Colorectal Quiz Episode 14: ARM Newborn Part 3

Hey there listeners, it's Amanda Jensen. And Rod Gerardo from Cincinnati Children's. Have you downloaded the new version of the State Current Pediatric Surgery app? It's in the Apple App Store, it's in the Google Play store. The reason we bring it up is because this podcast has a bunch of associated images. And all of the images are in the app that you can bring up in real time while Dr. Fisher and Dr. Levit are talking about them. So download the apps today, but in the meantime, enjoy the Colorectal quiz. Spoiler alert. This episode is the last of our three-part series on the newborn exam for anorectal malformations. So if you haven't heard the first two episodes, stop this episode right now, hit pause, get out of this episode, go listen to the last two episodes of the Colorectal quiz. If you've been keeping up every week, Amanda, give us a quick summary. We discussed the variations in physical exam findings in both the female patient and the male patient. Then we left it with a cliffhanger, we had a patient where the perineal exam did not reveal where the fistula was. So what did they do? They got some imaging. What kind of imaging you ask? Well, here's Dr. Levit from Children's National Hospital. This photo, there are actually two photos, one side by side, um are what um we would call a crossfire film, also known as a cross table lateral film. Or the old fashioned version of this was an invertogram. Uh this baby just needs to be placed prone in the NICU and a crossfire X-ray is is shot. Um, and the in there's an image on the left and there's an image on the right and both of them show a nice air column. So, what say you? What say me? Well, I think, That's Dr. Fisher from Cincinnati Children's. The importance of this is you can get this film early and then also get this around 24 hours later. These are different patients. It's 24 hours and there's no evidence of a fistula on exam. How do you decide between primary repair and colostomy? So, always the safe answer is if you're uncomfortable operating on a newborn, in this situation, a colostomy is certainly in the books. But if you look at the film on the left, the air column stops at about the fourth sacral vertebral body, give or take a little bit. And so what and you could see where the marker is or the BB is, uh where the where the sphincter complex appears to be located is a large distance between those. And so for me, this is a patient that I would be diverting, considering diversion and doing a distal uh colostogram to really delineate the that anatomy. All right, how about the image on the right? Oh, the air column is very close to where the anticipated anal opening should be located. And this is a case where you could take your barley bush potentially and make a nick, a scratch and and do your anoplasty. I really like that joke because it's a callback to part one from like two weeks ago. So if you haven't heard it, you got to go back and go listen to that episode. Or if you're practicing in the 21st century, you might want to take them to the operating theater and maybe do a formal posterior sagittal anoplasty. I don't think Barley comes in the form of a bush. All right guys, come on, let's refocus. I agree. I think the one on the left is almost definitely a rectourethral fistula, um worthy of a colostomy, that's what I would do based on this image. Um, and the one on the right is probably almost a perineal fistula or a no fistula and I would be um inclined to potentially do that one primary, but you got to be careful because you might be dealing with a low ball bar fistula. Why am I getting deja vu all of a sudden? That was what first podcast, I believe. Wow, I mean it's it all comes full circle at some point, doesn't it? It sure does. Um if you don't have a good memory then it's all brand new. Okay, let's get back to the subject here. This is probably a good time to reiterate that you should have a systematic way to rule out any other associated anomalies. And it's very well represented by the acronym VACTERL. Amanda, really quick, what's VACTERL? V is for vertebral, A for anorectal, C for cardiac, T and E for tracheoesophageal fistula, R for renal, and L for limb. Piggybacking off of that, multiple times on this podcast, we've talked about what you need to know for every patient who has an anorectal malformation. We should always know the type of malformation we're dealing with, the quality of the sacrum, and the quality of the spine. High malformation, poor sacrum, poor spine, not good continence potential. Low malformation, normal sacrum, normal spine, good potential for bowel control. And obviously a lot of gradations in between. And I hope one day we have real good predictions based on this data. And that's one of the values, a little shout out to the consortium, the PCPLC that is calculating all of this stuff across now 15 centers. And then one day we're going to actually be able to tell you, if your malformation is X and your sacral ratio is Y and your spine status is Z, your predicted continence is 82%. Imagine the power of that data one day. Definitely will be helpful for counseling families. No question about it. Can't wait for that data to come out and be able to use it for families. Let's move on in the podcast. Let's talk about surgical approaches to do that. Open up the next image under your media player. We see that's similar image to the perineal fistula. This time the beads of mucus are there. They're not black, they're white and the air column is super close. Would you go for a primary anoplasty in these two cases or a colostomy? I think I I think that's up to the individual surgeon. I think there's certainly a role for doing a primary anoplasty in these patients. It's a matter of level of comfort, matter of level of how the post-operative care in your institution might be for these patients. So certainly it's a possibility and something I would consider. Do you see the picture on the left with the little bead of white, the white dot? I see that white dot is in the sphincter, but in the northern most part of the sphincter ellipse. And this is the kind of case in a male that I would do a posterior rectal wall only mobilization and I would avoid any anterior wall mobilization at all, therefore removing the one major complication that you're always worried about and that is a urethral injury. But to be clear, that's only in situations like this where the dot of the fistula is in the sphincter ellipse. I think people don't realize that common wall or or that wall between the rectum and the urethra is a lot closer and a lot longer of a common wall than I think some people anticipate. A hole that's in the sphincter but just the most anterior portion of it. You do not need to dissect, you don't even have to touch the anterior rectal wall. All right, let's look at the last image. But there's no obvious fistula happening and it's 24 hours. I think you would agree this is a patient that needs a colostomy. Yep. This again, we would get our cross table, crossfire lateral, but assuming we don't see an air column very distal, an obvious colostomy is needed here. And now the Colorectal joke of the day. So, can I tell you a story, Mark? I have many many memories working with you and learning from you. One of them is you had a photo in your office and I don't know if you still do, of a fish you caught. It it's true. The fish has one opening. Yes, by definition. All fish. All fish. But you have a one with a prolapsed opening therefore accentratating the situation. And therefore, you know, symbolizing a cloaca. So what did that fish say when it swam into a wall? Um, could it be, damn. Damn. You got it. How do you know? You're too smart. It's funny, you know, most people don't believe me when I show that picture, but I actually caught that fish. I actually caught the fish with the prolapsed cloaca. Um, and then I um quickly did a um little anoplasty and returned the fish to the water. Yeah. It's wonderful. Yeah. It was uh you know, it was impressive piece of surgery. Did you use spinal anesthesia for that? All right, if you're waiting for the case report on that operation, don't hold your breath. But that's a wrap on the anorectal malformation, newborn perineal exam. I hope you enjoyed all three parts of this short series in the Colorectal quiz. Amanda, give us a summary. So just to go over part one and part two, we discussed the physical exams of both the female and male newborn with an anorectal malformation. And in this episode, we discussed, uh, what to look at on that, uh, cross lateral film and decision-making around a colostomy versus a primary repair. Thank you so much, Amanda. And I hope you guys enjoyed the episode. Make sure you download the Stay Current Pediatric Surgery app. I'm Rod and I'm Amanda Jensen from Cincinnati Children's. Remember, knowledge should be free.