Pediatric Colorectal Contraversies Part II: Pediatric Colorectal...

Yes, yes. How about this one? Let's put up a new poll. And, um, ask, do we have uh Professor Liam from Hanoi yet? On audio? I see you, but I don't hear you. Are we still uh Not able to talk to him? Liam, are you there? Yes. Do you hear me? Do you hear me? We hear you. Colostomy or primary repair for this case? Uh, is it, uh, uh, right on the vestibular fistula. Yes. Uh, I prefer primary repair around, uh, 75 or 7 days. It means I wait until 5th or 7th day, and I perform primary repair. Um, does anyone wanna, uh, uh, differ from that? I also would do a primary repair. Anyone else? Marcella primary repair? I wanna know who's who is saying no. Is any of the, uh, are any of the faculty saying no to this? And if so, what are your comments? And is anyone on the faculty? I, I, can I talk to please? Yes, yes, I think, uh, we would do a primary repair only in a neonatal period with a, with a very nice fistula like this. Maybe if we get older patients, we would prefer a colostomy. And, and, and Marcella can, can I, I, um, we, we do primary repair up to 3 to 4 months before we need because, uh, it, it could be that you receive in a neonic period but very often we receive beyond the first month of life and I still like the idea to, to do it primarily but not all of us from our staff do it so if they are not confident they open. A colostomy and do the repair, so 2 operations and, and now the classical 3 operations. I think that that that's the point. It depends on the on the group of surgeons, but we prefer not to have, uh, sequela in in these patients that have a very good. OK. Sure. Although Mark Mark can I. Mark, can I comment please? Yeah, uh, um, I've been, uh, follow up, um, teenagers now that have been repaired with the classical 3 operations and, uh, the perineum, uh, not operated from me, from, from the person who taught me, so, uh, very good surgeon and the perineum and their function is beautiful, perfect those that we, uh, operated beginning 7-8 years ago primarily. Uh, have a little more like stenosis, uh, they, and I recall that they, uh, heal with a little bit of adhesions, a little bit of a stenosis, because, of course, uh, feces are passing through all the time, even if you keep them fasting and, and neonate fasting it's, it's hard. So I'm, I'm thinking of back again to maybe to reconsider. Uh, a colostomy because the long term result it seems better, seems, but I, I have not, no such long experience. I don't know, Mark, how old are the oldest girls that you have been following without the colostomy? Are they teenagers? Yeah, the, the um. We all must keep in mind when we deal with a vestibular fistula that these babies with a normal sacrum and no cord, an excellent prognosis, and they have a good operation. And all of us must think back and how many cases have you seen that have been mismanaged by others or by ourselves and um so we must keep in mind that we are dealing with a patient that is that is the actual part of the pediatric surgery with a good operation, the patient is going to run, have a normal life basically and if we do something wrong what we we. Lately myself in the same center if a baby is born in the hospital, we try to operate the baby within the 1st 72 hours flight. Before the baby actually eats because we want the baby to be to be not colonized, and we believe that they do better so we are afraid and I personally like to take the babies about 5 days, nothing by mouth receiving spiritual nutrition. If I receive the baby with uh this malformation, the baby's already 6 months old and has a mega colon, and then, then my strategy changes. I go for, um, I clean the colon with Golightly completely, and then I put a central line and keep the baby between 7 and 10 days with nothing by mouth receiving parental nutrition, nothing by mouth. Now that sounds very radical, but I'm very proud of my results and I don't like to scratch the. Testicles of the tiger trying and see how, how, how much risk I can take at the expense of the patient. So again, we don't, we don't say that everybody should be doing what we are doing. You have to use your own experience, put into consideration the environment in which you work, how much experience do you have, and act accordingly and always asking yourself the ultimate question, which would be, what would you do if this was your own baby? All right, we're, we have a lot we want to cover. I want to just, uh, put, uh, give this one to. we talked a little bit about this baby, a similar baby, uh, in an earlier slide. Right. First of all, um, to answer the question, I, what I, my impression is that this, uh, anal opening looks very perfectly located. Uh, to me, based on our description before, that the, uh, at the sphincter was the pink ellipse. So, um, Sabine, what do you think about this baby? Um, I think, uh, the anus, uh, is, uh, uh, has a special shape which is like oval. Uh, I don't know it's a good term. And when we see this type of anus with no streak, it's not like, you know, little, little things around the