Stapled colostomy in infants

A divided colostomy using the GIA stapler is described. The procedure obviates faecal spillage and reduces blood loss, operating time, and prolapse rate.     

Colostomy prolapse and hernia following window colostomy in congenital pouch colon

Congenital pouch colon, a variant of anorectal malformation, is a rare anomaly with a high incidence in North India and although the anatomy and diagnostic features have been well described, the surgical treatment continues to be challenging. This report describes the complications following a less preferred but often practised surgical option—a temporizing window colostomy in three babies. A window colostomy predisposes to prolapse of the entire pouch colon with herniation of bowel loops, intestinal obstruction and failure to thrive. Depending on the state of the child, either a proximal diverting stoma or tubularization of the pouch with a terminal stoma is recommended as the procedure of choice for the initial surgical management of this complex and rare malformation.     

Abdominal posterior rectopexy with an omental pedicle for intractable rectal prolapse: a modified technique

Introduction  Rectal prolapse is a relatively common paediatric surgical condition. It has a number of benign aetiologies. Management is usually centred on regulating bowel habits. Surgery is considered after the failure of medical treatment. Numerous surgical techniques have been described with a spectrum of results. Materials and methods  We adopted a limited abdominal approach to achieve a posterior rectopexy using an omental pedicle in intractable cases. This technique has not been performed in children previously. Results  From 2005 to 2008 we have applied this technique on five patients with recurrent rectal prolapse which had failed to respond to medical treatment, injection sclerotherapy or perianal cercalage. One patient had solitary rectal ulcer syndrome, and was initially treated with a defunctioning colostomy, had a concomitant sigmoidectomy performed at the time of rectopexy. None of the patients had cystic fibrosis. There were three females and two males, with a mean age of 9.6 years (4.7–14.0). No operative complications were encountered. The mean hospital stay was 5.4 days (3–8). None of the patients experienced recurrence at a mean of 2.1 years (0.2–2.8) follow up. The cosmetic result was regarded as satisfactory by all patients. Conclusion  This early experience with abdominal posterior rectopexy using an omental pedicle graft is encouraging. This technique does not involve the use of synthetic material and hence the risk of infection is low.     

The role of colostomy in the management of anorectal malformations

The role of the colostomy in the definitive correction of anorectal malformations is controversial with regard no only to indications for its use, but also to location and type. We reviewed the records of 272 patients with 307 colostomies and analyzed the frequency of complications related to these controversial points. There were 250 completely divided and 57 loop colostomies, constructed in either the sigmoid or transverse colon. Twenty-five colostomies were associated with complications that included retraction, stenosis, dehiscence, prolapse, infection, bowel obstruction, sepsis, and death. Twelve additional colostomies were placed in positions that impeded the definitive correction of the malformation: 9 sigmoidostomies were too distal and 3 were located in the right-upper abdominal quadrant and did not permit pull-through without tension. Colostomy prolapse and pull-through infection were statistically less likely with a completely diverting colostomy. Thirty-five patients with rectovestibular malformations were encountered in this series. Ten were referred from other institutions after attempted repair without a colostomy and all 10 had complications of infection, dehiscence, retraction, and reopening of the fistula. In contrast, there were no complications in the remaining 25, in whom the repair was preceded by a colostomy, nor after re-repair of the other 10. These findings support the need for a colostomy prior to the repair of this malformation. We recommend a carefully constructed, high, completely diverting sigmoid colostomy prior to the initial definitive repair of anorectal malformations. A right transverse colostomy is preferable preceding redo operations.     

Prophylactic antibiotics for colostomy closure in children: short versus long course

A prospective, randomized clinical study was performed to compare the results of 1-day versus 7-day administration of the same prophylactic antibiotics to 30 consecutive patients undergoing colostomy closure. The antibiotics used were cotrimoxazole (8 mg/kg per day trimethoprim) and ornidazole (20 mg/kg per day), which were this department's standard prophylactic agents for colorectal surgery. Patients, in the first group received cotrimoxazole i. m. 1 h before the operation and ornidazole by i. v. infusion starting after induction of anesthesia. The same dosages of both drugs were repeated once 12 h after the initial dose. In the second group (7 days), both agents were started orally 48 h before the operation. The preoperative doses were given as in the short-course group and were continued in this fashion until the end of the 5th postoperative day. Mechanical cleansing of the bowel and the operative procedure were standardized for all patients. Intraluminal swab cultures were obtained during the operation; only aerobic cultures could be studied. Patients were closely monitored for septic complications during the post-operative period. Study groups were similar regarding age, sex, nutritional status, and micro-organisms isolated from the bowel. Wound infections confined to the subcutaneous tissue occurred in 2 patients, 1 in each group (6.6%). No intraperitoneal infection, anastomotic leakage/dehiscence, or wound dehiscence was encountered. While susceptibilities to antibiotics other than cotrimoxazole were similar in both groups, cotrimoxazole-resistant micro-organisms were found more often in the long-course group (P <0.05). Because we found no difference in the rate of infectious complications between groups, we recommend the use of short-term parenteral antibiotic prophylaxis for colostomy closure in children. Such an approach saves nursing time, reduces costs, and prevents the formation of bacterial resistance.     

