Coloplasty for congenital short colon

Congenital Pouch Colon: Further Histopathological Perspectives

Congenital pouch colon is an uncommon anomaly worldwide and is usually associated with anorectal malformations. Imperforate anus with a large air fluid level on the abdominal x ray suggests the diagnosis. Most cases are diagnosed in neonates and an early management limit complications. Few studies have documented the histopathological features of congenital pouch colon. We present two cases with varied associated anomalies (Case 1 with rectovesical fistula, Case 2 with Mayer Rokitansky Kuster Hauser syndrome) and their histopathological features. Immunohistochemistry for calretinin showed paucity of ganglion cells and intrinsic fibers with occasional punctate positivity. The c-Kit immunostain documented fewer interstitial cells of Cajal. Cystitis glandularis with intestinal metaplasia (Case 1) and an additional muscle layer (Case 2) are described. These novel histopathological features characterize the entity further and may be related to genesis of the pouch and its clinical manifestations.

Congenital Pouch Colon: Case Series and Review of Evidences for Resection

Background:

Congenital pouch colon (CPC) is a rare variant of anorectal malformations (ARM) with its highest reported incidence in India. We aimed to describe five patients affected by CPC, in which the tissue from the terminal dilated colon has been successfully used and to discuss our results on the light of an extended revision of the literature.

Materials and Methods:

The clinical details of five cases treated for CPC in two Italian Centers were retrospectively reviewed assessing the fate of the terminal dilated colon.

Results:

In all cases, the tissue from dilated colon has been used. The double vascular system of the dilated pouch allowed increasing bladder capacity (case 4), reconstruction of the vagina (case 3, 5), and lengthening of the colon (case 1, 2, 5).In our series, 3/5 have a good bowel control with daily bowel management after ARM correction. In literature, there are not differences in terms of dependence from bowel management in patients with pouch resected and in patients with pouch saved (P = 0.16).

Conclusions:

We acknowledge that the analysis of the available literature is limited by the absence of studies with high level of evidence and the removal or the preservation of the abnormal colon tissue seems to follow the surgeon preferences.

Congenital pouch colon: Our experience with coloplasty

BACKGROUND

Congenital pouch colon (CPC) or congenital short colon is an entity found mainly in Indian subcontinent. In CPC, colon is replaced with partially or completely abnormal pouch connected to the genitourinary tract by a fistula (colovesical). Management protocol is different in different institute. In this article, we are sharing our three stage standard management approach; principle and technique of coloplasty in cases in which colon length is not adequate for pull through and their follow-up. This study aims to show the result of coloplasty in complete CPC.

MATERIALS AND METHODS

This is retrospective observational study, of 5 years duration. The medical record of these patients was reviewed for demographic information, clinical features, investigations performed, operative notes, post-operative events and the outcome of surgery.

RESULTS

Total of 626 ARM cases were managed in 5 years duration in which 64 were of pouch colon. The age of presentation was 1-15 days. In fifty patients who completed their, all stage in that 34 patients were in which coloplasty were done in rest of 16 cases excision of CPC and colonic pull through done in view of adequate colonic length (type III and IV) for pull through. In 34 patient in which coloplasty were done showed satisfactory cosmetic and functional out came after stoma closer in follow-up.

CONCLUSIONS

Properly created coloplasty and three stage procedure for complete pouch colon give better result and less complications. Excision of pouch is not requiring in all cases of CPC.

Pouch colon associated with anorectal malformations fails to show spontaneous contractions but responds to acetylcholine and histamine in vitro

PURPOSE

Congenital pouch colon (CPC) associated with anorectal malformation (ARM) is most commonly reported from Northern India. So far, no physiologic study comparing the detailed contractile status of CPC with non-CPC conditions are available. The present article deals with the contractile study and histopathologic observations in CPC, which may be useful for better surgical management.

