A 4-month male with imperforate anus who had a descending colostomy at birth is being scheduled for a PSARP. The colostogram shown below demonstrates a high rectum and no fistula.

 

 

[size=20px]The most appropriate next step is:

 

A Repeat pressure colostogram

 

B PSARP only

 

C Laparoscopic assisted pull through

 

D Open abdominal mobilization with PSARP[/size]

A

B- PSARP only

mostly it’s with Down $

A

A

A-We need more pressure to win muscle complex.Until we see a concave cul di sac

A

B

A

this is in sufficient pressure colostogram , the lower rectum is flat which means that it has not over come the pressure of the pelvic floor

I would repeat the colostogram and be there at the time of doing it

A

A

correct answer

 

A Repeat pressure colostogram

 

Although this patient has a colostogram, is does not appear to be an adequate study (poor distention, visible folds - indicating low pressure). An augmented-pressure distal colostogram is the critical study to perform prior to a PSARP on a male. It identifies the entry site of the fistula into the urethra and determines if an abdominal (laparoscopic or open) or only a posterior sagittal approach is required. This study can be technically challenging, and surgeons need to be aware of pitfalls to avoid.

 

 

The study is completed with a foley inserted into the mucous fistula. 1-2 ml of air fill the balloon, and then traction is applied to provide a seal at the fascial level and to prevent leakage. The air allows visualization of the balloon on lateral views. A limited volume prevents perforation, especially in infants. In the lateral view, with femoral heads overlapping, contrast is slowly injected. A coin placed at the suspected center of the sphincter complex allows determination of the distance from the pouch to the skin. Signs of inadequate pressure include persistence of rectal folds and lack of filling of the urethra despite a tapered end. With adequate pressure, the rectal wall becomes rounded if no fistula is present (often seen with trisomy 21). A line drawn at the tip of the coccyx perpendicular to sacrum is an excellent guide. If the rectum is higher than the line, then laparoscopy is appropriate, if the rectum is below the line then a PSARP approach only will reach the rectum. The rectum will be the first structure encountered on dissection and laparoscopy is not needed.