From
Dr. Marc Levitt
Colorectal Quiz Episode 1 - Low Bulbar Fistua
With Dr. Jason Frischer & Dr. Marc Levitt · hosted by Dr. Rod Gerardo
Part of
Anorectal Malformation 101 items
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Patients with anorectal malformations require evaluation for associated VACTERL anomalies: vertebral abnormalities (plain X-ray), cardiac defects (exam and echo), esophageal atresia (NG tube passage), renal abnormalities (kidney ultrasound), and limb abnormalities (physical exam).
Sacral ratio measurements should wait until the child is 3 months of age for true accuracy, though early imaging gives a preliminary sense of pelvic development.
Presacral masses are rare in typical imperforate anus but occur in almost half of patients with anal stenosis or rectal atresia defects, requiring MRI evaluation.
Cross-table lateral X-ray should be obtained at approximately 24 hours of life (give or take a few hours) to assess gas column location, with the baby positioned prone to allow air to rise to the buttocks.
The 24-hour waiting period allows the baby to declare whether they need a colostomy or might benefit from primary repair if a perineal fistula develops.
Marking the expected anal location on cross-table lateral X-ray allows measurement of the distance between the air column and perineal skin to guide surgical planning.
A sacral ratio greater than 0.7 connotes very good prognosis for bowel control and provides peace of mind for families regarding potty training and school readiness at age 4 years.
Well-formed buttocks with visible sphincter mechanism location, combined with well-developed sacrum, indicate likely good prognosis for continence.
The key to deciding whether to perform primary posterior sagittal anorectoplasty is knowing where the rectum is located—the first structure encountered should be rectum, not urethra, bladder neck, or bladder.
Colostomies and distal colostograms are performed to know exactly where the rectum is and whether to approach it perineally or laparoscopically.
Never attempt posterior sagittal approach blind—only proceed when confident the first structure encountered will be the air pocket of the distal rectum.
Performing a colostomy is the safe choice and was the right decision in this case, though it subjects the child to colostomy-related complications and later colostomy closure with its own complications.
Colostomy makes the definitive anoplasty safer, representing a balance of risks in medical decision-making.
Very good surgeons have performed primary anorectoplasty on low defects without knowing about a fistula, resulting in children who later urinate through the anus.
During primary posterior sagittal repair, the surgeon should open the posterior wall of the rectum and inspect the anterior wall to rule out a fistula.
When a fistula is very close to the rectum, proper plane dissection along the urethra is critical because the two structures are not far apart.
A bulbar fistula is defined by its anatomic location at the elbow of the urethra, using pure anatomic nomenclature.
95% of patients with Down syndrome and imperforate anus have no fistula, but 5% do have a fistula, so distal colostogram is still indicated.
In patients with low rectum, dissecting a small portion of the anterior rectal wall and carefully lifting it off the urinary tract will usually rule out a fistula.
Complete workup for anorectal malformations includes evaluation for associated anomalies, preoperative cross-table lateral X-ray to evaluate air column, and surgical planning that considers colostomy as a reasonable and safe choice even when imaging suggests straightforward primary repair.
If proceeding with primary posterior sagittal anorectoplasty, the surgeon must rule out a fistula intraoperatively.