Colonic duplication: Treatment by limited division of common wall.

Colonic duplications are rare congenital anomalies. Treatment of choice is complete resection that in case of a long tubular duplication requires total or subtotal colectomy. A simple surgical technique for treatment of complete colonic duplication is described, which avoids the complications of extensive colonic resection.

INTRODUCTION

Colonic duplications are rare congenital anomalies that usually present during the first decade of life.[1] The clinical picture varies according to the location and extent of the lesion, as well as the type of mucosal lining. Treatment of choice is complete resection of the duplication that in case of a long tubular duplication of the colon entails total or subtotal colectomy due to shared blood supply of the native bowel and the duplication. Also, the sphincter complex may need reconstruction. These procedures are undesirable in children. A simple surgical technique for treatment of complete colonic duplication is described.

CASE REPORT

A 3-year-old boy presented with complaints of constipation and bleeding per rectum since birth. On digital rectal examination, two lumina were palpable with an intervening septum. Barium enema showed long segment colonic duplication with distal communication just above anal verge [Figure 1]. Colonoscopy and magnetic resonance imaging revealed similar findings. Meckel's scan for ectopic gastric mucosa was negative. On exploratory laparotomy, complete colonic duplication from cecum till 2 cm proximal to anal verge was observed [Figure 2]. Both the lumens were of the same caliber and appearance. On gross examination, it was difficult to identify the normal colon and duplication. The common wall between the two was divided at the distal end using a stapling device inserted through the anus. Postoperatively, the complaints were relieved. The child was asymptomatic at last follow-up, 1 year postoperatively.

Figure 1

Barium enema showing the rectum (r), the duplication (d) and common wall (Com)

Figure 2

Intra-operative photograph showing the total colonic duplication

DISCUSSION

Colonic duplication is a rare entity, though more common in children as compared to adults. Gastrointestinal bleeding in bowel duplications can result from angiodysplasia or ectopic gastric mucosa leading to ulceration.[1] This was ruled out by a Meckel's scan in the present case. However, the bleeding per rectum could have been caused by fissures due to the passage of hard constipated stool.

The constipation in the present case possibly occurred due to a fecaloma in the distal part of the duplication causing compression of the normal lumen, thus obstructing the evacuation of the rectum. Since the communication between the duplication and the normal large bowel was just proximal to the anal verge, the contraction of the external sphincter possibly allowed the feces to enter the duplication. And, as fecal matter continued to accumulate in the duplication, the constipation became progressive. By dividing the septum between the normal and duplicated distal large bowel, the rectum acquired a single lumen, and hence the evacuation became easy. A large communication between the duplicated and normal large bowel also ensured emptying of the fecal matter that collected in the duplication. This in turn ensured free passage of stools and eliminated the constipation.

CONCLUSION

Limited division of the common wall in case of a complete colonic duplication is a simple, safe, easy, and quick procedure. It avoids the complications of extensive colonic resection.