Panel Discussion and Case Presentation Part I: Pediatric Bowel Management 2013

Show you how to calculate the sacred ratio because as you saw in Doctor Pena's presentation many times we said a normal sacrum and I just saw that there's a question here in the poll asking if it's necessary for the gastroenterologist to know what kind of anorectal malformation. The patient has, well, ideally yes because that it correlates with the prognosis, but in our center we actually received many patients that were operated in China and we don't have access to any of their medical records. In that case we don't know what malformation they have and what we are looking for are signs to tell if this patient was born with good prognosis or not and the. Sacrum is one excellent sign to help us if the patient has good prognosis for bowel control or bad prognosis for bowel control, and I'll show you how to calculate right now. So here you can see an image of the sacrum and the 3 lines, the 4 lines that we're gonna draw, the first one is the middle one where we wanna draw the line in the direction of the sacrum. Then on the top line, we wanna go to the top of the iliac crest. The the second line is where the sacrum joins the iliac bones for the last time and the last line is the last bone of the sacrum that you can identify. Some patients have a. Coccyx other patients don't have a coccyx and then you're gonna divide and I'm gonna try to show with my arrow here you're gonna divide the distance between the 2nd line and the 3rd line by the distance between the first line and the 2nd line. And we know that in normal patients this ratio is 0.7 or more. So if you calculate the sacral ratio and your patient has 0.7 or more, that means good prognosis for bowel control, and we should do the same thing on the lateral view. So the first line is just on the direction of the sacrum the line A is on the top of the iliac. Bone line B is at the last point where the sacrum joins the iliac bone and the last line, line C, is at the last bone of the sacrum. Sometimes it will be the coccyx, sometimes it won't be, and then you divide, you divide the BC, the distance between B and C, to the. Distance between A and B and again 0.7 or above it's good prognosis for bowel control and when we have 0.4 or less, that means that the patient will be fecally incontinent regardless of the type of malformation that the patient has we have. Never seen a patient with a sacred ratio of less than 0.4 that is fecally continent, so if you calculate and you find 0.4, you know that this patient is fecally incontinent and he or she will need enemas for life. So now we're gonna see in a real case, so that's the first line. The second line in the top of the iliac bones some somebody's moving. The third line at the last point where the sacrum touches the iliac bone and the final line at the last bone that you can identify in this case the sacrum ratio was 0.6 and now in the lateral view we are gonna draw the first line on the direction of the sacrum. Line A is in the top of the iliac crest. Line B is at the last point where the iliac bones touch the sacrum, and then at the last bone we can identify and the lateral view was 0.7. So now we're gonna move to some case discussion to see if you already learned the first portion of this session. So we're gonna go to case discussion number one. So be ready to answer all the questions so we can see if you're really learning or if you're not paying attention. Yeah. You come up here first, OK? You want me to do it until it loads on you. So the first question. Is in which patient with anorectal malformation, a stoma for life is indicated. Option one, the ones that will be fecal incontinent. Option two, patients with a sacred ratio of less than 0.4. Option three, rectal bladder neck fistula. Option 4, complex cloacas. Option 5, none of the above. Please answer the questions and let's see what's the answer of the poll. Can you put the pole up? I'm activating. OK. Um, they may have to put their answers in the chat. People can write their, uh, their answers in the chat box as well. Do we have access to the chat? Uh, why don't you just go ahead and. So this one you were lucky you didn't have to answer but the answer is they did OK so the answer is none of the above we don't think the only indication for a stomach for life is incapacity to form solid stool because in. Those cases they are not going to respond to our bowel management as you're going to learn throughout the show. So all of those others, if the patient has bad prognosis for bowel control, that does not mean that he's a candidate for stoma for life. So Andrea, a lot of people answer number 2. Number 2, sacred ratio less than 0.4. That's because we didn't explain yet how to do bowel management. Once they learn how to do bowel management and treat patients with enemas, then they will know that this is not an indication for a stoma for life. Because the bowel management that we are discussing today is for patients with fecal incontinence, and our patients subjected to bowel management. Believe and they tell us that the bowel, the quality of life that they have with bowel management is much better than the quality of life of having a colostomy and that's why the only contraindication for a pull through or the only indication for a permanent stomach. Is a patient that is incapacity to form solid stool because with incapacity to form solid stool there is no bowel management and it would be tragic to have liquid stool and with no control in the underwear. So options 123, and 4 means that they are good candidates for bowel management with enemas, but they do not need a colostomy for life. So we're gonna move to the next question. So the next question, this is a male patient born with anorectal malformation and Down syndrome, so what is the prognosis for bowel control? This is just to see if you paid attention when Doctor Pena was speaking. So everybody can answer. Yeah, please, uh, for these couple of polls, just type your, your response into the chat box. So you tell us what the answer is. So 100%, 80%, 60%, 40% or 20%? We got some twos and threes, OK? And the answer is number 2. So patients with Down syndrome, if you remember from the talk, most of them, they have the anorectal malformation without fistula and they have a good prognosis for bowel control, 80% chance of bowel control. We're gonna move to the next question. If you have any questions, just please write in the chat and we'll be happy to answer. So this is a 3 year old male patient born and operated due to rectal. Bladder neck fistula. Parents want to know what is the prognosis for bowel control in a patient with rectal bladder neck fistula 95%, 75%, 50%, 25%, or 15%? Oh, some people in Brazil already know the answer. Some people in California also know the answer. So what's the answer? 5. Very good, 5. Only 15% of the patients have bowel control. It's a bad malformation in terms of prognosis for bowel control. So the next question, this is a newborn with a rectal perineal fistula. So look very carefully in his, um, x-ray cause I'm gonna ask you what's the prognosis for bowel control. So everybody looks careful, examine everything that you can. Take your time. Take your time. And I'm gonna move to the next slide so you can answer. So regarding the prognosis for bowel control, this patient has a 100% chance of bowel control because he has a rectal perineal fistula and it's the malformation with the best, best prognosis. Good prognosis depends upon having a good operation, good sacrum, no tetrachord. It is important to rule out a pre-saccrum mass before discussing prognosis for bowel control or options two and three. We're getting a lot of 4s here. A lot of 4s. 0, I see that my panelists, they get all of them right. I'm so proud. Very good. Options two and three. So, now we're going to go back to the x-ray so we can see for those of you that didn't notice, this patient has a hemisacrum right here and that indicate, Indicates that the patient has a presacral mass and even if the patient has a rectal perineal fistula, if we saw a hemisacral and a presacral mass that changed the prognosis for bowel control completely in this case we cannot tell the parents that the prognosis is good, very good people are doing very well. And we have seen, we have seen many patients in our hospital that were born with a perineal fistula. The surgeons did not take an extra film of the sacrum. They operated the perineal fistula, and the patient has terrible problems because the, the presaccular mass was not detected and was not treated. Now the next question, all patients with cloao atrophy will be fecally incontinent? Is this true or false? Option one or option two? Some people are saying I don't have that option, so you will have to pick one, true or false. So the thing we have to do is wait about 10 seconds because all the viewing audience is 10 seconds behind us. Oh, so I'm giving the answer to them. So you have to wait about 10 seconds. No, they're, everything's, but so we have to wait when they type. So everyone is saying 2. Everyone is saying false. That's very good. It's false. Not everybody. The majority of patients with cloaco atrophy will be fecally incontinent because we have a huge number of tetrachord of myelomeningocele of bed sacrum, but there are a few patients that are fecally continent, so very good the answer is false. Mm Is that the end? That's the end. So now we're gonna move.