Colorectal Quiz: Episode 2

The original malformation in case 1 was a prostatic fistula and the patient has a tethered cord with a sacral ratio of 0.66

The higher the malformation, the worse the prognosis for bowel control

Sacral ratio 0.7 or greater usually means normal sphincters and good muscle tone

Patients with myelomeningocele have much more trouble with continence than those with tethered cord

A key pitfall is opening the PSARP incision first; instead, mark the sphincters first with electrical stimulation, then open the PSARP

The electrical stimulator used for sphincter mapping is the same one anesthesia uses for train of four

Anesthesiologists should not give skeletal muscle relaxant when using the stimulator because it is weaker than traditional stimulators

In higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated

If anatomy is off, redo should be done, and there is an advantage to getting anatomy right when the child is younger

For a two-year-old with mislocated anus or bad prolapse, offer redo and let them live in diapers for a year or two with better anatomy before potty training

For patients presenting after potty training age with incontinence due to mislocated anus, do the redo and usually add a Malone at the same time

After redo with Malone, patients learn to get control with new anatomy before stopping Malone flushes and trying voluntary bowel movements; this process may take six to twelve months

For a patient with anus 50% within sphincter complex at age three and a half with incontinence, one approach is to redo and add Malone, get them clean mechanically, then see if they develop bowel control

Alternative approach for borderline anatomy: let the child try their current anatomy first; if it works well, stay with it; if not, consider redo

If patients haven't declared continence yet because they're not old enough behaviorally, give them a chance as they may succeed with current anatomy