-mm bipolar forceps connected to the electrical nerve stimulator. Anoplasty was performed between the rectal stump and perineal skin. After anoplasty, the patient was scanned with open MRI under general anesthesia. We attached the quadrature-detection (QD) head coil around the patient’s pelvis and inserted him in the gantry. A 0.45-T open MRI clearly revealed that the pulled through rectum was located in the center of the muscle complex on T2-weighted images. The postoperative course was uneventful. Oral intake was started on post-operative day 1. Postoperative dynamic urography showed no complication (e.g., leakage or residual fistula).ConclusionsWe successfully performed LAARP for ARM, with intraoperative confirmation of precision rectal pull-through in an open MRI operating theater. Further cases are required to evaluate the application of open MRI systems in pediatric surgery.

Anorectal malformation with long perineal fistula: one of a special type

The anorectal malformation with long perineal fistula is a rare anomaly in the spectrum of anorectal malformations. Aim of the study is to describe the series of patients with anorectal malformation with long perineal fistula and compare the outcome with patient with standard perineal fistula. From March 2012 to January 2019, 7 patients who suffered from anorectal malformation with long perineal fistula were retrospectively reviewed. Three were operated on primarily by our department, and 4 cases were re-operated after a perineal anoplasty repair performed elsewhere. Four were operated by laparoscopy assisted anorectoplasty, and 3 cases were repaired by posterior sagittal anorectoplasty. The follow-up outcomes were compared with 71 cases of normal perineal fistula (NPF) in the same period. 7 cases have been followed up for 0.5–4 years (M = 2.57 ± 1.26) after definitive surgery. Their bowel function score was lower than normal perineal fistula (SPF = 12, range: 5–18; NPF = 18.5, range: 18–20). Four cases underwent anorectomanometry. The incidence of rectoanal inhibitory reflex was lower in the special type group. (p = 0.14). Three cases of contrast enema using barium: 2 cases of colorectal dilatation and thickening changes, 1 case showed no obvious abnormalities. Anorectal perineal fistula should be examined by distal colostogram at preoperation. This should be altered in: When suspecting a case of anorectal malformation type long perineal fistula a preoperative contrast enema could give insight of the anatomy befor performing a anoplasty.

Neonatal Ultrasound for Anorectal Malformations in Male Newborns Without Perineal Fistula: A Good Diagnostic Tool for A Safe One-Staged Surgery

Background/Purpose: The standard neonatal approach for a male newborn with an anorectal malformation (ARM) and no perineal fistula remains the opening of a diverting colostomy. Here we describe radiological improvements in neonatal ultrasound (US) that characterize the recto-urinary fistula and allow a direct anorectal reconstruction. Material and Methods: This is a descriptive report of radiological findings in neonatal ultrasound in all newborn male patients with an ARM, no perineal fistula and no colostomy, recruited over a 6-year period. A paediatric radiologist actively looked for recto-urinary fistulas and their relation to anatomical landmarks. These findings, along with the clinical status and associated anomalies, were considered to indicate a single-staged procedure. Results: From 28 neonates with ARM only three met the inclusion criteria. The first 2 cases showed a bulbar and prostatic fistula in US but with associated malformations and benefited from a colostomy. The third baby presented a bulbar fistula in the US, normal sacrum and no lifethreatening malformations and benefited from a singlestaged procedure. Conclusions: Neonatal perineal US can give the same anatomical information than the distal colostogram and leads to a safe single-staged procedure in expert teams, if there is a lack of associated life-threatening malformations.

Inter- and Intraobserver Variation in the Assessment of Preoperative Colostograms in Male Anorectal Malformations: An ARM-Net Consortium Survey.

