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22 7

P ro n e C ro s s T a b le L a te ra l

V i e w : A n A lte rn a tiv e to th e

In ve rto g ram in Im p e rfo ra te A n u s

K . L . N ara sim ha ra o1

G .

R . P rasad1

S . K ata riy a2

K . Y adav1

S . K . M itra1

I. C . P a thak1

Rece iv e d Ju ne 28 , 19 82 : ac c ep ted a fte r rev i-

s ion S ep tem be r 1 4 . 19 82 .

‘D ep a r tm en t o f P ed ia tric Su rge ry , Po s tg ra d -

u a te Ins titu te o f M ed ic a l E du ca tio n a nd R ese a rc h ,

C h an d ig a rh 1 60 01 2 , Ind ia . Ad d re s s rep rin t re -

qu es ts to I . C . Pa th ak .

2

D epa rtm en t o f R ad io d ia gn os is , P o s tg ra du a te

Ins titu te o f M ed ic a l E du ca tio n a nd R es ea rc h ,

C ha nd iga rh 16 0 0 12 , Ind ia .

R 140 :2 27 -22 9 , F eb rua ry 19 83

03 61 -80 3X /83 /14 02 -02 27 00 .0 0

© American Roentgen Ray Society

T h e p ro n e c ro s s tab le la te ra l rad io g rap h p ro v id e s eq u a l o r s o m e tim es be tte r in fo r

m atio n c o m p a re d to th e in ve rto g ram fo r d em on s tra tio n of th e le ve l o f rec ta l a tres ia in

n eo n a te s . E as y po s itio n in g b ette r c oo p e ra tio n o f th e p atie n t e lim in a tio n o f the e ffe c t

o f g r av it y a n d bet te r d e lin e a t io n o f th e re c ta l g a s sh a d o w a re th e a d va n ta g es o f th e

p ro n e la te ra l v ie w . A m o n g th e 4 5 c as e s co m p ared eq u a l fin d in g s w e re n o te d in 37 b u t

in e ig h t b a b ies th e le v e l o f rec ta l a tre s ia w a s m o re c a u da l in th e p ro n e ra d io g rap h th a n

in th e in ve rto gra m.

In the rad io log ic eva lua tio n o f the neona te s w ith im pe rfo ra te anus, the inve r-

to gram , firs t de scribed by W angensteen and R ice [1 ] has s tood the te s t o f tim e.

The p re cau tio ns in the techn ique and the p itfa lls in its in te rpre ta tion have been

w e ll d ocum en ted [2 , 3 ]. S ince the re c tum is the h ighest pa rt o f th e bow el in the

p rone pos itio n [4 ], th e eva lua tio n o f the re c ta l gas shadow in a p rone cro ss-tab le

la te ra l v iew shou ld he lp in d is tin gu ish ing the supra leva tor from the trans le va tor

les ion s . O u r s tudy was conducted to te s t th is hypo thes is and to cons ide r whe the r

the prone la te ra l rad iog raph , w h ich has ce rta in advan tages over the conven tiona l

inve rtog ram , can rep lace the la tte r in the d iagnos is o f ano re c ta l m a lfo rm a tio ns .

Sub je c ts and M e thods

Ou r p ro spective s tudy cons is ted of 45 consecu tive neona te s w ith im pe rfo ra te anus,

adm itte d to th e D epartm en t o f Pe d ia tric S u rge ry o f the Po s tg ra du a te In s ti tu te o f M ed ic a l

E d uc a tion an d Re sea rc h , C h an d ig a rh (In d ia ), f rom J an ua ry 1 98 1 . The ba b ie s w ere e va lu -

a ted ra d io log ic a lly w ith in v e rtog ram s (f igs . 1 A and 2A ) a nd a ls o p ro ne c ros s -ta b le la te ra l

v iew s (figs . 1 B a nd 2B ) , ob ta ine d s im u lta ne ous ly in ea ch pa tie n t. In fo rm ed c on se n t w as

o b ta in ed from the p a re n ts . W e d id n o t us e s k in m ark e rs o f an y ty pe . Th e w e ll k n ow n

pre caution s o f a llow ing enough tim e afte r b irth fo r the a ir to reach the re c tum and 3 mm in

the in ve rted pos itio n w e re fo llow ed rou tin e ly fo r the in ve rtog ram s. The bab ie s w e re he ld

face dow n w ith the ir h ips fle xed and w ere kep t in th is genupectora l pos ition fo r 3 mm for

ob ta in in g the p ron e la te ra l ra d io g ra ph s wh ic h w ere ce n te re d ov e r th e g rea te r t rochanters

lik e in the in ve rtog ram . P ressu re ove r the abdom en was avo ided during th is pro cedu re .

