Newer variant of congenital pouch colon with double colovesical fistulae.

Sir,

We read with interest the article titled “Congenital pouch colon (CPC) with ileovesical and colovesical fistulae: A new variant,” published in this journal.[1] This report bears some similarity to our previously published report of a boy with CPC who had a Y-duplication of the bowel proximal to the colonic pouch.[2] We think that the case reported here[1] can be described as having a Y-duplication of the terminal ileum associated with CPC, with the two limbs opening into the colonic pouch and the urinary bladder, respectively, unlike our earlier report where both the limbs of the Y-duplication opened into the colonic pouch.[2] It would be also interesting to know from the authors if there were any associated abnormalities of the Mullerian structures.

In this regard, we would like to share our experience of managing a patient of CPC in whom the colonic pouch terminated in two colovesical fistulae. A full-term 1-day-old, 3 kg weight, boy was admitted with absence of the anal opening. There were no other obvious associated congenital anomalies. The invertogram suggested a high anorectal malformation with CPC. On exploration, cecum and appendix were found to be opening into the pouch, suggestive of type II CPC [Figure 1a]. The incision made on the anterior wall of the colonic pouch for performing colorrhaphy revealed two fistulae at the lower end of the pouch. Both fistulae were opening into the urinary bladder, although the exact level of termination could not be identified. Colorrhaphy was performed over a 12 Fr tube up to the peritoneal reflection, leaving the colovesical fistulae intact. A proximal ileostomy was constructed. The postoperative abdominal ultrasonogram showed bilateral hydroureteronephrosis, suggestive of bilateral vesicoureteric reflux. The baby was put on low-dose chemoprophylaxis. A distal cologram showed Y-shaped bifurcation of the distal end of the colonic pouch [Figure 1b]. At present, the patient is awaiting definitive surgery.

Figure 1

(a) Operative photograph showing the incision made on the anterior wall of type II congenital pouch colon with two colovesical fistulae, demonstrated by artery forceps (b) Distal cologram showing Y-shaped bifurcation (arrows) of the distal end of the tubularized colon

Variations in the termination of the colonic pouch in patients of CPC have been reported in the literature. Atresia of the distal end of the pouch with absence of a terminal fistula has been reported.[3] A low termination of the CPC with a colourethral fistula has also been described with type III/IV CPC.[34] A report by Luzzatto et al. suggested that the fistula in type I/II CPC opens into the bladder neck area and not higher up near the dome, as suggested earlier.[5] Conventionally, tubular colorrhaphy for the management of CPC involves division-ligation of the genitourinary fistula, subtotal excision of the colonic pouch with tubularization of the remaining portion followed by either an end-colostomy or a one-stage pull-through of the tubularised colon. Lately, as in this patient, one of the authors (AP) has been performing colorrhaphy in the neonatal period, leaving the genitourinary fistula undisturbed. The fecal stream is diverted by a proximal divided ileostomy. This technique not only ensures better healing of the tubularised colon but also provides access for performing a distal cologram so that the exact termination of the associated genitourinary fistula can be delineated.