The mechanical complications of colostomy in infants and children: analysis of 473 cases of a single center

The purpose of this study was to determine the morbidity, mortality and possible risk factors in children who underwent colostomy. A total of 473 children who underwent colostomy in our clinic between 1983 and 2005 were retrospectively reviewed. Of these patients, 278 were boys and 195 were girls. The major indications for colostomy were anorectal malformation (252 patients), Hirschsprung’s disease (117), and trauma (66). The patients’ age ranged from 1 day to 15 years. Of the 473 patients, 254 (53.6%) were < 1 month of age, 97 (20.5%) were 1–12 months of age, and 122 (25.7%) were > 12 months of age. The side of colostomy was transverse in 341 (72%) patients and sigmoid in 132 (28%). The type of colostomy was loop in 364 (77%) patients and diverting in 109 (23%). Postoperative complication was observed in 80.5% of patients; excoriation (46.5%), prolapse (20.5%), stomal obstruction/stenosis (6.1%), and stomal bleeding (2.1%). A stomal revision was required for 26 (5.5%) patients. Overall, 50 (10.5%) patients died; 37 were related directly to major congenital anomalies, while 13 (2.7%) patients had a colostomy complication. The age of patients who died was < 1 month in 46 (92%) patients. The incidence of morbidity and mortality in children with colostomy is significantly high, particularly in neonates. Prompt colostomy procedure by an experienced hand, prompt stomal care under the supervision of a trained and experienced stomal care giver and early closure of the colostomy may increase the survival of these patients.     

Urethral prolapse in girls

Urethral prolapse is a benign lesion of the terminal urethra, usually seen in young Negroid girls. Twenty-seven children with urethral prolapse treated at the University Hospital of the West Indies between January 1982 and December 1991 were prospectively studied; 74% were between the ages of 3 and 7 years. Bloody discharge was the most common symptom. Vulval bleeding together with a bruised appearance of the urethra resulted in erroneous initial suspicion of sexual abuse in 3 children. Prolapse was graded from I to IV depending on the extent of prolapse and degree of inflammation. Initial therapy in the 25 prepubertal girls consisted of sitz baths and topical application of either an antimicrobial ointment (15 girls) or 0.5% oestrogen cream (10), chosen randomly. Complete resolution of the prolapse occurred in only 4 children, 3 of them from the oestrogen group. Although the oestrogen led to a better response, it also caused theliarchy in 2 girls. Three children who had only transient improvement and 2 post-pubertal patients had surgical excision of the prolapse. Post-excision there were no complications or recurrence of prolapse. Three girls who had improvement with non-operative therapy continued to have grade II prolapse even after puberty. Initial therapy of urethral prolapse in prepubertal girls can be non-surgical, however, when this fails to achieve resolution surgical excision is simple, safe, and curative.     

经肛门乙状结肠直肠切除悬吊术治疗儿童直肠脱垂

目的探讨单纯经肛门乙状结肠直肠切除悬吊术治疗儿童直肠脱垂的疗效。方法对6例Ⅱ-Ⅲ型直肠脱垂患儿采取单纯经肛门乙状结肠直肠切除悬吊术治疗t。结果6例患儿手术均获成功。手术时间1．5～3h,平均2．5h。术中元大出血、副损伤,术后无肠瘘、感染、大便失禁等并发症。术后住院6～8d,平均7d。6例获随访6～24个月,平均14个月,无腹泻、便秘及排便不畅,排便控制功能正常,无复发。结论对儿童Ⅱ-Ⅲ型直肠脱垂采取单纯经肛门乙状结肠直肠切除悬吊手术,可针对性地消除复发因素,创伤小,疗效确切。     

Histopathologic evidence for cardiomyopathy in a child with mitral valve prolapse

An intriguing relationship between idiopathic mitral valve prolapse (MVP) and cardiomyopathy has been reported in adult cases of MVP. This paper reports a girl with idiopathic MVP, who presented with progressive cardiomegaly and cardiomyopathic findings on cardiac biopsy; right ventricular endomyocardial biopsy at the age of 15 years showed myocardial hypertrophy, disarray, myocardial degeneration, interstitial fibrosis and endocardial thickening. To our knowledge, this is the first case of idiopathic MVP in childhood that has been shown to have positive biopsy findings for cardiomyopathy.     

