EP400 - A Unique Presentation and Management of Total Colonic Duplication In An Adult Female

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Purpose/Background: Colonic duplication is an uncommon gastrointestinal malformation rarely described in adults. Discussed is a 40-year-old female patient presenting with abdominal pain found to have complete colorectal duplication and colovaginal fistula.

Methods/Interventions: This patient was a 39-year-old female transferred to the hospital with complaints of episodic vaginal discharge and lower abd pain.
Abd CT revealed findings consistent with duplicated colon and inflammation along the sigmoid colon. She had a known history of duplicated uterus, ovaries and appendix that had been removed several years prior.
A colonoscopy was done which was normal and failed to demonstrate the duplicated colon. The inflammation and pain were felt to be related to the inability of the duplicated colon to decompress normal mucus. After antibiotic therapy, the patient was taken to the OR for robotic creation of a common channel anastomosis between the duplicated and normal descending colon, as well as a common channel anastomosis created in the ascending colon between the duplicated and normal ascending colon in a side-to-side manner. The vaginal drainage was felt to be from retained endometriosis of the vaginal cuff which was resected robotically as well. Her postoperative course was uncomplicated. The duplicated rectum was not appreciated on this first surgery.
3 months post-op, she returned to ED with concerns of discharge from the vagina. She underwent an EUA showing a tunneling tract on the R posterolateral wall of the vagina separate from the rectum and an opening of the apex of the vaginal cuff which was repaired. Plans were made to return to the OR electively for repair of her colovaginal fistula.
During repair, the patient’s fistula was between the right posterior vagina and a duplicated rectum that ran along the right anterior normal rectum. The duplicated rectum was resected robotically, and a common channel created between the duplicated sigmoid colons as well as diverting loop ileostomy which was reversed 6 months later.

Results/Outcomes: On follow up she denies return of her vaginal drainage and having 1-3 regular bowel movements daily. She did have one episode of lower abdominal pain which on CT demonstrated to mild inflammation in her redundant transverse colon. This responded to a course of oral antibiotics.

Conclusion/Discussion: The aim of this discussion is to provide an example of outcome after one treatment modality of this rarely described condition.
Repair of these duplications managed to address her symptoms of vaginal discharge. She had one episode of abdominal pain, which we speculate may be related to delayed emptying of the unaddressed duplicate transverse colon.
This delayed presentation despite previous abdominal surgery suggests that while uncommon, colonic duplication should be included in the differential diagnosis of chronic abdominal pain.
Duplicated colon typically runs parallel to the primary colon and shares the same blood supply. This poses a question of abdominal colectomy or creation of common channel between affected segments. To preserve perfusion to the colon without undergoing total colectomy; creation of a common channel within the ascending and descending colon was chosen. However, for management of her duplicate rectum, resection of the entire duplicate rectum was selected. This was possible while preserving the native rectum as the rectum has multiple sources of blood supply.
This unique case presented a challenging approach which required consideration of anatomic variation, surgical approach, and postoperative course.