Functional outcome after operation for Hirschsprung disease—transanal vs transabdominal approach

Background

It has been hypothesized that the extensive transanal dissection in transanal endorectal pull-through (TEPT) for Hirschsprung disease (HD) can impair the anal sphincters in neonates and thereby cause incontinence. Theoretically, transabdominal endorectal pull-through might have less impact on the sphincters. The aim of this study was to compare functional outcome in HD patients operated with either TEPT or laparotomy-assisted endorectal pull-through (LEPT) with particular focus on soiling and fecal incontinence.

Patients and Methods

Anorectal function in 52 children older than 3 years is reported. The patients were operated for HD with either TEPT (n = 28) or LEPT (n = 24) and followed prospectively. Functional outcome was recorded by standardized interviews. The Krickenbeck criteria were used to classify voluntary bowel movements, soiling, and constipation.

Results

The median age at follow-up was 5.7 years (3.1-13.2) for TEPT and 10.1 years (7.7-16.2) for LEPT. Twenty-nine patients reported soiling at final follow-up. There was no difference in the rate of soiling between children operated with TEPT (54%) or LEPT (58%). Constipation was reported in 11 children (TEPT, 25%; LEPT, 17%).

Conclusions

The functional outcome and in particular the rate of soiling did not differ between patients operated with LEPT or TEPT.     

Clinical outcome in children after transanal 1-stage endorectal pull-through operation for Hirschsprung disease

Background/Purpose

Recently, the transanal 1-stage pull-through operation has been widely used in Hirschsprung disease (HD), and it is obviously superior to traditional approach in early term for its noninversion. However, the procedure is relatively so new that it makes assessment of the functional outcome and stooling patterns difficult. The aim of this study was to evaluate the clinical outcomes of the transanal 1-stage endorectal pull-through operation in the management of rectosigmoid HD.

Methods

Fifty-eight children (39 boys and 19 girls) aged 12 months to 13 years (mean, 2 years) who underwent transanal 1-stage endorectal pull-through operation for HD were followed up from 6 to 24 months. Clinical outcome was assessed by interviews and questionnaires. All patients had an aganglionic segment confined to the rectosigmoid area which was confirmed by the preoperative barium enema and postoperative pathological examination.

Results

Forty-six patients had satisfactory results without complications. In all the children, the mean stool times were 1 to 2 per day; only 4 had mean stool times of 8 to 10 per day. Postoperative soiling was present in 9, constipation in 5, and HD-associated enterocolitis in 3. There were no incontinence, cuff infection, anastomotic leak, and mortality in any of the patients. In the 12 symptomatic patients, there were 4 children with length of aganglionic segment less than 30 cm, and 8 had 30 cm or more. In the 46 asymptomatic patients, 42 had length of aganglionic segment less than 30 cm, and 4 had 30 cm or more. There was a significant difference between the group with less than 30 cm and the group with 30 cm or more of aganglionic segment. For statistical analysis, the Fisher exact test showed P < .05.

Conclusions

The transanal 1-stage endorectal pull-through is a feasible and safe procedure in children with rectosigmoid HD. The clinical outcome is satisfactory. A gradual recovery could be noted in the stooling patterns along with the time after surgery. The younger the patient operated on and the shorter the aganglionic segment, the lower do the stooling disorders occur and the faster does the stooling function recover.     

Aberrations of the intrinsic innervation of the anorectum in fetal rats with anorectal malformations

Background

Fecal accumulation, constipation, soiling, and incontinence are common sequelae after repair of anorectal malformations (ARMs) in children. It is believed that besides the abnormalities of sacral roots, certain inherent abnormalities of the myenteric plexuses may play an important role in the final outcome after definitive repair.

Methods

This study was conducted to investigate the distribution of neuron-specific enolase (NSE), vasoactive intestinal peptide (VIP), and substance P (SP)-100 neurotransmitters in the rectosigmoid and fistulous tract of the ethylenethiourea-treated rat with ARMs.