anus. It's, it looks like anus of Curarino syndrome. And I will, I will be afraid of that because it, it, it seems normal, but it's, it's not normal and this shape, uh, uh, in my experience is a very specific of this uh syndrome and on the right side you, you can see there are no radiation around the anus, which is also a good sign so. I agree 100% and that's what we were hoping people would see. Um, Jack Langer from Toronto has a question on the line I'm told. Is that you Jack? Jack, are you there? I guess I, I would, I would, can I add something, uh, I, I, I just want to comment about, uh, some slides before about, uh, about sexual mass pre sexual mass and ask, uh, to, uh, to you if you agree with that in my experience. When there is a pre-sacral mass, it is corresponding either to anorectal stenosis, and usually the presacral mass is just in front of the stenosis or it is in in the in the. In in a Cerinoud syndrome, but, uh, except of these two situations, I didn't see any presacral mass. Uh, are you, are you, uh, do you agree with that? Yes, this situation could be just anal stenosis or, or rectal atresia. But about 30 to 40% of these kinds of babies will have a presacral mass. You must screen for it. You need to tell the ultrasonographer to look for it, and ideally an MRI is the best way to show a presacral mass, and at the time of the repair, you can remove, presacral mass. One nice, one nice trick is to not, um, mobilize the full circle, but rather open posteriorly and allow that tight circle to become a half circle, so that the dentate line then becomes the anterior dentate line. The anterior 180 degrees, and you mobilize the posterior rectum forward and make your posterior anoplasty. And what that does is it saves you an anterior rectal wall dissection and preserves the dentate line because this baby has good sphincters and a normal sensation. I want to, uh, uh, move along a little bit. We have, oh, we're missing a picture. Um, well, for some reason, the picture in. A did not come up, but, uh, here's an image of an invertigram, and the point of this image is that distal rectum is quite far away, and I think the safe thing in that particular case is a colostomy. The image in. A, which seems to be missing, was to show that the rectum was very close and could potentially be approached primarily. Um, let's say we do go ahead with a colostomy. Um, His, uh, his computer has an advanced. Yeah, that's a, we'll just use it. Yeah. Um, is, uh, here is a baby opened, ready to do a colostomy. Could we put a vote up for. A, B, or C? Where would the audience open the colostomy? The feet and the head are marked, and you have three locations on the bowel. A, B, or C for the colostomy. OK. Let's put a pole. I think there's an enormous amount of morbidity that occurs with the colostomies that are not, uh, done, uh, correctly, and what we're going to do, so everyone has, has this image in mind. This is the um very proximal sigmoid. Where's my arrow? My arrow is hidden by the, uh, Todd, can you move that, uh, pole or someone moved the pole, because I think my arrow is hiding. OK. Here's your, my arrow is hiding underneath the, uh. Yeah, it'll show up in a second. There, there it is. It was hiding underneath the pole. So this is the proximal sigmoid. And this is going distal. You want to comment about, uh, about how you make sure to open the colostomy in the right location? Yes, yes, if you, if you see the, um, you are aware in the, in the, in this diagram where the head, the head of the patient. So remember that, um, the mobile portion, Move that arrow if you'd like. See, this is the arrow. Yeah. I can touch it and then hold the button down as you drag it. Yeah. OK. So this is, this is the end of the descending colon. This is the end of the descending colon, and we know under normal circumstances that colon is fixed. So opening the stomach right here will guarantee that the patient will not suffer from prolapse. And this is the mobile dilated sigmoid. If you open the colostomy in one of these places, most likely the patient will have severe prolapse. We have learned, it took me many years to make the observation. That if you open a colostomy in a mobile portion of the colon, for sure it will prolapse. So if you don't want your patient to have prolapsed, be sure that you open the colostomy in a fixed portion of the colon. So if you are, the, the, this is the abdomen of the baby, the belly button should be somewhere there. This is an oblique incision, like a, like a, um, like an appendectomy, but in the, but in the left side. And nobody does appendectomies now open, but anyway, and the, and the, this is the upper end of the, of the incision, and that's where the proximal stomach is going to be. And then the question is, uh, what to do with all this sigmoid and what we, I recommend is to empty the sigmoid, wash all the meconium out with a number 12 Foley catheter through a, First string suture and then when you open the mucous fistula, which should be separated from the, from the proximal stomach, the mucous fistula should be reduced in size. Don't open