Colonic Atresia Melissa Wong, M.D. SUNY Downstate Medical Center 24 July 2014 www.downstatesurgery.org
Colonic Atresia
Melissa Wong, M.D. SUNY Downstate Medical Center 24 July 2014
www.downstatesurgery.org
Case Presentation
2d old F, born 41+2 GA ● Pregnancy:
o recurrent UTIs o normal amniocentesis o prenatal US: cystic structure adjacent to GB (not
seen on subsequent study) o C-section for NRFHT
● Birth weight 3070 g ● Apgar 91’ / 95’ ● Breastfed ● “Passed meconium but no BM”
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Case Presentation
● DoL 2: bilious “spit up”, abdomen distended o NPO
o transfer to NICU
o hydrated, electrolytes corrected
o Ped Surg consult
o UGIS and BE on DoL 3
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Case Presentation
Physical Exam ● Vitals stable on room air ● OG sump tube ● Triangular faces, low set ears ● Abdomen soft, distended ● Normal external genitalia ● Patent anus
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Operation DoL #4
Findings ● 2 colonic atresias:
o membranous atresia at hepatic flexure o blind sac atresia at R transverse colon
● proximal dilated terminal ileum & R colon; microcolon distally o jejunum collapsed
● other findings: o staggered diverticuli of distal colon o normal appendix
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Operation DoL #4
Procedure ● Atresias resected ● distal colon irrigated w/ saline → patent ● stapled tapering coloplasty of dilated R colon ● hand-sewn end-to-end anastomosis x2
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Pathology
● Thinned colonic wall c/w atresia ● Dilated adjacent colon ● Ganglion cells present throughout, incl
atretic & dilated parts
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Post-Op Course POD 1: TPN started POD 2: Passed BM POD 4 / 7 / 11: abd distended, free air on XR → BE (+) for anastomotic leak
● 4 & 7: Ex Lap, washout, repair of anastomotic leaks (from both), omentopexy, Broviac placement
● 11: Ex Lap, resection of anastomoses x2, primary colo-colonic anastomosis
POD #13: BE shows no leak
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Colonic Atresia
Melissa Wong, M.D. SUNY Downstate Medical Center 24 July 2014
www.downstatesurgery.org
History
● 1673: 1st case reported by Binninger
● 1922: 1st survivor reported by Dr. Gaub o sigmoid atresia → colostomy
● 1947: 1st case of 1º anastomosis reported
by Dr. Potts o transverse colon atresia
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Epidemiology
● Intestinal atresias: 1 in 1500 - 40,000 o <10% colonic
● M = F ● full term ● 47% have other anomalies
o Gastroschisis o intestinal atresias o malrotation o Hirschsprung’s
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Etiology
● Vascular o Louw & Barnard 1955: dog fetus study o mechanical:
volvulus, intussusception, gastroschisis o fetal Varicella or Borrellia infection:
injury to enteric plexus → poor vessel development → ischemia
o genetic: familial clustering
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Presentation & Imaging
● bilious vomiting ● distension ● failure to pass meconium ● US
o prenatal US
● XR o dilated loops o air-fluid levels o intraperitoneal calcifications
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Operative Approaches
● Historically: by location o proximal to splenic flexure → 1º anastomosis o distal → ostomy
● Calibre discrepancy
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Operative Approaches
● Historically: by location o proximal to splenic flexure → 1º anastomosis o distal → ostomy
● Calibre discrepancy o ostomy o tapering o end ileostomy + cecal blow hole + mucus fistula
(Corbett, Turnock) ● Current approach: primary anastomosis
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Operative Approaches
● Operate early o surgery at >72 hrs → higher mortality
o closed loop obstruction
● Check patency
● Rule out other anomalies
● Resect both atretic ends
● Decompress proximal bowel
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Outcomes
● low operative mortality
● major risk factors for poor outcome: o associated anomalies
o late diagnosis/tx
o TPN-related complications (e.g. cholestatic liver
damage, line sepsis)
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Summary
● Rarest type of intestinal atresia ● Probable vascular etiology ● 4 types ● Workup: AXR, BE ● OR: resect atretic ends, primary
anastomosis
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References Benawra R, Puppala BL, Mangurten HH, Booth C, Bassuk A. Familial occurrence of congenital colonic atresia. J Pediatr 1981;99:435-6. Chester ST, Robinson WT. Congenital Atresia of the Transverse Colon. Ann Surg 1957 Nov;146(5):824-9. Corbett HJ, Turnock RR. An alternative management option for colonic atresia preventing loss of the ileocecal valve. J Pediatr Surg 2010;45:1380-2. Cox SG, Numanoglu A, Millar AJW, Rode H. Colonic atresia: spectrum of presentation and pitfalls in management. A review of 14 cases. Pediatr Surg Int 2005;21:813-8. Dalla Vecchia LK, Grosfeld JL, West KW, Rescorla FJ, Scherer LR, Engum SA. Intestinal Atresia and Stenosis. Arch Surg 1998 May;133:490-7. Dassinger M, Jackson R, Smith S. Management of colonic atresia with primary resection and anastomosis. Pediatr Surg Int 2009;25:579-582. England RJ, Scammell S, Murthi GV. Proximal colonic atresia: is right hemicolectomy inevitable? Pediatr Surg Int 2011;27:1059-1062. Etensel B, Temir G, Karkiner A, Melek M, Edirne Y, Karaca I, Mir E. Atresia of the Colon. J Pediatr Surg 2005;40:1258-1268. Haxhija EQ, Schalamon J, Hollwarth ME. Management of isolated and associated colonic atresia. Pediatr Surg Int 2011;27:411-6. Karnak I, Ciftci AO, Senocak ME, Tanyel FC, Buyukpamukcu N. Colonic atresia: surgical management and outcome. Pediatr Surg Int 2001;17:631-5. Louw JH, Barnard CN. Congenital Intestinal Atresia: Observations on its origin. Lancet 1955;2:1065-7. Selke AC, Jona JZ. The Hook Sign in Type 3 Congenital Colonic Atresia. Am J Roentgenol 1978 Aug;131:350-1. Watts AC, Sabharwal AJ, MacKinlay GA, Munro FD. Congenital colonic atresia: should primary anastomosis always be the goal? Pediatr Surg Int 2003;19:14-7. Winters WD, Weinberger E, Hatch E. Atresia of the Colon in Neonates: Radiographic Findings. Am J Roentgenol 1992 Dec;159:1273-6.
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