[size=20px]A 5-year-old male with a history of a previously repaired rectobulbar fistula presents for evaluation of severe constipation and fecal incontinence over the last year. On examination, the child is noted to have an adequately sized anus located within the sphincter complex. There is no stricture or prolapse. The sacrum and spine are normal. The child is currently managed successfully with rectal enemas, although his parents state the child is becoming less cooperative with enemas and they would like to discuss an antegrade option. He had several urinary tract infections in infancy but has not had any in nearly 3 years. He remains diapered and has several wet diapers daily along with nightly bedwetting. He is followed regularly by a pediatric urologist who recommends continued surveillance for now. What would you recommend?

 

A Offer appendicostomy

 

B Offer appendicostomy, appendicovesicostomy

 

C Offer laparoscopic cecostomy

 

D Recommend continued rectal enemas[/size]

I Would like to order a Plain abdominal x-ray.

D

D

D

D

D

correct answer

D Recommend continued rectal enemas

 

• The urologic status is unknown in this child at this point, and thus it is not clear whether he will require any future urinary reconstruction.

 

• A cecostomy in this patient offers the child an antegrade enema route, while preserving the valuable appendix for future urinary reconstruction if needed.

 

• If an appendicovesicostomy is needed in the future, the cecostomy can be taken down simultaneously and an appendicostomy can be created using the split appendix technique.

 

• If an appendicovesicostomy is not needed, the cecostomy can be taken down and an appendicostomy can be created using the in situ technique if the parents desire.

 

• Appendicostomy should not be performed until the urologic status is fully known, with the appendicovesicostomy preferentially using the appendix.

.

D