A case of urethral prolapse in a young girl

Urethral prolapse is rarely reported in the pediatric literature. We report a 4 year old female with urethral prolapse and discuss the etiology and the treatments in children documented in the literature.     

Transanal and intraperitoneal prolapse in intussusception

An infant with intussusception who developed an unusual complication of transanal and intraperitoneal prolapse is reported. Complete venous occlusion of the intussusceptum for a prolonged period in a patient with congenital anomalous vascular supply of the colon is suggested as a mechanism responsible for rupture of the intussuscepiens.     

Outcome of submucosal injection of different sclerosing materials for rectal prolapse in children

Parasitic infestations, mainly enterobiasis and amoebiasis, and poor toilet training practices are commonly associated with rectal prolapse in developing countries. Injection sclerotherapy is one of the commonly used modalities for treating partial rectal prolapse in children. Various materials are available for such injection, but each has its advantages and complications. Comparing different materials used in the treatment of such pathology form the basis of this study trying to define the best material with the least complications. Data records of 130 children with partial rectal prolapse referred to the Department of Pediatric Surgery at Al Galaa Teaching Hospital, Cairo, over a 3-year period were analyzed. Their ages ranged from 6 months to 12 years (mean 6.14 years ±3.4). Forty-five patients (35%) responded to conservative treatment, and 85 patients (65%) required injection sclerotherapy and were divided into three groups: Group 1 (35 patients) was injected with 98% ethyl alcohol, group 2 (22 patients) was injected with phenol in almond oil 5%, and group 3 (28 patients) was injected with Deflux (Q-Med, Uppsala, Sweden). The follow-up period ranged from 2 months to 3 years; clinical data and all complications were recorded. Submucosal injection of the three sclerosing materials showed no mortality in this series, but in group 1, seven had recurrence on short-term follow-up that required reinjection, and long-term follow-up in this group showed a recurrence rate of 11% (four patients), plus two patients had mucosal sloughing and one girl developed a rectovaginal fistula. Group 2 showed abscess formation and mucosal sloughing in four patients (18%), and two developed perianal fistula. Group 3 showed immediate postoperative prolapse in two cases that ameliorated spontaneously. No patients had mucosal ulceration or abscess formation, and long-term follow-up showed no recurrence. Deflux had the lowest complication rate with no recurrence on long-term follow-up. Phenol in almond oil 5% injection should not be used for treating such conditions because of its high complication rate. Alcohol is commercially cheap and available and should be considered an alternative for Deflux.     

Benefits of primary surgical resection for symptomatic urethral prolapse in children

ObjectiveUrethral prolapse (UP) is a complete eversion of the distal urethral mucosa through the external meatus. UP must be distinguished by examination from trauma, prolapsed ureterocele, tumors or sexual abuse. Its management remains controversial. The aim of the study was to promote the benefits of primary surgical management for UP.MethodsA retrospective multicenter review of children who received surgery for UP between 1991 and 2011 was carried out. Non-complicated UP was primarily treated conservatively. A total of 19 patients were referred for complicated UP and underwent resection of the prolapsed urethral mucosa.ResultsThe mean delay in diagnosis was 2.2 days (range 1–6) and the most common symptoms were vaginal spotting and bleeding. No predisposing factor was found, but most patients had a mean weight, height and BMI greater than the 50th percentile. All patients underwent surgery successfully. One patient experienced a complication, i.e., dysuria. There was no case of recurrence after a mean 28 months of follow-up.ConclusionEarly detection is based on bedside examination. The first-line treatment strategy for uncomplicated UP should be conservative management. Surgical resection is safe and effective for patients with significant symptoms.     

Persistent rectal prolapse in children: sclerotherapy and surgical management

Persistent rectal prolapse is an uncommon but distressing condition in children. Significant controversy exists regarding its surgical management. The aim of this study was to identify a successful management strategy for persistent rectal prolapse in the paediatric population. Records of all children with rectal prolapse treated surgically at Birmingham Childrens Hospital between 1995 and 2003 were retrospectively reviewed. Demographic data, clinical presentation, investigations, treatment modality, complications, and outcome were recorded. Inclusion criteria for the study were failure of conservative management leading to operative treatment. An exclusion criterion was cystic fibrosis. A total of 24 patients with persistent rectal prolapse were identified. Two children with cystic fibrosis were excluded from the analysis. Children below the age of 5 years, group I (n=17), were successfully managed by submucous hypertonic saline injections. Eighty-three percent (14/17) were cured by injection sclerotherapy in this group, 12/14 (71%) requiring one injection and 2/14 requiring a second injection. In the three (17.6%) children in group I in whom sclerotherapy failed, cows milk protein (CMP) allergy was identified as the causative factor. Children older than 5, group II (n=5), either had behavioural problems (n=3) or were autistic (n=2). This group of children with adult-type, full-thickness rectal prolapse were found to be refractory to initial attempts of injection sclerotherapy. All five children were successfully managed with surgical correction. We conclude that rectal submucous hypertonic saline injections are highly effective for managing early-onset idiopathic childhood rectal prolapse. CMP allergy should be considered in young children with recurrent rectal prolapse. We recommend early definitive corrective surgery in older children with persistent rectal prolapse, as they do not respond to conservative measures or injection sclerotherapy.     