Results

ARMs were induced by administering 1% ethylenethiourea (125 mg/kg) on gestational day 10, and the litter was harvested on gestational day 21 by cesarean section. Forty-eight controls and 63 with ARMs (46 high-type and 17 low-type) were recovered. Whole-mount preparations of each rectosigmoid and fistulous communication between the rectum and genitourinary tract were stained with fluorescent antibodies against NSE, VIP, and SP-100. The tissues were counterstained with Eriochrome black-T and methyl green dyes to improve the visualization of the myenteric plexuses.

Conclusions

The immunoreactivity of NSE, VIP, and SP-100 was markedly reduced in the rectum and fistulous tract of high-type ARMs and slightly reduced in low-type ARMs compared with controls. Intramural nerves stained by VIP and SP-100 antisera were decreased in both types of ARM, indicating that both inhibitory and excitatory motor neural elements were affected, and this may explain the distal colonic dysmotility seen postoperatively in both high and low ARMs.     

Colonic motility and functional assessment of the patients with anorectal malformations according to Krickenbeck consensus

Background/Purpose

In this study, the patients operated on for anorectal malformations (ARM) were evaluated in terms of segmental (SCTT) and total colonic transit times (TCTT) and clinical status according to Krickenbeck consensus before and after treatments.

Methods

Forty-one patients with ARM (28 males/13 females) older than 3 years (median age, 7.7 years; range, 3-25) who had no therapy before were assessed for voluntary bowel movements (VBM), soiling (from 1 to 3), and constipation (from 1 to 3), retrospectively. Distribution of the patients were rectourethral fistula (17), perineal fistula (PF; 8), vestibular fistula (VF; 8), cloaca (3), rectovesical fistula (1), rectovaginal fistula (1), pouch colon with colovestibular fistula (1), no fistula (1), and unknown (1). The patients ingested daily 20 radiopaque markers for 3 days, followed by a single abdominal x-ray on days 4 and 7 if needed. The results were compared with the reference values in the literature.

Results

Mean follow-up period was 36 months (range, 1-108.5 months). All patients but 1 had soiling in different degrees. Twenty-one patients who had VBM were divided into group 1, with constipation (n = 9), and group 2, without constipation (n = 12). The other 19 patients who had no VBM were divided into group 3, with constipation (n = 14), and group 4, without constipation (n = 5). The longest TCTT and rectosigmoid SCTT were found in group 3 (69.5 and 35.2 hours, respectively). Group 1 had long SCTT in rectosigmoid but normal TCTT (27.8 and 47.4 hours, respectively). Groups 2 and 4 had normal SCTT and TCTT, and there was no significant difference between them. After the appropriate treatment, of the patients, 45% (18/40) had no soiling, and the soiling score decreased to grade 1 in 27.5% (11/40) and to grade 2 in 10% (4/40). Four had unchanged soiling score, and 3 were excluded from the study because of follow-up problems. Half of the patients in group 3 (4 VF, 2 rectourethral fistula, PF) gained VBM without soiling after laxative treatment. Only four of 23 patients had decreased constipation score (2 cloaca, PF, VF).

Conclusions

In this study, ARM patients complaining of constipation with or without VBM had prolonged SCTT in the rectosigmoid region. Percentage of the improvement in soiling scores was more conspicuous than that of constipation scores. The dismal figure observed at the first examination in the assessment of VBM was not associated with an unfavorable improvement with laxative treatment. So, it is suggested that assessment of VBM initially may be deceptive for clinical status.     

Is there a role for surgery beyond colonic aganglionosis and anorectal malformations in children with intractable constipation?

Purpose

The aim of this study was to assess benefit of surgery in the treatment of childhood constipation in children without aganglionosis or anorectal malformations.

Methods

Retrospective chart review and follow-up questionnaire of 19 children (10 girls, age 7.6 ± 3.9 years) who underwent surgery after colonic and anorectal manometry had documented abnormal motility. Children at the time of manometric evaluation had symptoms of intractable constipation a mean of 5.1 ± 2.5 years. Follow-up questionnaires were administered to caregivers a mean of 11.4 ± 9.3 months after surgical intervention.