METHODS

Freshly excised 12 neonatal CPC and similar number of non-CPC (control) specimens were transferred to ice-cold (4 degrees C-6 degrees C) Krebs-Ringer solution bubbled with 100% oxygen. Longitudinally prepared 2 to 4 colonic strips were obtained from central part of each specimen and subjected to the contraction recording after exposure to cumulative concentrations of acetylcholine (ACh) and histamine. Acetylcholine-induced contractions were evaluated after application of atropine (muscarinic blocker), and histaminergic contractions were recorded after pheniramine (H(1) blocker), lignocaine (neuronal blocker), and atropine. Histopathologic observations were made by using H&E and Masson trichrome stains.

RESULTS

Control specimens showed spontaneous contractions, but CPC strips did not. Both control and CPC responded to ACh and histamine. The response to histamine was greater (P < .05) in CPC as compared to control, whereas the response to ACh was more (P < .05) in control. In CPC, response of histamine (100 micromol/L) was blocked by pheniramine (0.32 mmol/L) and lignocaine (4 mmol/L) by 97% and 80%, respectively, and enhanced by 57% after preapplication of atropine (10 micromol/L). Acetylcholine (100 micromol/L)-induced contractions were attenuated (86%) in presence of atropine. Histopathologic examination showed fewer mature ganglion cells with various changes in muscle layers including fibrosis, disruption, hypertrophy, atrophy, and constriction bands.

CONCLUSION

Congenital pouch colon associated with ARM lacks normal spontaneous contractions but retains ACh and histamine-induced contractility. In view of the functional and histologic abnormalities, we propose that CPC associated with ARM is an abnormally functional and developed tissue. Therefore, resection of the pouch should be considered for better functional outcome of the remaining bowel.

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.

Congenital pouch colon associated with anorectal malformation-histopathologic evaluation

BACKGROUND

Although enough literature is available on the descriptive and the management aspects of congenital pouch colon (CPC) associated with anorectal malformation (ARM), there is paucity of its detailed histopathologic studies. The present article details the histopathologic observations in the excised specimens of CPC in the neonates operated on for ARM.

MATERIAL AND METHODS

Formalin-fixed specimens of CPC were evaluated both grossly and microscopically. They were stained by H&E stain and Masson trichrome stain.

RESULTS

Haustrations and tenia coli were uniformly absent in all the CPC specimens. Mucosa showed focal erosion, hemorrhage, and disruption in the muscularis mucosae. Submucosa showed congested blood vessels, hemorrhage, and thrombosis. Both the circular and the longitudinal muscle layers showed hypertrophic and atrophic appearance. Both the muscle layers also showed disruption. There was presence of fibrosis in all the muscular layers on Masson trichrome stain. There was presence of unique constriction bands in the muscularis propria. These were seen as focal dipping and narrowing of the muscular layers at intermittent intervals. They were more prominent in the circular muscle layers.

CONCLUSION

Congenital pouch colon seen in association with ARM is an abnormally developed tissue and needs to be resected for better functional outcome of the remaining gut. However, further physiologic and immunohistochemical studies are warranted to observe the contractile and innervation pattern of CPC.

Technique and long-term results of coloplasty for congenital short colon

PURPOSE

This paper aims to present the modified technique of coloplasty for congenital short colon (CSC) and analyse the long-term results of this operative procedure.

METHODS

A total of 310 patients of CSC have been admitted to out department between 1975 and 2007; 138 have been treated by the modified technique of coloplasty. Seven patients expired after coloplasty and nine are awaiting ileostomy closure. One hundred and twenty-two have completed all stages of surgery (study group). In these patients, three-stage surgical management (window colostomy, coloplasty with ileostomy and ileostomy closure) was performed. The range of follow-up is from 2 months to 18 years. The patients have been observed for: quality of muscle at the time of PSARP, Kelly's continence score, growth and development, schooling and social interactions and complications. Contrast study of the coloplasty tube has been done at different stages during follow-up with observation of colon diameter, evidence of peristalsis and colon emptying.

RESULTS

Ninety-seven patients from the study group have good quality of life, normal growth and development, where appropriate, they go to school and have normal social interactions. Using Kelly's scoring system, the results are good in 97 (stool frequency up to 3/day, no perineal excoriation, no soiling), fair in 9 (stool frequency 3-5/day, occasional perineal excoriation and occasional soiling) and poor in 16 (continuous stooling, soiling, perineal excoriation or complications). Complications include perineal dehiscence needing permanent colostomy (n=1), closure of the distal end of the coloplasty tube requiring revision (n=2), adhesive intestinal obstruction requiring re-exploration (n=2). Additionally intractable perineal excoriation (n=8), colonic dilatation requiring pouch excision and conversion to ileal 'S' pouch (n=2) and failure to thrive (n=4) were also seen.