a mucous fistula the size of this colon. I'll show you. Because that would be very ugly. So now you are seeing the way we do it. This is the descending colon, that will not prolapse. Unless the patient has mild rotation or some bad fixation of the colon. This is the incision, and this is the mucous fistula that we make tiny because it only, is only necessary for irrigation and for diagnostic tests. Are they looking into this pole. Are they look into this other image. Um-hum. Move the pole to a different. Place in the slide there. So there, there you see that the mucous fistula must be tiny. And the, the, uh, and you have to separate the stomach enough as to be able to adapt the stomach back to the proximal stomach. So, that, I want to then address a question that came, uh, from Jeffrey Pence about loop versus end colostomy. Uh, he wants to know, um, I think, I think the answer is going to be. Majority of end, but I want to see if anyone here. Let's, let's take a vote on that. Uh, you know, my, my concern about a loop is it's never completely diverting. No matter how much people believe their loops are diverting, it's never completely diverting, um, because you do not want any spillage downstream. It's about 20% of people, uh, would do a loop. Yeah, the audience here. And, and, and, and if, if I have a baby with an anorectal malformation, who's had a colostomy elsewhere and the, and the baby is having urinary tract infections, my first question is, what does the stoma look like? And when you're talking to a pediatrician, you say, is there one or two stomas? One meaning a loop, or are they bagging the two stomas together? Because if there's spillage across, there's going to be contamination of the urinary tract if there's a fistula, and in the cloaca, there's going to be contamination. So I think those need to be properly separated, uh, and loops, uh, simply don't completely divert. Um, Paula is commenting, I, is commenting here about the importance of cleaning out the distal colon. That is absolutely correct. Um, this, uh, uh, and that's, um, a very important part of the opening of the colostomy. You need to spend about 2030 minutes sometimes cleaning out the distal segment. Yamataka talks about a transverse colostomy. Do you want to comment on. Yeah. That? We, we have been exposed to over, Over 1500 patients that came to us already with a colostomy open. So we have seen all kinds of colostomies, basically, and we have seen the pros and cons of the different types of colostomy. The inconveniences of the transverse colostomy is that, number one, you dysfunctionalize a very long piece of colon. It, number two, it's extremely difficult to do a good distal cholostogram through a transverse colostomy because it's very difficult to apply, enough hydrostatic pressure through the transverse colon to the pressure to, To, to overcome the, uh, the, um, the, um, the, the muscle, the tension in the pelvis. It's very difficult to demonstrate the fistula applying pressure in a distal colostogram from the transverse colon. The, the, the, um, incidence of perforation of the colon with a distal colostogram occurred mainly through transverse colostomy. In addition, the, um, cleaning of the colon distant to the colostomy through a transverse colostomy is almost impossible. So you leave a patient with a pool of meconium distally, and then that meconium colonizes, and in addition, when patients have a rectal urinary fistula, the meconium, May go through the urine, but also the urine may go into the colon. And if you have, um, descending colostomy like the one that we propose, the urine may come out through the mucous fistula, whereas if you have a transverse colon, the urine gets trapped into that colon, it's absorbed and it's not unusual to see babies that suffer from, Um, um, hyperchloremic acidosis. So for all those, in addition, if you leave the baby with a transverse colostomy a long time, the distal colon becomes extremely dilated and full of meconium. Um. And the more dilated the rectal pouch, the more constipation the patient will have. Now, you're looking at a typical image of a patient who underwent a transverse colostomy. So the colostomy, the colostomy is here, And then you see what happens to the, to the distal column, becomes dysfunctionalized, and, but this column continues having peristalsis and continues passing mucus and continues passing, um, uh, uh, mucosal cells, and all of that accumulates in the distal bowel and produces an enormous mega, mega rectum. And when you, when you repair that, uh, like we saw many of these colons in the past, and that's why we were, Doing so many taperings. Now we don't do taperings because surgeons are doing better colostomies, but we have, there's a direct relationship between the degree of megacolon and the degree of constipation that the patient will have. This colostomy, it was opened in a, I'm sorry, this colostomy was opened in a mobile portion of the colon. It's a loop colostomy. By the way, loop colostomies perhaps more than separated, and this is a loop colostomy, but I, I agree that there are