Results

Proximal colonic abnormalities were seen in 2 patients, abnormalities involving the distal colon and rectosigmoid region in 13 patients, pancolonic abnormalities in 2 patients, and incomplete relaxation of the internal anal sphincter in 2 patients. Surgery led to increase in frequency of bowel movements per week (8.1 v 1.9; P < .005), decrease in soiling episodes per week (2.20 v 4.7; P < .01), and decrease in daily use of medications for constipation (0.8 v 2.3; P < .05). Adverse events included skin breakdown at site of ostomy (9%), fecal incontinence after pull-through procedure (13%), and persistent constipation (4.5%). Parents felt that the symptoms after surgery were completely resolved in 89% of patients.

Conclusions

Surgery may be beneficial in the management children with chronic intractable constipation and documented abnormalities in motility.     

Antegrade colonic enemas and intestinal diversion are highly effective in the management of children with intractable constipation

Purpose

Intractable constipation in children is an uncommon but debilitating condition. When medical therapy fails, surgery is warranted; but the optimal surgical approach has not been clearly defined. We reviewed our experience with operative management of intractable constipation to identify predictors of success and to compare outcomes after 3 surgical approaches: antegrade continence enema (ACE), enteral diversion, and primary resection.

Methods

A retrospective review of pediatric patients undergoing ACE, diversion, or resection for intractable, idiopathic constipation from 1994 to 2007 was performed. Satisfactory outcome was defined as minimal fecal soiling and passage of stool at least every other day (ACE, resection) or functional enterostomy without abdominal distension (diversion).

Results

Forty-four patients (range = 1-26 years, mean = 9 years) were included. Sixteen patients underwent ACE, 19 underwent primary diversion (5 ileostomy, 14 colostomy), and 9 had primary colonic resections. Satisfactory outcomes were achieved in 63%, 95%, and 22%, respectively. Of the 19 patients diverted, 14 had intestinal continuity reestablished at a mean of 27 months postdiversion, with all of these having a satisfactory outcome at an average follow-up of 56 months. Five patients underwent closure of the enterostomy without resection, whereas the remainder underwent resection of dysmotile colon based on preoperative colonic manometry studies. Of those undergoing ACE procedures, age younger than 12 years was a predictor of success, whereas preoperative colonic manometry was not predictive of outcome. Second manometry 1 year post-ACE showed improvement in all patients tested. On retrospective review, patient noncompliance contributed to ACE failure.

Conclusions

Antegrade continence enema and enteral diversion are very effective initial procedures in the management of intractable constipation. Greater than 90% of diverted patients have an excellent outcome after the eventual restoration of intestinal continuity. Colon resection should not be offered as initial therapy, as it is associated with nearly 80% failure rate and the frequent need for additional surgery.     

Single-incision laparoscopic surgery in children: initial single-center experience

Background

In continued efforts to further improve the advantages of minimally invasive surgery to patients, surgeons have developed single-incision laparoscopic techniques. We report our initial experience in children with a variety of single-site procedures.

Method

A retrospective chart review was performed on patients who underwent a single-site procedure from April 2009 to April 2010.

Results

There were 142 consecutive procedures: 24 cholecystectomies, 103 appendectomies for nonperforated appendicitis, 2 splenectomies, 1 combined splenectomy/cholecystectomy, 8 ileocecectomies, 2 Meckel diverticulectomies, 1 small bowel duplication resection, and 1 jejunal stricture resection. There were 12 conversions to conventional laparoscopy: 10 during appendectomy and 2 during cholecystectomy. Mean operative time was 34 minutes for appendectomy, 73 minutes for cholecystectomy, 90 minutes for splenectomy, 116 minutes for combined splenectomy/cholecystectomy, 86 minutes for ileocecectomy, and 43 minutes for the small bowel procedures. The only complications were umbilical surgical site infections after appendectomy in 6 patients.

Conclusion

This institution's preliminary experience suggests that single-incision laparoscopic surgery in children has at least comparable outcomes to conventional laparoscopic surgery. However, prospective data are needed to prove that single-incision laparoscopic surgery is superior to conventional laparoscopy.     

The functional sequelae of sacrococcygeal teratoma: a longitudinal and cross-sectional follow-up study

Aim

The purpose of the study was to determine clinical manifestations, prevalence, and natural history of functional sequelae in patients operated on for sacrococcygeal teratoma (SCT) during infancy.

