The Colorectal Quiz: Episode 1
With Dr. Jason Frischer & Dr. Mark Levitt · hosted by Dr. Em Gootee & Dr. Rod Girardo · Marc Levitt
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
VACTERL mnemonic stands for: V (vertebral abnormalities), A (anorectal malformations), C (cardiac abnormalities), E (esophageal atresia), R (renal abnormalities), and L (limb abnormalities)
Plain x-ray of the abdomen can identify vertebral abnormalities including hemivertebra in anorectal malformation workup
Cardiac evaluation should include both physical exam and echocardiogram in anorectal malformation patients
NG tube should be passed to rule out esophageal atresia in anorectal malformation workup
Kidney ultrasound is needed to evaluate for renal abnormalities in anorectal malformation patients
True sacral ratio measurements should wait until the child is three months of age
Pre-sacral mass is rare in typical imperforate anus but occurs in almost half of anal stenosis or rectal atresia cases
Patients with anal stenosis or rectal atresia and pre-sacral mass will need MRI evaluation
Cross-table lateral x-ray is typically obtained at about 24 hours of life, give or take a few hours, to visualize the gas column position
A sacral ratio greater than 0.7 connotes a very good prognosis for bowel control
Well-formed buttocks, good muscle mass, and identifiable sphincter mechanism location on physical exam contribute to favorable prognosis in anorectal malformation
The key to deciding whether to approach perineally via posterior sagittal incision is knowing where the rectum is located
The danger of blind posterior sagittal approach is finding midline white structures like urethra, bladder neck, or bladder itself instead of rectum
Colostomy and distal colostogram are performed to know exactly where the rectum is and determine whether to approach perineally or laparoscopically
Performing a colostomy is the safe choice and carries its own set of potential complications, as does colostomy closure
Surgeons have performed primary anorectoplasty without identifying a fistula, resulting in children later urinating out of their anus
During primary posterior sagittal approach, the posterior wall of the rectum should be opened and the anterior wall inspected to rule out fistula
A bulbar fistula is named for its location at the elbow of the urethra, using pure anatomic nomenclature
95% of patients with Down syndrome and imperforate anus have no fistula, but 5% do have a fistula
Distal colostogram should still be performed in Down syndrome patients with imperforate anus despite the low probability of fistula
For cross-table lateral imaging, the baby is positioned prone with buttocks at the highest point where air will rise to, and can be done at bedside in the neonatal unit with a bump under the buttocks
In patients with low rectum, dissecting a bit of the anterior rectal wall and carefully lifting it off the urinary tract will usually rule out fistula