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    Abdalla 2017

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    of 3

    Journal of Pediatric Surgery 52 (2017) 1207–1209

    Contents lists available at ScienceDirect

    Journal of Pediatric Surgery


    journal homepage: www.elsevier.com/locate/jpedsurg

    Pediatric Surgical Image

    The high pressure distal colostogram in anorectal malformations:


    technique and pitfalls
    Wael M.A. Abdalla ⁎, Luis De La Torre
    University of Pittsburgh School of Medicine, Childern's Hospital of Pittsburgh of UPMC, Pittsburgh, PA

    a r t i c l e i n f o a b s t r a c t

    Article history: The importance of technically adequate high pressure distal colostogram in planning management for patients
    Received 8 December 2016 with anorectal malformations and how technically inadequate examination could delay management and affect
    Received in revised form 17 March 2017 the outcome cannot be over emphasized as shown in this article.
    Accepted 19 March 2017
    © 2017 Elsevier Inc. All rights reserved.
    Key words:
    Colostogram
    Anorectal malformation
    Fistula
    Stoma
    Rectum

    High pressure distal colostogram is an essential element during the in- which is very important to avoid leakage and to obtain high pressure
    vestigation of patients with Anorectal Malformation (ARM) [1–7]. It is of ut- into the distal pouch. Inject the contrast (water soluble contrast, never
    most importance to perform the exam adequately. It is readily available barium) by hand and observe for abnormalities (e.g. areas of diameter
    almost anywhere, can be done quickly and provides valuable information sudden change, filling defects). Inject contrast while keeping pressure
    to the surgeons. There are other potential alternatives like MR colostogram until the blind distal end of the colon distends and become convex. Un-
    [2], but this is more expensive, less easily available, some patients are un- fortunately there is no way up to our knowledge that could measure the
    able to hold still, are claustrophobic, need sedation or have metal implants. pressure real time (unlike the air system used to reduce intussuscep-
    Voiding cystourethrogram (VCUG) is also mandatory in all patients with tion), that is why the study must be done under fluoroscopy and the per-
    ARM who have renal or vesical abnormality detected by US. Most authors son in charge must notice the degree of distension and the resistance felt
    recommend VCUG for all patients with ARM regardless of the ARM type [7]. during injection of the contrast. Acquire images in straight lateral posi-
    tion and then in AP position.
    1. Case example What to look for?

    A 3 month old male patient with hypospadias and imperforate anus 1. Look for the distance between the most distal part of the fully distended
    post colostomy. This is a good example of how a technically adequate colon “the convex part” and the radiopaque marker, this gives an idea
    high pressure distal colostogram is important for careful evaluation regarding the distance between the distal pouch and the future anal
    and surgical planning. Fig. 1 shows how inadequate study could be mis- orifice and how much colon is needed for the pull-through.
    leading, Fig. 2 shows what an adequately performed study could reveal. 2. Measure the length of colon that was de-functionalized. It is the useful
    length of the distal colon pouch. This helps surgeons to evaluate if the
    distal colon is adequate for the pull-through, or it is short, and they need
    2. Technique to ensure an adequate high pressure distal colostogram
    to perform an additional abdominal procedure to mobilize more colon
    to have the adequate amount of colon needed for the pull-through.
    Place a radiopaque marker in the perineum where the anal sphincter
    3. Determine if there is a communication or fistula between the rectum
    or anal dimple is and place a ruler parallel to the patient's back. Intro-
    and other structure such as urethra or bladder. The maximum
    duce a Foley catheter through the distal stoma also named “mucous fis-
    distension of the colon is extremely important in revealing a fistula.
    tula”. Inflate the balloon and pull back on it lightly to ensure a tight seal,

    ⁎ Corresponding author at: Children's Hospital of Pittsburgh, 4401 Penn Ave.,


    Fig. 3 shows an example of a technically well done study.
    Pittsburgh, PA, 15224, USA. Tel.: +1 412 692 5032; fax: +1 412 864 8622. Inadequate distension of the colon (no convex blind end obtained),
    E-mail address: [email protected] (W.M.A. Abdalla). could result in failure to reveal a fistulous tract causing a potential

    http://dx.doi.org/10.1016/j.jpedsurg.2017.03.050
    0022-3468/© 2017 Elsevier Inc. All rights reserved.
    1208 W.M.A. Abdalla, L. De La Torre / Journal of Pediatric Surgery 52 (2017) 1207–1209

    Fig. 1. The distal colon is not well distended throughout the study (no convexity of the colon blind end – arrows) and no fistula is identified.

    Fig. 2. Same patient a week later; (A) without full distension of the distal colon, no fistulous tract is seen. (B) Progressive increased pressure distal colostogram produced a good distension
    of the colon (Note the convexity of the blind end, thin arrow) and a fistulous tract connecting the rectum to the urethra is revealed (Thick arrow). (C) Radio opaque marker is placed
    (double head arrow is the distance between the distal end of the colon and the location of the sphincter marked by the radio opaque marker). (D) The black lines measure the length
    of the distal colon; this enables the surgeon to decide if there is enough length for the pull through or not.
    W.M.A. Abdalla, L. De La Torre / Journal of Pediatric Surgery 52 (2017) 1207–1209 1209

    Fig. 3. Another example of a technically well-done high pressure distal colostogram and shows a recto- vesical fistula (Arrow). The sequence of images shows the significance of obtaining
    the maximum distension of the distal colon; otherwise, a fistula could not be revealed at all or overlooked.

    incorrect surgical management. VCUG is an important part of fully in- References


    vestigating patients with potential fistula; however, in our experience
    the high pressure distal colostogram is more successful in revealing [1] Levitt HP, Pena A. Anorectal malformations. Orphanet J Rare Dis 2007;2:33.
    the fistulous tract. VCUG should not be performed at the same session [2] Kavalcova L, Skaba R, Kyncl M, et al. The diagnostic value of MRI fistulogram and MRI
    distal colostogram in patients with anorectal malformations. J Pediatr Surg 2013;
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    Possible complications of high pressure distal colostogram include [3] Pena A, Levitt M. In: Stringer M, Oldham K, Mouriquand PDE, editors. Anorectal
    stoma rupture by the distended balloon and the significantly less likely malformations. In Pediatric surgery and urology: Long term outcomes. 2nd ed. Cam-
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    bowel perforation. Once there is significant distension of the distal [4] Levitt MA, Peña A. In: Holschneider AM, Hutson J, editors. Management in the New-
    pouch, further contrast administration must be done under extreme born Period. In anorectal malformations in children. Heidelberg: Springer; 2006. p.
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    [5] Peña A, Levitt MA. In: Grosfeld JL, O'Neill JA, Fonkalsrud EW, Coran AG, editors.
    Anorectal malformations. In Pediatric surgery. 6th ed. Philadelphia: Mosby Elsevier;
    3. Conclusion 2006. p. 1566–89.
    [6] Bischoff Andrea, Levitt Marc A, Peña Alberto. Update on the management of anorectal
    malformations. Pediatr Surg Int 2013;29:899–904.
    It is crucial when doing a distal colostogram to ensure that an ade-
    [7] Alamo Leonor, Meyrat Blaise J, Meuwly Jean-Yves, et al. Anorectal
    quate technique is used, otherwise a fistulous tract may not be visual- malformations: Finding the pathway out of the labyrinth Ragiographics, 33; 2013
    ized, which will affect the management plan of the patient. 491–512.

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