T he film s w ere rev iew ed in a b lind fas h io n b y a co ns u ltan t ra d io lo g is t, an d the lev e l o f

the re c ta l gas shadow w as eva lua ted accord ing to the bony landm a rks o f the pubococcygea l

line an d the is c h ia l po in t [2 ]. T he d is tance of the rec ta l gas shadow from the pubococcygea l

lin e was a lso m easu red . In h igh and in te rm ed ia te anom a lie s , the u ltim ate proo f o f the leve l

o f the rec ta l gas shadow was the ba rium exam inatio n o f the d is ta l loop o f the co lon , a fte r

th e n eo na ta l co lo stom y.

R e s u l t s

In te rm s of h igh , in te rm ed ia te , and low types, there w as no d iffe rence in the

in te rp re ta tion o f the leve l o f re c ta l a tre s ia in 43 sets o f rad iog raphs (h igh in 21 ,

in te rm ed ia te in 18 , and low anom aly in four). Two o the r cases w ere in te rp re ted



22 8

NARAS IM HARAO ET A L.

AJR :140 Febru a ry 19 83

F ig . 1 -A , In v e r tog ram . R e c ta l ga s

s ha dow a t the p ubo co c c yge a l line (h igh

a nom a ly ) . B , P ro ne c ros s -ta b le la te ra l

v iew o f s am e c as e sh ow s lev e l o f ga s

s ha dow be tw ee n pu bo co c c y ge a l l ine

a nd is c h ia l line (in te rm ed ia te a nom aly ) .

F ig . 2 .-A . Inv e rtog ram . Low anorec -

ta l an om a ly . R ec ta l g as sha dow d is ta l to

is c h ia l lin e . B , P ron e la te ra l v iew a ls o

sh ow s low anom a ly , bu t le v e l o f gas

sh ad ow is 4 mm cauda l to tha t s hown in

inv e r t og r am.

as h igh and in te rm ed ia te on the in ve rtog ram , bu t a s in te r-

m ed ia te and low , re spective ly , on the prone la te ra l film s.

W hen the m easu rem ents we re m ade on the rad iog raphs

in re la tio n to the pubococcygea l lin e to judge the te rm ina tion

o f the rec ta l gas shadow in the p rone cro ss-tab le la te ra l

v iew , in none of the pa tie n ts was it m ore cepha lic than

shown in the inve rtogram . O n the con tra ry , th e gas shadow

on the p rone la te ra l v iew was m o re cauda l (1 -4 mm ) in e igh t

o f the 45 cases.

The m os t im p re ss ive d iffe rence w as in the de lin ea tio n o f

the rec tum . In 15 o f 45 cases, the re c tum was m o re d is -

te nded , g iv in g be tte r de lin ea tio n o f the gas shadow in the

prone la te ra l fi lm s , com pared to the in ve rted rad iographs.

N ine o f these 15 bab ies had c lin ic a lly e v ident re c tourina ry

comm un ica tio n as ind ica ted by the passage o f m econ ium

pe r u re th ra be fo re decom p ress ion .

D i s c us s i on

In the m anagem en t o f neonate s w ith im pe rfo ra te anus ,

the d is tin c tio n be tween the le s ions in w h ich the re c tum ends

above the le va to r an i and those in wh ich it ex tends be low

th is leve l is o f param ount im portance in p lann ing the type of

su rg ica l tre a tm en t. The eva lua tion o f the re c ta l gas shadow

in acco rdance w ith the bony landm a rks , like the pubococ -

c ygea l lin e , the is ch ia l po in t, and the ‘ ‘M ’ ‘ line o f C rem in [5 ]

on an invertogram is the m os t u se fu l inves tiga tio n in de riv in g

the le ve l o f the anom aly . The sam e in fo rm a tio n can be

ob ta ined by a p rone cro ss- tab le la te ra l v iew rad iog raph

ins tead o f an in ve rtog ram . There are ce rta in advan tages we

found in the p rone la te ra l pos itio n :

1 . The pos itio n ing o f the pa tie n t in the p rone , h ip s-flexed

and genupecto ra l pos itio n is m uch eas ie r and le ss tim e

consum ing , com pared to the pos itio n requ ired fo r an inver-

tog ram w ith sp lin ts and adhes ive tapes. Th is is the m ajor

advantage ove r the trad itiona l invertogram .

