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.............A
properly functioning rectum is an unappreciated gift of greatest price.
......................................................-
Wills Potts, Surgeon in Chief, Children’s Memorial Hospital, Chicago.
One in every 5000 children born have a congenital and a rectal anomaly.
They usually present immediately after birth or sometimes a bit late.
The case about to be described is a 16-year-old female with recto vaginal
fistula and imperforate anus, a unique case in itself. The patient was
treated by repositioning of the anus. The clinical presentation and the
operative procedure is discussed with brief review of the literature.
The time of presentation of the imperforate anus with the rectovaginal
fistula is unique and hence the presentation. |
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Fig. 1 : Observe of oval opening and evidence of faecal material
at the posterior vaginal wall (vaginal opening of Rectovaginal fistula).
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CASE
A 16 year old female patient came with the complaints of passage
of stools per vaginum since birth. The patient also gave history
of the absence of anal opening since she remembers. The patient
had never consulted a specialist for this problem before.The patient
had menarche at the age of 12 years and had regular menses. The
examination was unremarkable, she had well developed sexual characters.
Local examination revealed absence of an anal opening. External
genitalia were well developed. Per speculum examination revealed
puckering of the left posterolateral wall of the vagina with evidence
of faecal matter at the introitus. Per vaginal examination was
possible with only one finger (Fig. 1).
The patient was investigated which were in normal limits. |
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Fig. 2 : Fistula dissected out. last for follow up after six months.
She was continent and had good sphincter tone. |
Fig. 3 : New
oval opening. |
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Operative
procedure
In lithitomy position an artery forceps was inserted in the fistulous
opening in the vagina. There was evidence of low variety of fistula. Incision
was taken over perineum from proposed anal site of the foruchette. The
rectum was dissected
anteriorly posterior and on both the lateral walls upto 5 cms (Figs. 2
and 3).
Incision was taken around the fistulous opening in the posterior vaginal
wall and separated. Anterior wall of the rectum
was separated from the posterior vaginal wall and closed with 3-0 vicryl.
Hitch stitches were taken around the surrounding rectum and the surrounding
tissue. Sphincter was closed anteriorly and the rectum sutured to the
skin forming the new anal opening. The postoperative recovery was uneventful.
The patient came last for follow up after six months. She was continent
and had good sphincter tone. |
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DISCUSSION
Taneja et al have noted that 75.5% of cases presented in the first month
of life and the rest in the postnatal period.1 Acosta and Faria report
a case of a girl.2 In jijipan Ecuador who presented with imperforate anus
with a rectovaginal stula at the age of seven years. The authors have
attributed the late presentation to social taboos and child neglect in
developing countries.
To the best of our knowledge there is no report quoting presentation of
imperforate anus as late as 16 years as in this case. |
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ACKNOWLEDGEMENT
The authors wish to Thank the Dean, Dr. VM Medical College Solapur, allowing
us to carry out this work. |
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REFERENCES
1. Taneja, Sharma, Mukherji. Management of congenital anorectal malformations.
Archives of Surgery 1970; 100 : 47-54 pg. 1410.
2. Acosta Faria, Jr, Ortiz, Interian CJ, et al. Imperforate anus - delayed
presentation in a seven year old girl. J Pediatr
Surg 1993; 28 (7) : 962-5. |
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LUNG
PATHOLOGY IN SARS
‘The case definition of SARS should acknowledge the range
of lung pathology associated with this disease’
Although the causal agent of severe acute respiratory syndrome
(SARS) has been identified, many of the features of this disease’s
pathology remain to be elucidated. John Nicholls and colleagues
studied lung pathology in post-mortem tissue samples and an open
lung-biopsy sample from six patients with SARS infection confirmed
by reverse-transcriptase PCR. The most frequent findings in the
lung samples were diffuse alveolar damage, giant-cell infiltrate,
and cytomegaly with granular amphophilic cytoplasm. Bronchial
epithelial denudation and haemophagocytosis were also noted. The
investigators conclude that SARS is associated with epithelial-cell
proliferation and a rise in the number of macrophages. They note
also that the presence of haemophagocytosis suggests cytokine
dysregulation that may account, at least partly, for the severity
of clinical disease.
BMJ, 2003. |
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