Experience with 40 cases of congenital pouch colon

Congenital pouch colon in girls: An algorithm for preoperative diagnosis

Aim:

The aim of the study was o define the preoperative diagnostic clinical and radiological features in girls with congenital pouch colon (CPC).

Materials and Methods:

Records of 47 girls with CPC, managed from 1996 to 2018, were reviewed. There were two age groups: Group A (newborn to 12 months; n = 26) and Group B (>12 months to 20 years; n = 21). The important clinical and radiologic features to help in a preoperative diagnosis were noted.

Results:

The most common subtype was Type II (57.4%), followed by Type I (23.4%) and Type III (12.8%). The features common to both the groups were abdominal distension (A = 53.8%; B = 9.52%), severe perineal excoriation (A = 19.2%; B = 23/8%), and urinary incontinence (A = 30.7%; B = 85.7%). In addition, in Group B, fecaloma on abdominal palpation was noted in 28.6% of patients. The characteristic appearance of the perineum including external genitalia and findings on plain abdominal X-ray (AXR) were 100% accurate and hence diagnostic. These unique features helped us formulate an algorithm for preoperative diagnosis of this uncommon form of anorectal malformation in girls seen in North India.

Conclusions:

The characteristic features on clinical examination should alert one to the presence of CPC in the outpatient clinic. The AXR was diagnostic in 100% of cases and is mandatory. If any doubt persists, examination of the genitalia under anesthesia with more retraction of the labial folds and endoscopy can be performed for confirmation. These measures should enable a clinician to make an accurate preoperative diagnosis in every girl with CPC.

Management options of congenital pouch colon--a rare variant of anorectal malformation

PURPOSE

Congenital pouch colon (CPC) was analysed for anatomical variations and surgical options.

METHODS

Records of CPC patients managed between 1999 and 2014 were studied. CPC was classified as complete (CCPC) and incomplete (ICPC) pouch.

RESULTS

Of 400 cases of high anorectal malformations, 68 cases were CPC (17%). Male:female ratio was 2:1. Fistulous communication was colovesical, colocloacal, colovaginal and absent in 42, 15, 8 and 3 cases. ICPC and CCPC was 48 (70%) and 20 (30%). In neonatal period, proximal/end colostomy (31), ileostomy (6), pouch excision with abdominoperineal pull-through (18 cases) and coloplasty with end colostomy (7) were done. 6 presented as infants including 3 referred cases of CCPC with a window colostomy. Definitive surgery was completed in 56. Severe colonic dilatation after coloplasty was noted in 5, requiring excision of coloplasty segment in 2. Histopathology of excised pouch (45) showed muscle layer disorganization, widened sub mucosa, prominent vasculature and mature and immature ganglion cells, with no hypertrophy of nerve fibres. Diarrhoea and faecal incontinence (soiling) were more frequent in patients with CCPC versus ICPC. Six neonates with CCPC died. Six are awaiting definitive surgery.

CONCLUSION

CPC had 8.8% neonatal mortality. Pouch excision and definitive procedure are feasible in neonates with CPC. Coloplasty in CCPC may result in postoperative colonic dilatation.

The anomalous clinical anatomy of congenital pouch colon in girls

BACKGROUND/PURPOSE

The aim of this study was to evaluate the anomalous clinical anatomy of congenital pouch colon (CPC) associated with anorectal agenesis in 22 consecutive girls managed over a study period of 7 years.

METHODS

The 22 patients were categorized into 2 groups. Group A consisted of 10 patients who presented during the neonatal period (n = 9) or as a young infant (n = 1). In these patients, only preliminary assessment results were available. Group B (12 patients) comprised 5 newborns who remained on follow-up and 7 patients who presented after the age of 1 year. These 12 patients were assessed and investigated in more detail.