Methods

The medical records of 18 infants operated on for SCT were reviewed. Data recorded during admission and during routine outpatient appointments were analyzed. Moreover, 13 surviving patients (mean age, 25 years) and 65 age- and sex-matched controls were evaluated at a special outpatient clinic.

Results

Seven adult patients and 25 controls presented with one or more functional disorders including abdominal pain, constipation, diarrhea, soiling, enuresis, urinary frequency, urinary stress incontinence, and urinary straining. In 7 of 8 symptomatic children, one or more functional disorders disappeared during adult life. In comparison with controls, adult patients had a nonsignificant higher prevalence of each individual dysfunction.

Conclusions

Sequelae of SCT tend to improve with time, and the disorders reported are relatively common complaints in the general population.     

10-Year outcome of children born with anorectal malformation, treated by posterior sagittal anorectoplasty, assessed according to the Krickenbeck classification

Background

Anorectal malformations (ARMs) affect 1 in 4000 to 5000 births. The Krickenbeck conference developed a classification based on anatomical and functional criteria to better compare treatment outcome.

Aim

The aim of this study is to evaluate the functional outcome in patients 10 years following standardized surgical treatment of ARM related to the Krickenbeck classification. .

Methods

Anatomical anomalies were classified as above. Children and carers were followed closely in a multidisciplinary clinic. Data were collected using a functional outcome questionnaire for a minimum of 10 years after surgical reconstruction. Outcome measurements were related to the Krickenbeck classification.

Results

There were 53 children in the study group (29 male, 24 female). Krickenbeck anatomy: perineal fistula, 36%; vestibular fistula, 26%; rectourethral fistula, 36%; rectovesical fistula, 2%.All children were treated by posterior sagittal anorectoplasty.In children with perineal fistula, continence was achieved in 90%. Grade 2 constipation was noted in 21%. One child had a Malone antegrade continence enema (MACE) procedure.In children with vestibular fistula, continence was achieved in 57%. Grade 3 constipation was noted in 28%. One child had grade 1, and one child had grade 2 soiling. Two children had a MACE procedure.In children with rectourethral fistula, continence was achieved in 58%. One child had grade 3 soiling. Grade 3 constipation was found in 42% of children and grade 2 constipation in 1 child. A MACE procedure was performed in 36%.The only child with a bladder neck fistula had a MACE procedure for intractable soiling.

Conclusions

The outcome for patients with ARM is related to the severity of the anomaly. The uniform application of the Krickenbeck classification should allow rational comparison of treatment outcome.     

The Delorme repair for full-thickness rectal prolapse: a retrospective review

Background

The purpose of this study was to assess our colorectal surgical training program experience with the Delorme procedure for complete rectal prolapse.

Methods

Consecutive patients were identified from a surgical database and evaluated by chart review.

Results

Seventy-six patients with a mean follow-up period of 3.6 years were included. Outcomes included a recurrence rate of 14.5%, an overall complication rate of 25%, and a surgical site-specific complication rate of 8%. For patients younger than 50 years old (mean age, 36 y; range, 19-49 y), the recurrence rate was 8% with a mean follow-up period of 4.1 years. Their total complication rate was 15%, with no surgery site-specific complications.

Conclusions

Our results are consistent with previously published experiences in that most preoperative evacuatory symptoms resolve with repair of the prolapse, and serious complications are uncommon. The observation that recurrence and complication rates may be lower in younger medically fit patients suggests the Delorme repair need not be restricted specifically to older, medically unfit patients.     

Efficacy of complete resection for high-risk neuroblastoma: a Children's Cancer Group study

Background/purpose

Previous reports indicate that complete resection of high-risk neuroblastoma improves outcome but may entail high surgical complication rates. The authors evaluated the effect of complete primary site resection on event-free survival (EFS), overall survival (OS), and complication rates in patients entered on a high-risk neuroblastoma treatment protocol.

Methods

A total of 539 eligible patients with high-risk neuroblastoma were entered on protocol CCG-3891. Patients were assigned randomly to continuation chemotherapy or autologous bone marrow transplantation. Surgical resection was performed at diagnosis or after induction chemotherapy. Surgeons assessed resection as complete (CR), minimal residual (<5%, MR), or partial (PR). Incomplete resections received secondary resection or 10 Gy of external beam radiation. Patients were evaluated for EFS, OS, and complications of surgery based on completeness of overall best resection.