CONCLUSIONS

Congenital short colon is the most severe colonic malformation barring cloacal exstrophy; however, good quality of life can be offered to these patients by coloplasty. The important technical step is to make the colonic tube long and small in diameter, so that it can propel stools and resist dilatation. These steps have been highlighted in the paper.

Classification of congenital pouch colon based on anatomic morphology

BACKGROUND AND AIMS

Congenital pouch colon (CPC) is an extremely rare variant of anorectal malformation (ARM), in which varying lengths of the colon is replaced by a dilated pouch accompanied by a fistula communicating with the genitourinary tract. The aim of this study was to determine the incidence and prevalence of various forms of CPC and to classify it according to anatomic localization of malformation.

PATIENTS

During a period of 10 years, from 1996 to 2006, 390 patients with ARM were presented and managed at the Rabindra Nath Tagore Medical College, Udaipur, Rajasthan. CPC patients were identified at the time of presentation after abdominal films, and the anomaly was classified according to the form of pouch presentation only during surgical exploration.

RESULTS

Of the total number of ARM cases, the incidence of CPC was 17.2% (67 cases); however, it constituted 55.8% cases of high ARM. Among the CPC patients, type 1 was documented in 19 (28.4%), type 2 in 17 (25.4%), type 3 in two (3%), type 4 in 25 (37.3%), and type 5 in one (1.5%). Multiple large colon segmental dilatations were documented in one patient (1.5%); and in two patients (2.9%), the type of CPC was not known.

CONCLUSION

Classification based on the anatomic morphology has the advantage of identifying the pouch based on the segment of the colon involved, rather than the previous classification based on the length of the colon.

Congenital pouch colon: follow-up and functional results after definitive surgery

PURPOSE

In this study, functional results with regard to fecal continence levels and other parameters were studied in 22 patients with congenital pouch colon associated with anorectal agenesis (CPC) more than 3 years old who had undergone definitive pull-through surgery 1 to 13 years earlier. An attempt was made to formulate treatment protocols for management of fecal incontinence and other problems associated with CPC.

METHODS

The study sample consisted of 14 males and 8 females. Three of the 8 female patients had had a cloacal malformation. The medical records of the patients were scrutinized and they were classified into 4 subtypes based on the length of normal colon proximal to the colonic pouch. The patients were further categorized into 3 groups based on the terminal bowel that had been pulled-through, namely, the ileum or colon proximal to the colonic pouch or a tubularized segment of the colonic pouch. The somatic growth of the patients was studied. Clinical assessment of fecal continence was performed by the Kelly and the Kiesewetter and Chang scoring systems. A computed tomographic scan of the pelvis with a barium enema was performed to assess the terminal bowel and its placement as well as the bony and muscular anatomy of the pelvis. The urinary system was assessed by a clinical history as well as by abdominal ultrasound and a micturating cystourethrogram. Various treatment modalities including dietary modifications, drugs, and enemas were instituted in patients with poor continence levels, and the response to treatment studied.

RESULTS

Thirteen patients (59.2%), all with an ileal pull-through, had height and weight less than 50% of that expected for their ages. Overall fecal continence was "poor" in 17 patients and "fair" in only 5 patients. Patients with pull-through of either ileum or normal colon often had very frequent passage of liquid or semisolid stools, whereas the 4 patients with pull-through of tubularized colon had infrequent passage of semisolid stools with abdominal distension and bloating. One of these 4 patients had massive colonic redilatation necessitating surgical correction. Mucosal prolapse and perineal excoriations were frequent findings. Ultrasonography and micturating cystourethrogram showed hydroureteronephrosis and vesicoureteric reflux in 5 patients. Radiologic assessment revealed that there were no significant sacral abnormalities and the striated sphincteric musculature was well developed, although the levator ani was thinner than normal in 15 patients (68%). The bowel was very well placed in the sphincteric complex in 19 patients (86%). In 7 of the 13 patients who had pull-through of normal ileum or colon, some improvement in continence levels was seen 3 to 6 months after institution of dietary measures, loperamide, and saline-water enemas. Two of 3 patients with pull-through of tubularized colon improved to some extent with colonic washouts alone. Overall, quality of life was poor in the 22 patients.