RESULTS

In group A patients, apart from absence of the normal anal opening, the appearance of the external genitalia and perineum was essentially normal. Retraction of the labial folds showed radiation of folds inward from the margins of the vulval vestibule toward the center, at a point of confluence located at a higher level. At laparotomy, the subtypes of CPC were type I (n = 4), type II (n = 5), and type III (n = 1). In 8 patients, uterus didelphys was present. In all group B patients, the appearance of the external genitalia was similar to that in group A patients. However, separate openings of the urethra, septate vagina, and vestibular fistula (if present) were visible in 5 patients, whereas in 3 patients, a single perineal opening was identified. A total of 9/12 patients (75%) had urinary incontinence. Examination under anesthesia and endoscopy revealed a septate vagina in all 12 patients and an open, incompetent bladder neck with reduced bladder capacity in the 9 patients with urinary incontinence. The terminal fistula of the colonic pouch opened just distal to the bladder neck (n = 1), just posterior and cephalad to the urethral opening (n = 2), low in the vestibule (n = 5), and undetermined (n = 4). The subtypes of CPC were type I CPC (n = 2), type II CPC (n = 9), and type III CPC (n = 1). All 12 patients had uterus didelphys.

CONCLUSIONS

The characteristics in the anomalous clinical anatomy of CPC in girls, as described here, appear to be almost invariable and, especially in regions where CPC is common, should alert the clinician to the presence of this malformation.

Colon agenesis with ileovesical fistula and anorectal malformation

Colonic agenesis is a rare cause of congenital bowel obstruction and is usually associated with other malformations such as abdominal wall defects or gastrointestinal, cardiac, urogenital, and musculoskeletal lesions. Although many uncommon types have been reported, ileovesical fistula (IVF) associated with total colonic agenesis (TCA) has not been reported in a newborn with anorectal malformation (ARM). This is the first report of a 1-day-old newborn with ARM, IVF, and TCA.

The colovesical fistula in congenital pouch colon: a histologic study

PURPOSE

The aim of this study was to perform a detailed histopathologic examination of the terminal colonic pouch and the colovesical fistula (CVF) excised during surgical management of male patients with the more severe forms (types I/II) of congenital pouch colon (CPC) associated with anorectal agenesis.

METHODS

From January 2005 to December 2006, 25 male patients with types I/II CPC underwent abdominal exploration with dissection of the terminal portion of the colonic pouch and associated CVF till the bladder, division-ligation of the fistula, and excision of the colonic pouch. In 6 of the 25 patients, a complete dissection of the fistula to the bladder was possible, and in them, the terminal portion of the colonic pouch and the CVF were subjected to detailed histopathologic examination. The 6 patients included 3 newborns in whom this surgery was performed as a primary procedure, and 3 patients aged 3 months, 15 months, and 2 years, respectively, in whom a window colostomy of the pouch had earlier been performed. After due processing, multiple sections from the specimens were stained using the routine H&E method and examined under the microscope under different magnifications.

RESULTS

In 4 specimens, the epithelial lining of the CVF consisted of transitional stratified epithelium with underlying anal/urethral glands. In 2 specimens, obtained from patients 15 months and 2 years old, respectively, the lining was of nonkeratinizing, stratified squamous epithelium. Other findings included aganglionosis in the muscle layers (n = 2), submucosal and subserosal fibrosis (n = 1), and thickening of muscle layers in the fistulous portion, suggestive of the presence of an internal sphincter (n = 2).

CONCLUSIONS

The CVF in patients with types I/II CPC shows histologic features of the normal anorectal canal.

Congenital pouch colon syndrome in a Saudi Arabian neonate

Congenital pouch colon syndrome is partial or complete replacement of the colon by a pouch-like structure and anorectal malformation. Commonly reported from northern India, we believe this is the first report of congenital pouch colon syndrome in a Saudi Arabian neonate. He was referred with an imperforate anus and diagnosed as having a high anorectal malformation. The patient underwent a sigmoid colostomy. Continued abdominal distension after the colostomy prompted sonography and computed tomography, which showed an air- and fluid-containing cystic structure in the abdomen. Exploration revealed a thick-walled cystic structure in continuity with the distal colostomy and with a blood supply mainly from the superior mesenteric artery. The ureters were dilated and tortuous and the pouch opened into the posterior vesical wall. The pouch was resected and an end colostomy fashioned. The etiopathogenesis classification and management of the congenital pouch colon syndrome are discussed.