Results

The proportion of patients resectable at diagnosis was 27% for CR and 14% for MR. This improved after chemotherapy to 45% and 25%. Complication rates based on completeness of resection were 29%, 38%, and 36% for CR, MR, and PR, respectively. Estimated 5-year EFS rate was 30% ± 3% for patients who achieved CR (n = 210) compared with 25% ± 3% (P = .1010) for those with less than CR (n = 258).

Conclusions

Resectability improved after neoadjuvant chemotherapy. Complete resection did not increase complications. There was a small survival benefit for complete resection. This study suggests that complete resection may still be important in the current era of intense chemotherapy and transplant.     

Stabilization period after 1-stage transanal endorectal pull-through operation for Hirschsprung disease

Purpose

The aim of this study was to evaluate postoperative outcomes and to find the period required for normal stooling pattern after the 1-stage transanal endorectal pull-through operation (TERPT).

Method

The authors retrospectively reviewed the clinical data and postoperative courses of 61 patients who had the aganglionic bowel confined to rectosigmoid and underwent TERPT between 2001 and 2007.

Results

Thirty-three patients (54.1%) were neonates, and 56 patients (91.8%) were less than 6 months old at operation. The mean age at TERPT was 90 ± 216 days, and the mean body weight at TERPT was 4.5 ± 2.8 kg. The average operating time was 189 ± 49 minutes, and mean length of bowel resection was 11.1 ± 3.2 cm. The mean postoperative hospital stay was 8.0 ± 3.6 days. Postoperatively, 5 (8.2%) patients were considered as failure of TERPT because of persistent problems in defecation. Fifty-six (91.8%) patients finally had normal stooling patterns and normal findings in abdominal radiography after 9.4 ± 6.2 weeks of the mean postoperative stabilization period. Neonatal cases had significantly longer postoperative stabilization periods than nonneonatal cases (11.3 ± 6.9 weeks vs 7.3 ± 4.6 weeks, P = .016). The postoperative stabilization period significantly decreased by age at operation as the patient's age increased (P = .018).

Conclusion

Clinical outcomes after TERPT are satisfactory, but a postoperative stabilization period is required for a normal stooling pattern to develop. The outcome of TERPT should consider a postoperative stabilization period.     

Primary surgery for oropharyngeal cancer

Objective

The development of new techniques for transoral resection has led to a renewed interest in primary surgical treatment of oropharyngeal squamous cell cancer (SCCA). We reviewed our experience with primary surgery for oropharyngeal SCCA to identify factors associated with survival.

Study Design

Case series with chart review.

Setting

Tertiary medical center.

Subjects and Methods

Patients who underwent primary surgical treatment of oropharyngeal SCCA from 1985 to 2002 were analyzed. Patients who failed nonoperative treatment or had distant metastases at presentation were excluded.

Results

A total of 105 patients met study criteria. The majority of patients (91%) had advanced stage disease (III/IV). All patients received postoperative radiation; chemotherapy was used in eight patients. Five-year disease-free survival was 83 percent for stage I, 67 percent for stage II, 56 percent for stage III, and 43 percent for stage IV disease. Crude local control rates were 94 percent for T1 disease, 90 percent for T2 disease, 81 percent for T3 disease, and 80 percent for T4 disease; crude regional control rates were 100 percent for N0 disease, 90 percent for N1 disease, 84 percent for N2 disease, and 82 percent for N3 disease. Cox proportional hazards models revealed that nodal stage (hazard ratio [HR] 2.3, P = 0.02) and black race (HR 2.6, P = 0.004) were the only significant predictors of disease-free survival.

Conclusion

Primary surgical treatment of oropharyngeal SCCA is effective in achieving excellent locoregional control and permits deintensification of adjuvant therapy, even in patients with advanced stage disease. Nodal status and race are the primary determinants of disease-free survival. These data provide useful information for counseling and treatment planning.     

Thoracoscopic versus open resection of congenital lung lesions: a case-matched study

Purpose

The purpose of the study was to compare the outcomes in children undergoing thoracoscopic versus open resection of congenital lung lesions.