loop colostomies that are diverting and the loop colostomies that don't divert that keep passing the stool. There are different types of loops, but in general, it's a risk to do a loop, and this is a patient that comes with an impacted bowel that requires a separate procedure just to clean the colon. Uh, Yama wants to make a comment. Yama? Yama. Um, transfers colostomy colossogram again in the previous maybe previous, yeah, I think, uh. You know, I'm afraid, uh, I cannot see any, uh, fecal mass in the, even, uh, colostomy performed in the transverse colostomy. I think, uh, in the long term, I think, uh, uh, we, we can wash out and also I think this colosgram showed unusually long sigmoid column. In the, in the majority of malformations, I think how long is much shorter than this. So I, I never had any promise about the uh making a stoma in transfers. Let's, uh, let's hear some of the problems about this type of colostomy. Uh, Professor Liam commented that, uh, a properly done colostomy is very important to set up the patient for a proper laparoscopy, which we're going to get to in a couple slides. Let's talk about the problem with this colostomy. Uh, I think I prefer the proximum, uh, sigmoid colostomy or, or the left transverse colon because, uh, I only perform laparoscopic operation in 2, 2nd step. So if we perform it in distant sigmoid, it, uh, it makes the operation, laparoscopic operation more difficult. Yeah, so this, this, uh, was an avoidable problem. The surgeon here opened the colostomy to distal, which brings up problems for the mobilization of the distal segment and actually has been the reason why some of this, these cases cannot be done laparoscopically without, uh, essentially opening to take down the mucous fistula. So it's definitely avoidable. I'm going to, uh, move ahead. Shala wants to make a comment. Is that OK? Can I make a comment on that, OK. Uh, it's just, uh, sometimes for laparoscopic operation, having that colostomy helps because it acts as a, as a traction. And you can dissect the fistula and then, of course, take down the colostomy and open a new one at the same time. Because the traction of, if it, if it is a high case as it looks like, you can still use it as traction. So, I think maybe Depending on the case, you don't need to open a new colostomy first. You can go on with the reconstruction, close it and open a new one at the same time. We're, we're going to talk about laparoscopy in a minute, but let's cover, uh, the newborn cloaca briefly. Um, I passed over a couple of the slides about constipation and ARM. We will try to get to those. If we don't, there are, that section is also covered in the third portion of today. About constipation. So, um, let's ask, um, Let's ask, uh, uh, Paula, what are your thoughts about these prenatal images? So, so you know it's a female and uh probably a female. OK, yeah, no, I, I'm saying that when, when you see some, uh, of this picture, you, you must know the gender first of all, and, uh, probably the 3rd trimester, uh, ultrasound because it's rarely encountered during the 2nd trimester. So these are probably uh in the in the left picture these are probably the two hemi vaginas and anteriorly there is the bladder that's my guess. I don't know and on MRI it's um uh hydrocorpus knowing that is a is a female. But it's, it's not easy, it's not easy and it's not common to have a prenatal diagnosis of cloaca. It's always always a, a good guessing, but not a certainty. Yes. So let's talk about the newborn. Uh, Long Lee, you want to tell us what is your opinion about this malformation? Uh, this girl suffered from persistent re maybe, uh, with the lung common channel. All right. And let's, uh, let's see this baby, um, this is that baby? Let's talk about the management of that baby. How would you, uh, how would you proceed? Uh, in the new neonatal period, a colostomy is needed for this girl. Now also, the, the investigations to be on the vaginal, bladder, and the urinary system. During the colostomy. The patient, The. Yeah, go ahead. The patient that you are seeing in the, in the screen is a baby with a cloaca, and the, uh, the, um, what you see in the abdomen is a, a mass located in the midline. Um, that mass, when, when you are dealing with a cloaca, most likely it's a hydrocorpus. We have never seen a patient with a cloaca with that abdominal mass that was not a hydrocorpus. And, and as, as said, You have to do an ultrasound in these babies, an ultrasound of the kidneys, but also an ultrasound of the pelvis, looking for that mass. And if it happens that the baby has hydronephrosis, as you can see, this is the ultrasound, an ultrasound of the same, An ultrasound of the same baby showing, showing, showing hydronephrosis. And on the right side, you're saying, you see the same kidney of the same baby the day after she underwent a drainage of the hydrocorpus. In other words, it is mandatory to drain this hydrocorpus. When you see an abdominal film with an occupying mass image like this, you know, That it's a hydrocorpus. A radiologist that is not trained in, in dealing with cloacas