Saving the neo-Malone for later: A case report

Introduction

Patients with complex anorectal malformations may undergo multiple abdominal operations, which may result in a hostile abdomen. We report a case of fashioning a neo-Malone during the creation of an ileovesicostomy that was kept in the subcutaneous tissue until antegrade flushes were needed.

Case presentation

A premature female born at 32 weeks of gestation was found to have a cloaca malformation at birth. She developed severe pulmonary hypertension and abdominal compartment syndrome, requiring an exploratory laparotomy and placement of a temporary abdominal closure. She subsequently required five more operations before the abdomen was closed and a proper ostomy was created. At the age of one year, she underwent a cloacagram, a cystoscopy and a vaginoscopy. The length of the common cloacal channel was 4 cm at that time. She subsequently underwent a posterior sagittal anorectal vaginal urethral plasty (PSARVUP), reversed rectal neovagina creation, and urethroplasty. At the age of three years, she underwent an ileovesicostomy due to hostile urodynamics. Anticipating that she could need antegrade enemas in the future, a neo-Malone was created at the time of the ileovesicostomy. A pedicle of tissue was dissected out of the anti-mesenteric wall of the colon to create the channel. A valve was fashioned around the base. Metal clips were placed for future identification. The neo-Malone was pulled through a 3-mm fascial defect and sutured to the deep dermis. At the age of six years, the neo-Malone was matured. Using fluoroscopy to visualize the clips, the neo-Malone was identified, and a Y opening created. Patency of the Neo-Malone was confirmed by fluoroscopy. The neo-Malone was sutured to the skin. At one year of follow-up, she remains free of accidents between antegrade flushes.

Conclusion

Patients with complex anorectal malformations may require multiple operations that may lead to a hostile abdomen. Anticipating potential future surgical needs and combining procedures, when possible, constitutes an important aspect of the care of these patients.