Methods

Retrospective review of 12 consecutive children (<3 years of age) undergoing thoracoscopic resection of a congenital lung lesion between 2004 and 2005 was performed. Intraoperative and early postoperative results were compared with randomly selected age- and sex-matched (2:1) patients undergoing thoracotomy between 2000 and 2005.

Results

Twelve children underwent thoracoscopic resection and were compared with 24 that underwent thoracotomy. Seventy five percent of the lesions in both groups were congenital cystic adenomatoid malformations. There were no major intraoperative complications. Two thoracoscopic procedures were converted to a thoracotomy. Perioperative outcomes including operative time, length of stay, duration and volume of chest tube drainage, and dose and duration of intravenous opioids were similar for the procedures. However, children undergoing thoracoscopic procedures were less likely (odds ratio = 0.07) to have received adjunctive regional anesthesia. Overall morbidity was 33% thoracoscopic and 25% open (P = .70).

Conclusion

Thoracoscopic resection is a safe and feasible alternative to open resection of congenital lung lesions. Examination of long-term advantages of the thoracoscopic approach such as decreased risk of chest wall deformity and scoliosis and improved cosmesis will require longer follow-up.     

Laparoscopic and transanal approach for rectal atresia: a novel alternative

Aim

The aim of this study is to present the details and outcomes of laparoscopic and transanal approach in the management of rectal atresia.

Patients

Two female patients with rectal atresia were operated upon using laparoscopic and transanal approach. There were no intraoperative and postoperative complications. Follow-up at 5 and 4 months, respectively, after closure of colostomy has shown both patients with good fecal continence.

Conclusion

Laparoscopic and transanal approach is a novel and good alternative to the current surgical techniques in the management of rectal atresia.     

Single-stage transanal endorectal pull-through for Hirschsprung's disease: perspective from a developing country

Background/Purpose

The aim of this study was to evaluate the feasibility, results, and cost-effectiveness of totally transanal endorectal pull-through (TEPT) in the management of rectosigmoid and midsigmoid Hirschsprung's disease (HD) in a low-income country.

Methods

Between March 2004 and December 2005, 19 children underwent totally TEPT procedure. The patients' ages ranged from 6 days to 13 years. The primary diagnosis in all 19 patients was HD confined to the rectosigmoid region in 15 and midsigmoid in 4. None had a preoperative colostomy. Follow-up period ranged from 4 to 20 months (mean, 8 months).

Results

Ages ranged from 0.25 to 65 months, with a mean of 16.24 months. Weights ranged from 3.4 to 13 kg, with a mean of 6.5 kg. Mean time from diagnosis to pull-through procedure was 26 days (range, 6-39 days). The mean length of rectosigmoid resection was 30 cm (range, 20-50 cm). The mean operative time was 95 minutes (range, 75-140 minutes). Mean intraoperative blood loss was 25 mL (range, 15-40 mL). There was one death unrelated to the procedure. One patient had enterocolitis 3 months postoperatively. Average frequency of defecation was 3 (range, 1-6) stools per day. TEPT was associated with a shorter operating time, less blood loss, early return to feeds, and an overall reduced cost.

Conclusion

The safety and cost-effective benefits of transanal endorectal pull-through in the treatment of HD are of special interest for a developing country. Our data also suggest that functional outcome following TEPT is highly satisfactory and comparable with other established procedures.     

Management of pectus chest deformities in female patients

Background

There is sparse published information regarding surgical management of females with pectus excavatum (PE) or carinatum (PC) deformities.

Methods

During the past 33 years 104 females with PE, and 21 with PC underwent surgical repair using extensive modifications of the Ravitch technique. Seven had previous right breast implants, 3 had prostheses placed in the PE deformity. Nine PE patients underwent successful pregnancy before repair, but had severe third trimester dyspnea.

Results

Very good to excellent results were reported by 96% (mean follow-up, 6 years). Increased endurance, decreased dyspnea, reduced chest discomfort, and less tachycardia occurred in all within 6 months. No patients had significant breast asymmetry after repair. Complications included mildly hypertrophic scar (8), transient pleural effusion (3), bar displacement (1), and mild recurrence (3).