Aim: Male patients with anorectal malformations (ARM) are classified according to presence and level of the recto-urinary fistula. This is traditionally established by a preoperative high-pressure distal colostogram that may be variably interpreted by different surgeons. The aim of this study was to evaluate the inter- and intraobserver variation in the assessment by pediatric surgeons of preoperative colostograms with respect to the level of the recto-urinary fistula.Materials and Methods: Sixteen pediatric surgeons from 14 European centers belonging to the ARM-Net Consortium twice scored 130 images of distal colostograms taken in sagittal projection at a median age of 66 days of life (range: 4–1,106 days). Surgeons were asked to classify the fistula in bulbar, prostatic, bladder-neck, no fistula, and “unclear anatomy” example. Their assessments were compared with the intraoperative findings (kappa) for two scoring rounds with an interval of 6 months (intraobserver variation). Agreement among the surgeons' scores (interobserver variation) was also calculated using Krippendorff's alpha. A kappa over 0.75 is considered excellent, between 0.40 and 0.75 fair to good, and below 0.40 poor. Surgeons were asked to score the images in “poor” and “good” quality and to provide their years of experience in ARM treatment.Results: Agreement between the image-based rating of surgeons and the intraoperative findings ranges from 0.06 to 0.45 (mean 0.31). Interobserver variation is higher (Krippendorff's alpha between 0.40 and 0.45). Years of experience in ARM treatment does not seem to influence the scoring. The mean intraobserver variation between the two rounds is 0.64. Overall, the quality of the images is considered poor. Images categorized as having a good quality result in a statistically significant higher kappa (mean: 0.36 and 0.37 in the first and second round, respectively) than in the group of bad-quality images (mean: 0.25 and 0.23, respectively).Conclusions: There is poor agreement among experienced pediatric colorectal surgeons on preoperative colostograms. Techniques and analyses of images need to be improved in order to generate a homogeneous series of patients and make comparison of outcomes reliable.

A call to ARMs: Accurate identification of the anatomy of the rectourethral fistula in anorectal malformations

Recto-urethral fistulae are the most common finding in males born with an anorectal malformation (ARM). A high pressure distal colostogram is an important tool in visualizing the fistula, although the precise level at which the fistula communicates with the urethra may be difficult to interpret and is not reported in a uniform manner. This anatomy affects the surgical plan; determining the likelihood that the rectum is reachable via a posterior sagittal incision or better approached through the abdomen via laparoscopy or laparotomy helps counsel families and stratifies diagnoses for outcomes work. Herein we present a figure used at our Center to assist with correlating findings on the distal colostogram with the anatomic level of the recto-urethral fistula in males with anorectal malformations.

Error traps and culture of safety in anorectal malformations

IntroductionAttempting to decrease iatrogenic injuries and preventable harm, safety initiatives have become a priority in surgery. For adult hepatobiliary surgery, it has become common to study and consider “error traps” or common pitfalls that exist for laparoscopic cholecystectomy.1–4 Extending this work to children, we have attempted to apply some of these initiatives by identifying error traps common to the care of patients born with anorectal malformations (ARM). MethodsFive error traps were identified based on a retrospective analysis of operative records and radiographic studies from 398 re operative ARM cases performed by the authors. Once identified, the authors constructed a specific safety plan for each trap to promote a culture that will hopefully prevent ARM iatrogenic injuries. ResultsThe identified error traps are: 1) creation of a colostomy too distal in the sigmoid colon, 2) inaccurate distal colostogram and definition of the patient's preoperative anatomy 3) absence of a Foley catheter during the repair of an ARM in males and the hazards of separating the anterior rectal wall from the genito-urinary (GU) tract 4) mismanagement of a post-operative anal stricture following an ARM reconstructive procedure 5) limited or unstructured follow up of these patients. For each of the five traps the authors present suggestions for their avoidance. ConclusionThe repair on an anorectal malformation is an elective procedure and while not completely avoidable, there should be little tolerance for iatrogenic injury and preventable harm. A culture of safety should be followed, beginning with a recognition of the common error traps associated with ARM procedures.

Augmented-pressure distal colostogram: the most important diagnostic tool for planning definitive surgical repair of anorectal malformations in boys.

There is little current literature on the augmented-pressure distal colostogram, the single most important diagnostic study performed in boys with imperforate anus prior to definitive repair. Accurate understanding of the anatomy of the anorectal malformation including an associated fistulous communication between the rectum and the urogenital tract is essential for optimal surgical management. Specifically, the position of the rectal pouch and recto-urinary fistula relative to posterior sagittal structures of the perineum, especially the sacral spine, dictates the operative approach. This pictorial essay is a guide for those who encounter such children with relative infrequency to become more comfortable with the technique. We report how to perform this radiologic exam and the potential pitfalls from our experience of performing the technique in our large pediatric colorectal practice.

