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StayCurrentMD
Pediatric Colorectal Contraversies Part II: Pediatric Colorectal...
With Dr. Long Lee · hosted by Dr. Em Gootee
Chapter 1 of 5 · Surgical Management
Vestibular repair timing
Vestibular fistula: primary repair versus colostomy timing and technique
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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
Primary repair is preferred in the neonatal period with a very nice fistula; older patients may require colostomy
Primary repair can be performed up to 3-4 months of age if surgeon is confident; otherwise two-operation approach is used
Teenagers repaired with classical three-operation approach have beautiful perineum and perfect function
Patients repaired primarily 7-8 years ago have more stenosis and adhesions because feces pass through during healing even with fasting
Vestibular fistula patients with normal sacrum and no cord have excellent prognosis with good operation
For babies born in hospital, operate within first 72 hours before colonization occurs
For 6-month-old baby with megacolon, clean colon with GoLYTELY completely, then central line with 7-10 days NPO on parenteral nutrition before repair
Oval-shaped anus with no radiating streaks is very specific for Currarino syndrome
Presacral mass corresponds to either anorectal stenosis (mass just in front of stenosis) or Currarino syndrome
Opening colostomy in fixed portion of colon (end of descending colon) prevents prolapse
Opening colostomy in mobile portion of colon will cause severe prolapse
Mucous fistula should be reduced in size and made tiny, only necessary for irrigation and diagnostic tests
Transverse colostomy dysfunctionalizes a very long piece of colon
It is extremely difficult to do a good distal colostogram through transverse colostomy because of difficulty applying enough hydrostatic pressure
Colon perforation with distal colostogram occurred mainly through transverse colostomy
Cleaning colon distal to transverse colostomy is almost impossible, leaving pool of meconium that colonizes
With transverse colostomy and rectourinary fistula, urine gets trapped in colon, is absorbed, and can cause hyperchloremic acidosis
Long-term transverse colostomy causes distal colon to become extremely dilated and full of meconium
There is a direct relationship between degree of megacolon and degree of constipation the patient will have
Loop colostomies have more prolapse than separated colostomies
For laparoscopic repair, distal colostomy can act as traction to help dissect fistula, then take down and open new one simultaneously
Cloaca is rarely diagnosed prenatally in second trimester; third trimester ultrasound more common
Midline abdominal mass in cloaca patient is always hydrocolpos; never seen a cloaca with that mass that was not hydrocolpos
Hydrocolpos compresses bladder trigone and produces acquired ureterovesical obstruction with megaureters and hydronephrosis
Draining hydrocolpos makes hydronephrosis disappear
Unnecessary nephrostomy, ureterostomy, or vesicostomy may be performed if urologist does not recognize that hydrocolpos drainage is the key
Consequences of not draining hydrocolpos are urosepsis and infected hydrocolpos (pyocolpos) that permanently damages vagina
Transperineal catheter drainage of hydrocolpos will come out in two days and hydrocolpos will reform
Drain hydrocolpos with permanent catheter through abdomen, not by dilating common channel
Interventional radiology can drain hydrocolpos under ultrasound guidance if it is large enough and close to abdominal wall
Vesicostomy is indicated when common channel is almost atretic and baby has difficulty emptying bladder after hydrocolpos drainage
For vestibular fistula, Professor Liam prefers primary repair around day 5-7 of life
About 30-40% of anorectal stenosis or rectal atresia cases will have a presacral mass
MRI is the best way to show a presacral mass
For anorectal stenosis repair, open posteriorly only to preserve anterior dentate line and avoid anterior rectal dissection
Loop colostomy is never completely diverting no matter how much surgeons believe it is
Spillage across loop colostomy causes urinary tract infections in patients with fistulas
Cleaning out distal colon at colostomy creation takes about 20-30 minutes and is very important
Distal sigmoid colostomy makes laparoscopic operation more difficult and may require opening to take down mucous fistula
Best tube for hydrocolpos drainage is curled pigtail tube because hydrocolpos recedes into pelvis over months; straight tube will fall out