Antegrade enemas for defecation disorders: do they improve the colonic motility?

Purpose

The aim of the study was to describe the changes in colonic motility occurring after chronic antegrade enema use in children and young adults.

Methods

Colonic manometry tracings of patients who had used antegrade enemas for at least 6 months and were being evaluated for possible discontinuation of this treatment were retrospective reviewed.

Results

Seven patients (median age of 12 years, range 3-15 years) met our inclusion criteria. Four patients had idiopathic constipation, 2 had tethered cord, and 1 had Hirschsprung disease. Colonic manometry before the use of antegrade enemas showed dysmotility in 6 (86%) children, mostly in the distal colon. None of the patients underwent colonic resection between the 2 studies. All the patients had colonic manometry repeated between 14 and 46 months after the creation of the cecostomy. All patients with abnormal colonic manometry improved with the use of antegrade enema with a complete normalization of colonic motility in 5 (83%) patients.

Conclusion

Use of antegrade enema alone, without diversion or resection, may improve colonic motility.     

A pilot study using total colonic manometry in the surgical evaluation of pediatric functional colonic obstruction

Background/purpose

Total colonic manometry (TCM) can directly measure intraluminal pressures and contractile function of the entire colon. The utility of TCM to guide the surgical management of functional colonic obstruction has not been reported.

Methods

Total colonic manometry was performed on all patients referred for surgical evaluation of refractory functional colonic obstruction. Manometric tracings were obtained while fasting, after feeding, and after pharmacologic stimulation.

Results

Nine patients were referred for refractory colonic obstruction. The mean age was 4.8 years, and the mean duration of follow-up was 29 months. Two patients had functional obstruction after repair of Hirschsprung’s disease, and 7 patients had idiopathic functional obstruction. In the idiopathic group, 4 distinct motility patterns were identified: (1) normal colonic motility, (2) dysmotility with massive distension, (3) persistent segmental dysmotility, and (4) global neuropathy/myopathy. Both Hirschsprung’s patients showed globally abnormal motility. Surgical management was guided by TCM results. There was significant improvement in bowel function and weight gain after manometry-guided intervention. An unnecessary laparotomy was avoided in 2 patients.

Conclusions

TCM can be valuable in deciding the need for and timing of diversion, the extent of resection required, and the suitability of the patient for restoring bowel continuity in refractory functional obstruction.     

Stooling patterns and colonic motility after transanal one-stage pull-through operation for Hirschsprung's disease in children

Background

The transanal one-stage endorectal pull-through operation for Hirschsprung's disease is relatively new and makes assessment of the functional outcome and colonic motility difficult. The aim of this study was to evaluate the stooling patterns and colonic motility after a one-stage transanal pull-through operation for Hirschsprung's disease in children.

Methods

Twenty-two children who underwent a one-stage transanal pull-through operation for Hirschsprung's disease were followed up for at least 6 months. The children (17 boys and 5 girls) were from 12 months to 13 years of age (mean age, 4 years). All patients had an aganglionic segment confined to the rectosigmoid area (confirmed by preoperative barium enema and postoperative histology). Clinical outcome was assessed by interviews and questionnaires, and children were divided into symptomatic and nonsymptomatic groups. Contrast barium enema and defecography and determination of total and segmental colonic transit time (using radio-opaque markers) were performed on all 22 children.