The high pressure distal colostogram in anorectal malformations: technique and pitfalls

The importance of technically adequate high pressure distal colostogram in planning management for patients with anorectal malformations and how technically inadequate examination could delay management and affect the outcome cannot be over emphasized as shown in this article.

Currarino syndrome and the effect of a large anterior sacral meningocele on distal colostogram in an anorectal malformation

Currarino syndrome and the effect of a large anterior sacral meningocele on distal colostogram in an anorectal malformation

Anorectal Agenesis with Rectovaginal Fistula: A Rare/Regional Variant.

Aims and Objectives:The anatomical types of female anorectal malformation (ARM) are complex and include several rare and regional variants. The aim of this report is to highlight the diagnosis and management of cases of anorectal agenesis with rectovaginal fistula (RVF).Materials and Methods:This is a retrospective chart review of cases of RVF who underwent definitive surgery between November 2000 and September 2016 in a single institution.Results:Of the 244 female patients with anorectal anomalies treated in our institution over a 16-year period, there were 15 cases of RVF with anorectal agenesis giving it an incidence of 6%. All cases of RVF with anorectal agenesis presented with absence of anal opening, varying degree of abdominal distension, and history of passage of fecal matter per vaginum. The mean age of presentation was 3 months (newborn to 1 year). Sigmoid colostomy was done in 13 cases. Distal colostogram demonstrated high RVF which was further confirmed by examination under anesthesia (EUA) and endoscopy before definitive surgery. With the posterior sagittal approach, division of the RVF and anorectoplasty was possible in 14 cases; however, one patient required an abdominal mobilization of the colon for pull through due to a very short distal bowel segment. During a mean postoperative follow-up of 5 years, cosmetic and functional results were satisfactory.Conclusion:RVF with anorectal agenesis is a rare/regional variant of female ARMs. Clinical examination along with distal colostogram, EUA, and endoscopy clinches the diagnosis. Anorectal reconstruction by posterior sagittal anorectoplasty results in a satisfactory outcome.

Voiding Cystourethrography in the Diagnosis of Anorectal Malformations

Introduction In a newborn with an anorectal malformation (ARM), it is vital to determine the anatomy of the underlying defect. After a colostomy has been created, distal colostography (DCG) is currently the chosen modality for the detection of fistulas. The role of voiding cystourethrography (VCU) is unexplored. Aim The aim of this study was to analyze the reproducibility of DCG and VCU in assessing the underlying malformation in ARM, and to evaluate any degree of concordance among them. Materials and Methods A retrospective evaluation was undertaken comparing DCG and VCU findings with definitive surgical findings in children who received both investigations for the initial management of ARM. Results In this study, 26 boys were included. Malformations were classified according to Krickenbeck classification. Four boys with perineal fistula were excluded from the analysis, as none of them needed a colostomy; therefore, comparison between both methods was not possible. VCU identified a rectourethral fistula in 12 cases, a rectovesical fistula in 4 cases, and excluded a fistula in 6 cases. VCU was false negative for a rectovesical fistula in one case. VCU showed a vesicoureteral reflux in 16 patients. Results obtained by VCU were compared with DCG. DCG showed a rectourethral fistula in 11 cases, a rectovesical in 3 cases, and excluded a fistula in 6 cases correctly. DCG was false negative in two cases, a rectoprostatic and a rectovesical fistula. The diagnostic accuracy, measuring the sensitivity was 95% in VCU (range: 76.18-99.88%) and 90% (range: 68.30-98.77%) in colostogram. Conclusion VCU can be as accurate as distal colostogram in the evaluation of male patients with ARM. VCU uses a natural orifice, without the need of a colostomy. VCU can be performed as an initial modality to determine the type of malformation and to decide on the type of early surgical management.

Imaging in anorectal malformations: What does the surgeon need to know?