CONCLUSIONS

Despite the fact that the sacrum is usually normal, the sphincteric musculature well developed, and the terminal bowel well placed without any anal strictures, long-term prognosis with regard to fecal continence, growth and development, and quality of life appears to be dismal for all subtypes of CPC, irrespective of the type of definitive surgery performed. Corrective measures also appear to be of limited value. Various newer management modalities for management of fecal incontinence may be considered, but in several patients a permanent abdominal stoma may be a more practical solution.

"Pouch colon patch graft"--an alternative treatment for congenital short colon

A patch graft of the pouch colon over the pulled-through ileum in a patient with long-length pouch colon (in whom the entire colon was replaced by a pouch that communicated with the urinary bladder) was tried with good results for the first time. At follow-up the patient was found to have normal bowel patterns and weight gain. Though colon patch grafts have been widely used in patients with total colonic aganglionosis, they have not been tried for the short colon. The authors discuss the clinical setting in which the procedure may prove useful in patients with pouch colon and why these patch grafts may yield comparable or even better results in patients with pouch colon compared with those with total colonic aganglionosis.

Congenital pouch colon associated with anorectal agenesis

This article presents a review of the history and development of the various types of congenital pouch colon. Also described are the criteria for diagnosis, the treatment modalities and the results of follow-up studies to emphasize the post-operative problems. The problem of pre-operative and post-operative fecal incontinence is dealt with in more detail.

Congenital pouch colon: Massive redilatation of the tubularized colonic pouch after pull-through surgery

BACKGROUND/PURPOSE

Children with a type I/II congenital pouch colon (CPC) malformation associated with imperforate anus usually are treated by subtotal excision of the colonic pouch, tubularization of the remaining portion, and pull-through of the tubularized colon during definitive surgery. The authors report 3 patients treated in this fashion who presented 2 to 10(1/2) years later with massive redilatation of the previously tubularized colon and enterocolitis

METHODS

There were no anal strictures or malpositioning of the pulled through bowel. Contrast enema showed massive redilatation of the colonic pouch. Near-total excision of the redilated pouch with anastomosis of normal proximal ileum/colon with the retained distal portion of the pouch was performed by the abdominal approach.

RESULTS

Anastomotic leaks occurred in 2 patients but were treated successfully. Postoperatively, the patients had relief from their abdominal symptoms and improvement in fecal continence.

CONCLUSIONS

The colonic pouch in CPC has a marked tendency to undergo redilatation, even after tubularization. The surgical procedure described here for the treatment of these patients appears to be satisfactory.

Congenital pouch colon revisited

BACKGROUND/PURPOSE

The authors' recent experience with the study of the presentation, the pathological anatomy, and results of management of congenital pouch colon (CPC) malformations is presented. The possible embryogenesis of this condition is discussed.

METHODS

Between January 1991 and June 1997, CPC with anorectal agenesis was diagnosed in 39 patients, 27 boys and 12 girls, who were classified in four groups, based on the length of the normal colon proximal to the distended segment. In 31 patients with little or no normal colon, the choice of primary procedure was based on the condition of the infant and the viability of the colonic pouch. Definitive surgery has been performed in 15 patients from this group. The eight patients with a suitable length of normal colon had a lower level of termination of the colonic pouch and a lower fistula. In these, a colostomy was constructed just proximal to the pouch, with later definitive surgery in four patients consisting of excision of the colonic pouch and pull-through of the proximal colon.

RESULTS

Mortality after primary surgery was 13%. Definitive surgery was well tolerated in all 19 patients.

CONCLUSION

In patients in whom a tubularized segment of the colonic pouch was used, continence was only fair to poor a year later.