Conclusions

Females with symptomatic PE or PC, can be repaired with low morbidity, mild pain, low cost, and improvement in body image and symptoms. Prostheses are not beneficial in the treatment of physiologic symptoms caused by pectus deformities.     

Surgical treatment of pectus excavatum: 30 years 398 patients of experiences

Purpose

The aim of the study is to review the surgical experiences with pectus excavatum (PE) chest deformities at the Department of Pediatric Surgery, West China Hospital of Sichuan University (Sichuan, PR China), during a 30-year period.

Method

Records of 398 PE patients (396 congenital, 2 acquired) who underwent surgical repair between 1975 and 2005 were reviewed. Modified sternal elevation was applied in all patients. Repair was performed with subperiosteal resection of the abnormal cartilages, transverse wedge osteotomy of the anterior sternum, and internal support with a metal strut for 1 year. Five technical details were strictly followed for each case. Three hundred twelve patients (78.39%) were followed up from 1 to 16 years.

Result

There were no deaths. Normal contour of the costal cage was constructed postoperatively in 98.74% (393/398) of the patients. Exercise tolerance was improved, and cardiac function recovered to the healthy level of same age. But pulmonary function recovered slowly after surgery.

Conclusions

The 5 technical details are key principles for sternal elevation. Normal appearance of chest wall can be recovered; normal cardiopulmonary function can be restored by the modified sternal elevation with excellent long-term physiologic, cosmetic results and low rate of complications.     

Induction therapy does not increase surgical morbidity after esophagectomy for cancer

Background

A complete pathological response after induction therapy for esophageal cancer offers survival benefits, but induction therapy may increase the risk of postoperative complications and mortality.

Methods

We performed a retrospective review of consecutive patients who underwent esophagectomy for esophageal cancer to identify preoperative predictors of complications and assess the possible influence of induction therapy on surgical outcomes.

Results

Between 1988 and 2003, 170 esophagectomies were performed on our service; 95 (55.9%) underwent surgery alone and 75 (44.1%) received preoperative chemotherapy, 35 of whom also had preoperative radiation therapy. Based on multivariable regression analyses, independent covariates for complication categories included performance status (pulmonary, cardiovascular, total complications, and death), age (cardiovascular and other complications), and FEV₁% (pulmonary complications). Whether patients received induction therapy was unrelated to the incidence of postoperative complications.

Conclusions

We found no evidence that induction therapy adversely influences the incidence of postoperative morbidity or mortality after esophagectomy for cancer.     

Radionuclear transit to assess sites of delay in large bowel transit in children with chronic idiopathic constipation

Purpose

Chronic idiopathic constipation (CIC) with soiling in children may result from slow colonic transit (SCT) or anorectal dysfunction and/or psychological problems known as functional fecal retention (FFR). Evidence is accumulating that SCT and FFR need different treatments, but they are poorly distinguished by solid marker studies. The authors used radionuclear transit scintigraphy to categorize children with CIC as having either FFR or SCT.

Methods

Children (N = 101) with CIC (and soiling) who were referred for further investigation after failure of standard treatments (diet, laxatives) received radiolabeled colloid orally, and scintillation images were collected at 0 to 2, 6, 24, 30 and 48 hours (total radiation dosage = 2 standard x-rays). Radioactivity in 6 regions (precolonic, ascending, transverse, descending, rectosigmoid, and evacuated feces) was measured, and the median position (geometric center) of radioactivity at each time was determined.

Results

In children, meals normally reach the cecum at 6 hours and are evacuated in 30 to 58 hours. Fifty patients had retention of radioactivity in the proximal colon at 48 hours, indicating SCT. Analysis of the images and the geometric center showed that passage through the ascending colon and transverse colon was delayed in SCT. In 24 patients, radioactivity was passed by 30 hours, indicating normal transit or possible FFR. Twenty-two patients had retention in the rectum, indicating definite FFR. Five studies were borderline.

Conclusions

Radionuclear transit scintigraphy is useful for categorizing patients with CIC as having either FFR or SCT, allowing for different treatments. Radionuclear transit scintigraphy provides more detail and greater sensitivity than solid marker studies in diagnosing CIC. Radionuclear transit scintigraphy showed that half of our patients had SCT.