made to give you all the diagnosis. They usually they say that it's a cystic mass, most likely an ovarian cyst, but if you know that this is a cloaca, you can guarantee it's a hydrocorpus. The hydrocorpus compresses the trigon of the bladder and produces, as you can see here, it's very easy to understand. That this dilated vagina is compressing the trigon of the bladder and producing an acquired. Uh, urethral vesicle obstruction. By draining, that produces mega ureters in hydronephrosis. When you drain the hydrocorpus, the patients, uh, the hydronephrosis disappears. Now, it's extremely important for you pediatric surgeons to know that before the urologist, you may be dealing with a urologist with experience in cloaca, or you may be dealing with a urologist with no experience in cloacas, and that's why the babies are under the, Risk of undergoing an unnecessary nephrostomy, unnecessary ureterostomy, unnecessary vesicostomy, because they think that by doing those operations, the hydronephrosis, the urinary tract will decompress, but actually, the, the key is draining first the hydrocorpus. If the patient doesn't improve in terms of mega ureters and hydronephrosis after you drain the hydrocorpus, then you are justified to do other studies, And consider other operations to drain the urinary tract. If you don't drain the hydrocorpus, the consequences of not draining the hydrocorpus is, number one, urosepsis, the patient will continue being sick, and number two, the, the hydrocorpus may become infected. The baby may have pio corpus, and once they have piocorpus, that vagina gets damaged permanently, and it's going to be very difficult to repair those cases. And talking about drainage of the hydrocorpus, many pediatric urologists, um, um, like to try to do it by passing catheters from below through the, through the synco perinealorrisis. You may be lucky and drain the hydrocorpus, but the catheter will come out and in two more days, the hydrocorpus will form again. So we like to drain the hydrocorpus with a permanent catheter through the abdomen, not, not, uh, by, and don't, don't try to dilate the common channel because it's very difficult. Uh, this, this photograph shows the divided colostomy and the hydrocopos. A lot of people ask, uh, what type of tube to use. Um, and, uh, we've learned the hard way that the best tube is one of the curled pigtail tubes because the hydrocopos at first is very, uh, inflamed and dilated, but over several months, becomes less and less swollen. So the, uh, the hydroculpus at first is very stuck to the anterior abdominal wall, but eventually recedes into the pelvis. So if you have a straight tube, the tube will fall out. If you have a curled tube, it stays in. It's very, uh, sort of a nice technical point, makes it less likely that your tube is going to fall out. Um, Are there any, any questions here? Doctor Sarki saying something about. Yeah, you have a question? Yeah, she said something about the drainage of the, of the hydrocorpus by ultrasound guide. Yeah. Yes, that, that's feasible to drain the hydrocorpus in the, by, uh, interventional radiology. They are very good, provided the hydrocorpus is large enough to be close to the abdominal wall. Because if the hydrocorpus is not large enough, particularly with a large bladder and bowel, it's difficult for them to do it. So, but if you are going to be in the abdomen anyway when you open the colostomy, that's what we think is a great opportunity, but uh, we, sometimes we have tried to drain in the way you described. Now, uh, Marcella is saying that they routinely use vesicostomy. Vasicostomy, the vasostomy, I, I don't say it routinely. I say that in some cases, the vagina is full with urine, and if we can, in the cases that we can do a, uh, and, uh, dye it in or and see that all urine coming from the bladder. Which may be the case, we do a vasicostomy instead of a colpostomy. It depends on the coaca, but if we have a huge dilated vagina, we prefer to drain it through the abdomen. And I, I would like to know the catheter Bark was telling about, I think we don't have that. You, you do. In interventional radiology, they use pearl tubes to drain abscesses. I'm sure you have an 8 French curl tube somewhere in the hospital. It's called pigtail, a pig, pigtail tube Pigtail. Um, but, but let me just mention that the vasicostomy. Is sometimes indicated in these babies when because some babies have an almost atricia of the common channel. In other words, some babies have a such a narrow common channel that and when you see a tiny or single orifice in the perineum. And, uh, and you cannot catheterize that because it's very narrow. You cannot pass a cystoscope because it's extremely narrow. Those babies have difficulty emptying the bladder, and that's when a vesicostomy is indicated. But, um, in general, I suggest you first to drain the hydrocorpus, because that will take care of most of the problems. And as I said, you drain the hydrocorpus and you see a persistently full bladder that doesn't empty, then it's indicated, from my point of view, uh, vasicostomy. I want