Mitral valve prolapse in Turner syndrome

We have evaluated 46 patients with Turner syndrome by clinical examination, M-mode and two-dimensional echocardiography, dynamic exercise testing and 24h Holter monitoring. Twelve patients (26.1%) had mitral valve prolapse and 7 patients (15.2%) had isolated non stenotic bicuspid aortic valve. Aortic root dilation was present in 2 patients (4.3%). Our data indicate that incidence of mitral valve prolapse is significantly higher in Turner syndrome than in the general population (P<0.025).     

Mitral valve prolapse and body habitus in children

Summary Mitral valve prolapse has generally been associated in adults with a thin body habitus. However, prior studies used biased samples or limited anthropometric measures. In addition, no information has been available on the subjective assessment of body habitus and diagnosis of mitral valve prolapse, especially in children.We conducted a cross-sectional study on 813 children with uniform assessment of anthropometric measures and mitral valve prolapse.Consistent with research conducted on adults, those subjects with mitral valve prolapse were lighter, thinner, and had, on average, lower values for several, quantifiable anthropometric parameters with the exception of height. However, the subjective assessment showed that while the assessment did not differ by diagnosis, those subjects with mitral valve prolapse were never described as fat.These data support an association between mitral valve prolapse and slender body habitus and extends it to children, thus underscoring the clinical importance that a thin body habitus may be a marker for mitral valve prolapse throughout the age span. This association may partly explain the observed genetic distribution of mitral valve prolapse.     

婴幼儿持续性高胰岛素血症的术中冰冻诊断意义及病理分析

目的探讨婴幼儿持续性高胰岛素血症(persistent hyperinsulinemic hypoglycemia in infancy,PHHI)的病理分型以及术中冰冻病理对外科手术治疗方法选择的指导意义。方法2011年4月至2016年10月,复旦大学附属儿科医院共25例PHHI患儿经外科手术治疗,回顾性分析其相关临床资料、手术治疗经过及术后病理特征。结果25例患儿中男17例,女8例,年龄16 d至12个月,术前经内分泌科明确诊断患有PHHI,空腹血糖0.6~5.5 mmol/L,禁食实验胰岛素水平为3.1~50.1 mU/L。结合术前检查及术中冰冻结果,5例患儿诊断为局灶性病变,行胰腺病灶切除术,20例诊断为弥漫性病变,行胰腺次全切术。术后随访2~38个月,空腹血糖3.0~12.6 mmol/L,15例术后血糖恢复较好,1例仍有低血糖症状,需加用激素治疗,3例空腹时血糖偏低,进食后可恢复,另6例有术后高血糖症状,需药物治疗。1例术前疑诊为局灶性病变,行50%胰腺切除术后2周复发。术后病理检查有5例诊断为局灶型,1例为不典型型,余19例为弥漫型。结论对于内科治疗无效的PHHI以手术治疗为主,术前明确病理分型对手术方式的选择极为重要,术中快速冰冻切片结合术前辅助检查可以较为准确的指导手术方式。婴幼儿PHHI主要以弥漫型为主,但从术后病理区分弥漫型及局灶性仍存在困难,其中不典型型尚无明确的定义或分类,还有待在病理学方面进一步详细研究。     

Changes in nutritive sucking during a feed in two-day-and thirty-day-old infants

Twenty-four infants were given a standard formula at 2 days and 1 month of life. The amount consumed, the feeding time, and the sucking amplitude were examined in 1-min trials. The data indicate that while the volume of intake did not change the feeding time decreased over the first month. Moreover, while sucking time and amplitude were independent of each other at the initiation of a feed at two days, they were correlated when the feed began at 30 days of age. It is, therefore, concluded that nutritive sucking efficiency changes and improves in the first month of life. Finally, a comparative analysis of the bottle feeding data from this study and data from two other published studies on breast feeding suggest the emergence of a regulatory mechanism that modulates the pattern of intake.