2 . M ost o f the tim e , the baby keeps cry ing dur in g in ve r-

tog raphy wh ich causes contra c tio n o f the pubo re c ta lis s lin g

and hence deceptive ob lite ra tion o f the low er re c tum , re-

su ltin g in fa lla c iou s assessm en t o f the type o f m a lfo rm a tio n

[2 ]. The bab ie s a re usua lly ca lm and re laxed in the genu -

pec to ra l pos itio n , and the fu ll ex ten t o f th e re c ta l gas shadow



A JR : 4 F eb ru ar y 9 83

PRONE LATERAL V IEW OF IMPERFORATE ANUS 229

F ig . 3 .-A , In v e rto g ram . Poor ly d e l in -

ea te d re c ta l g as s ha dow . T h is ba by ha d

c lin ic a l ly ev ide n t rec to u re th ra l fis tu la

a nd h ig h a nom a ly . B , P ron e la te ra l v iew

be tte r d e lin ea tes re c ta l g as sh adow th an

in ve rte d ra dio gr ap h.

wou ld be shown on the rad iog raph . The bette r appea rance

of the rec ta l gas shadow in the prone la te ra l v iew in som e o f

ou r cases m ay be due to th is fa c to r.

3 . The re c tum m ay be pu lle d in a cepha lic d irec tion due

to gra v ity in the inve rted pos itio n , dep ic ting a h ighe r le ve l o f

gas shadow in re la tion to the bony landm a rks (Rhoads c ited

in [2 ]). Th is is a vo ided in a prone la te ra l pos itio n .

4 . In those anom a lies whe re there is a fis tu la w ith the

u rina ry or gen ita l tra c t, th is fis tu la becom es the h ighest pa rt

o f th e rec tum in an in ve rtog ram and gas m ay escape,

resu lting in less d is tens ion o f the re c tum [3 ]. In the p rone

la te ra l pos ition , th e fis tu la is low es t in pos itio n and the

chances for be tte r d is tens ion o f the rec tum a re h igh , caus ing

be tte r de linea tion o f the re c ta l gas shadow (fig . 3 ). Th is is

supported by the fac t th a t n ine of the bab ie s w ith ev iden t

rec tou rin ary comm unica tion have show n bette r de lin ea ted

rec ta l gas shadow in the prone la te ra l film .

O u r resu lts ind ica te tha t in about 1 8 {176 } /o8 /4 5 ) o f c a se s ,

the le ve l o f th e rec ta l gas shadow was 1 -4 mm lowe r on the

prone la te ra l v iew than on the in ve rtog ram . In ou r series ,

the the rapeu tic dec is io ns w ere a lte red in on ly one case: The

anom aly appea red in te rm ed ia te on the in ve rtog ram and w as

to be m anaged w ith a co lo s tom y, bu t the anom aly was low

on the p rone la te ra l fi lm so anop la s ty w as done in s tead .

T h is c e rta in ly is p roo f o f a t lea s t the equ a l v a lu e o f the tw o

types o f rad iog raphs for day-to -day p ra c tice and the occa -

s iona l supe rio rity o f th e p rone film . W e recommend the

rou tin e use o f the prone c ross -tab le la te ra l v iew in the

eva lua tio n o f the bab ies w ith im perfo ra te anus, because it

p rov ides equ iva len t o r som etim es be tte r in fo rm a tion than an

in ve rtog ram .

REFERENCES

1. W angens teen OH , R ice CO . Im pe rfo ra te a nu s : a m e tho d o f

d e te rm in ing the su rg ic a l app ro ach . Ann S urg 1930:92 :77-81

2. S tephens FD , Sm ith ED . A no rec ta l m a lfo rm a tion s in ch ild ren

C h ic ag o : Y ea r B oo k M ed ic a l, 19 71

3 . G o rdo n

IR S , Ross FGM . D iag no stic rad io log y in pe d ia trics

L ond on : B u tte rw o rth s , 1 97 7

4 . B e rd on W E , Ba ke r OH , Le on ida s J . A dva n tag es o f p ro ne

p os ition in g in ga s tro in tes tina l an d ge n itou r ina ry ro en tge no log ic

s tud ies in in fan ts a nd c h ild re n . AJ R 1968:103:444-455

5 . C rem in BJ . Th e rad io log ic a l a s se s sm en t o f a no rec ta l an om a-

l ies . C lin R ad io

1 97 1 : 22 :2 39 24 4