The Colorectal Quiz: Episode 1

VACTERL workup for anorectal malformations includes: V (vertebral abnormalities via plain x-ray), A (anorectal malformations), C (cardiac abnormalities via exam and echo), E (esophageal atresia via NG tube passage), R (renal abnormalities via kidney ultrasound), and L (limb abnormalities via physical exam)

Sacral ratio should be measured at three months of age for true measurement, though early measurement gives a feel for how normally the pelvis has developed

Pre-sacral masses are rare in typical imperforate anus but occur in almost half of anal stenosis or rectal atresia cases, requiring MRI

Cross-table lateral x-ray should be obtained at approximately 24 hours of life to assess gas column height and guide surgical planning

Sacral ratio greater than 0.7 connotes very good prognosis for bowel control and provides peace of mind for families regarding potty training at age four

Well-formed buttocks, good muscle, true sphincter mechanism area, and well-developed sacrum together indicate likely good prognosis

With air column 8.8mm from skin, primary posterior sagittal anorectoplasty is a reasonable option based on imaging

The key to deciding whether to approach perineally via posterior sagittal is knowing where the rectum is—must be confident the first structure encountered will be rectum, not urethra, bladder neck, or bladder

Colostomies are done to know exactly where the rectum is via distal colostogram and to determine whether to approach perineally or laparoscopically

Should never try to go in blind—must know what structure will be encountered before making posterior sagittal incision

Colostomy is the safe choice and was the right decision in this case, though it carries its own complications including those from colostomy closure

The anal repair is made safer by having a colostomy, though everything in medicine is a balance

Very good surgeons have done beautiful anoplasties but ignored fistulas, resulting in children urinating out their anus postoperatively

During primary posterior sagittal approach, open the posterior wall of rectum and inspect the anterior wall to rule out fistula

Bulbar fistula nomenclature refers to anatomic location at the elbow of the urethra

Fistula can be very close to rectum, making proper plane dissection along urethra important

95% of Down syndrome patients with 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 95% having no fistula