Congenital pouch colon with duplicate bladder exstrophy

Type IV Congenital Pouch Colon in Male Children: Anatomical Variations and a Proposed New Subclassification

Background:

Congenital pouch colon (CPC) is a rare variant of anorectal malformation. In male patients, CPC communicates distally with the urogenital tract by a large fistula. The CPC cases which do not fulfill the criteria as mentioned in the classical description are reported along with the pertinent literature review.

Materials and Methods:

This was a retrospective study from January 2004 to December 2017 of male children with Type IV CPC. We evaluated clinical presentation, primary management, anatomical relationship, previous surgical intervention, definitive management, result, and outcome in terms of continence status on Templeton score.

Results:

Fifty-one children were included in the study among whom 36 children (Group 1) had a colovesical fistula and 15 children (Group 2) had no communication of the pouch with the genitourinary tract. In Group 2 children, the clinical presentations and management were varied: 4 underwent primary pull-through procedure, whereas 11 underwent staged procedure. Group 2 included three children in whom a narrow and thin-walled anal canal or anal canal with lower rectum was present, which was incorporated during the pull-through procedure. On continence assessment, only one child in Group 1 had “good” continence score compared to four children (three having anal canal) in Group 2.

Conclusion:

CPC Type IV can present without genitourinary tract communication (fistula), contrary to its emblematic description. Awareness about anatomical variations and adaptation of surgical technique accordingly is vital. The identification of the anal canal with or without the lower part of the rectum (even though apparently narrow and thin walled) and incorporation of this in bowel continuity lead to better outcomes in terms of continence.

Antero-posterior Duplicate Exstrophy with a Wet Bladder Plate: A Diagnostic Dilemma

Variants of exstrophy are rare anomalies seen in the spectrum of bladder exstrophy-epispadias complex. We present a rare case of duplicate exstrophy with a wet bladder plate. This is a deviation from the classical description of antero-posterior duplicate exstrophy that is associated with a dry bladder plate.

Role of plain abdominal radiographs in predicting type of congenital pouch colon

BACKGROUND

Congenital pouch colon (CPC) is a rare form of high ano-rectal malformation (ARM) in which part of or the entire colon is replaced by a pouch with a fistula to the genito-urinary tract. According to the Saxena-Mathur classification CPC is divided into five types. Although plain abdominal radiographs are taken in infants with suspicion of CPC to detect large dilatation of the pouch, the determination of the type of CPC is made during surgical exploration. Since large variations in the length of normal colon are present in the various types, management strategy options can be determined only at the time of surgery.

OBJECTIVE

The aim of this study was to review abdominal radiographs of children with congenital pouch colon (CPC) and evaluate their value in determining the type of CPC prior to surgical exploration to assist pre-operative planning.

MATERIALS AND METHODS

Over a 12-year period (1995-2007), CPC was documented in 80 children (52 boys and 28 girls, age range 1 day-9 years, median 2.4 days) and retrospective analysis of plain abdominal radiographs of 77 children at the time of presentation was performed. Radiographic findings were correlated with surgical findings.

RESULTS

Of 77 children, 5 were excluded from the study since the pouch colon was perforated. The direction of the pouch apex was correlated with surgical findings to determine the CPC type (P<0.0001, Fisher exact test). Type 1 (17/18) and type 2 CPC (18/18) were characterized by a single large pouch with the apex positioned in the left hypochondrium. In type 3 CPC (2/2) the pouch apex was directed towards the right hypochondrium. In type 4 CPC the apex of the pouch was directed towards the right hypochondrium (28/33); however in 5 children it was towards the left hypochondrium. In type 5 CPC (n=1) the radiograph was inconclusive.

CONCLUSION

Plain abdominal radiographs have a predictive value in determining the type of CPC and obviating the need for an invertogram.

Management of congenital pouch colon based on the Saxena-Mathur classification

BACKGROUND

Management guidelines with regard to congenital pouch colon (CPC) are not clearly defined with regard to the type of pouch present. The aim of this study was to outline the management strategy and surgical approach to CPC using the Saxena-Mathur classification based on anatomical morphology of the pouch.

METHODS

During a 12-year period (1995-2007), 426 patients were surgically managed for anorectal malformations at the RNT Medical College, Udaipur. Congenital pouch colon was documented in 80 patients and categorized into 5 types according the anatomical morphology. The management strategy depended upon the location of the pouch and its condition at the time of the surgery.

RESULTS

In type 1 and type 2 CPC, a 1-stage (pouch excision and pull-through) or 3-stage procedure (ileostomy, pouch-coloplasty with pull-through, and ileostomy closure) was performed depending on the condition of the pouch (ischemic or healthy). In type 3 and type 4 CPC, a 3-stage procedure (pouch excision with colostomy, pull-through, and colostomy closure) was performed in all patients. In type 5 CPC, a 3-stage procedure (distal pouch excision with proximal pouch-coloplasty with ileostomy, pull-through, and colostomy closure) was successful.

CONCLUSION

Management of CPC patients according the Saxena-Mathur classification provides a well-defined algorithm in the surgical approach according to the anatomical morphology of the pouch.