Imaging is essential in the diagnosis, management, surgical planning and eventual outcome in patients with anorectal malformation (ARM). This article outlines the imaging that may be required and the information needed by the surgeon to attain the best possible surgical outcome. ARM encompasses a wide spectrum of congenital malformations relating to the distal rectum and anus as well as the urinary and or gynaecological systems. The malformations range from a relatively simple perineal fistula with the potential for an excellent functional outcome, to complex cloacal malformation that requires specialist care and intervention. Approximately half of these children will have associated abnormalies. In the first 24–48 hours of life, imaging is used to determine if any associated anomalies are severe enough to preclude an operation, and what operation will be required so that the child can grow as normally as possible. If a colostomy is done, pre-definitive repair imaging in the form of a high-pressure distal colostogram determines the surgical approach required to repair the malformation. In more complicated cases of cloacal malformation, advanced imaging in the form of MRI or 3D fluoroscopy is valuable. In the South African setting, 2D fluoroscopy with the surgeon present is adequate to help in planning for the surgical management. Communication between the radiologist and paediatric surgeon is essential to ensure that such patients have the best possible outcome.

A new approach for persistent cloaca: Laparoscopically assisted anorectoplasty and modified repair of urogenital sinus

PurposeThe aim of this study is to describe the surgical technique and evaluate midterm outcomes of the technique: laparoscopically assisted anorectoplasty (LAARP) and modified repair of urogenital sinus. MethodSeven patients with persistent cloaca underwent LAARP and modified repair of urogenital sinus between November 2005 and December 2010. The ages of the patients at the time of operation were 6months to 15years. Distal colostogram and micturating cystogram were performed preoperatively to identify the type of persistent cloaca. The rectal pouch was above the pubococcygeal line in all patients. The operations were carried out using 3 trocars. CO2 pressure was maintained at 8–12mm Hg. ResultLaparoscopically assisted anorectoplasty and modified repair of urogenital sinus were successfully performed in all cases. Mean operation time was 125.7±8.4minutes (range, 110–135minutes). Intraoperative blood loss was minimal. There were no intraoperative complications. Follow-up was obtained in all patients. The median follow-up period was 5.7±2.1years (range, 4–9years). Mucosal prolapse occurred in 2 cases (28.6%). No urethrovaginal fistula, acquired anorectal atresia or urethral injury was observed. Only 1 patient (14.3%) was incontinent of urine occasionally but urine retention or vesicoureteral reflux was not observed. Two patients (28.5%) had 2–4 stools per day but no social problem. Only 1 patient (14.3%) had constipation and required laxatives. ConclusionAnoplasty, vaginoplasty and urethroplasty can be performed simultaneously in patients with persistent cloaca through LAARP and modified repair of urogenital sinus.

Barium stone formation in the vagina of a child with persistent cloaca following a distal colostogram

Persistent cloaca is a severe form of malformation of the anorectum. A distal colostogram is important in the planning of its treatment. We report herein a case of a girl who had barium stone formation within her vagina following a distal colostogram. Water soluble contrasts are recommended for this procedure.

Nonfluoroscopic well-tempered pressure augmented distal colostogram in high-type anorectal malformation: Our experience

Background: Accurate imaging of rectourethral fistula is essential for optimal surgical management of infants with high-type anorectal malformation (ARM). The aim of this study was to study the role of nonfluoroscopic well-tempered pressure-augmented distal colostogram in high-type ARM in demonstrating rectourinary fistula, bladder anomalies, and for the presence of vesicoureteral reflux (VUR). Patients and Methods: We present a prospective study of 10 male infants who underwent a diverting colostomy in the neonatal period from January 2011 to December 2012. Our method of performing a colostogram is similar to conventional colostogram, but involves (a) meticulous bowel preparation preoperatively, ensuring that while doing the last distal colostomy wash before colostogram there is passage of clear saline from the urethral meatus to establish the presence of rectourinary fistula; (b) nonfluoroscopic study (c) performed with gentle and sustained pressure of contrast media, maintained over the period of the investigation; (d) bladder is completely filled with contrast media through rectourinary fistula and it is confirmed clinically; and (e) radiographic films in addition are taken in the micturating phase. Results: Rectourinary fistula was demonstrated in all (100%) cases. Rectoprostatic urethral fistula was present in three (30%) infants, rectobulbar urethral fistula in six (60%) patients, and one (10%) infant had type 4 congenital pouch colon (CPC) with colovesical fistula. Also three (30%) patients demonstrated unilateral primary vesicoureteral reflux (VUR), which was previously undiagnosed in all of them, as micturating cystourethrogram (MCU) was not attempted. Conclusions: Our study confirmed the level of anomaly and accurately demonstrated the type of fistula in all patients. It also detected the undiagnosed VUR in three (30%) cases. It obviated the need for a MCU.