Results

The stooling patterns were considered satisfactory in 17 children. Of all the children, the mean stool times were 1 to 2 per day and only 2 were 8 to 10 per day; postoperative soiling was found in 4, constipation was observed in 2, and Hirschsprung-associated enterocolitis in 1. There was no incontinence, cuff infection, anastomotic leak, or mortality noted. Barium enema showed that the dilated and spastic colonic segment disappeared in all 22 children. The dilated sigmoid loops decreased in 17 (2 symptomatic, 15 nonsymptomatic) and disappeared in 5 (4 symptomatic, 1 nonsymptomatic). There was a significant difference between the decreasing and disappearing loop group in regard to stooling disorders (P < .05). Postoperative defecography showed that the anorectal angle of all children was open, fixed, and significantly larger than that of the preoperative and control groups (123.3° ± 15.1° vs 84.7° ± 8.3° vs 79.0° ± 11.6°, P < .01) and larger in the symptomatic group when compared with the nonsymptomatic group (135.6° ± 15.9° vs 111.0° ± 14.3°, P < .05). Postoperatively, the total gastrointestinal transit time, left colonic transit time, and rectosigmoid colonic transit time of all the children were shorter than preoperatively (26.8 ± 8.2 vs >188 hours, P < .01; 6.3 ± 4.1 vs >60 hours, P < .01; 11.8 ± 4.4 vs >120 hours, P < .01) and similar to controls. The total gastrointestinal transit time and rectosigmoid colonic transit time of the symptomatic group were significantly shorter than the nonsymptomatic group (25.2 ± 5.6 vs 28.1 ± 10.1 hours, P < .05; 12.2 ± 6.7 vs 9.8 ± 4.0 hours, P < .05).

Conclusions

The stooling pattern and colonic motility are satisfactory in most children after the one-stage transanal pull-through operation for Hirschsprung's disease. Normalization of colon appearance and total and segmental colonic transit time are signs of recovery of colonic motility. Stooling disorders were noted in a few cases and may be related to decrease or disappearance of the sigmoid loop, dysfunction of the “neorectosigmoid”, an open and fixed anorectal angle, and ischemia of the pull-through segment.     

Colonic manometry via appendicostomy shows reduced frequency, amplitude, and length of propagating sequences in children with slow-transit constipation

Background/Purpose

We wish to define colonic motor function in children with slow-transit constipation (STC) using manometry catheters introduced through appendiceal stomas, previously sited for controlling fecal retention by colonic irrigation.

Methods

We undertook 24-hour pancolonic manometry of 6 children (5 boys; mean, 11.5 years; SD, 3.0) using a multilumen silastic catheter. Results were compared to nasocolonic motility studies obtained in healthy young adults.

Results

Antegrade propagating sequences (APSs) originated less frequently in the cecum compared to controls. There were fewer APS (mean ± SEM: STC, 13 ± 6 per 24 hours; controls, 52 ± 6 per 24 hours; P < .01) and high-amplitude propagating contractions (HAPCs: STC, 5 ± 2 per 24 hours; controls, 9.9 ± 1.4 per 24 hours; P < .05). The amplitude of APS and HAPC was less in STC (APS, 39 ± 9 mm Hg; controls, 54 ± 3 per 24 hours; P < .05) (HAPC: STC, 94 ± 10 mm Hg; control, 117 ± 3 mm Hg; P < .01), whereas the amplitude of retrograde propagating sequences was greater in STC (43 ± 6 mm Hg; control, 27 ± 1 mm Hg; P < .01). The distances propagated by HAPC were significantly less in STC (36 ± 4.5 vs 47 ± 2.3 cm, controls; P < .05), and there was no evidence of a region-specific difference in propagation velocity of APS. Neither meal ingestion nor waking significantly increased colonic motor activity in patients with STC.

Conclusions

Despite the small numbers available to be studied, we found that children with STC in whom an appendicostomy had been placed show significant abnormalities in pancolonic motor function.     

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.     

Laparoscopic seromuscular colonic biopsies: a surgeon's experience

Background

Colonic dysmotility is a recognised cause of chronic constipation in children. Colonic dysmotility is better analysed by examination of the colonic muscle than rectal biopsy, which does not examine the defective area and has a low yield. We explored the role of laparoscopic colonic muscle biopsies to investigate children with intractable constipation. The authors describe the technique, its application, and results from a large series.

Methods

A retrospective review was conducted of all patients undergoing laparoscopic seromuscular colonic biopsies (hepatic flexure, mid-transverse colon, splenic flexure, and sigmoid colon) by a single surgeon for the investigation of chronic constipation over a 10-year period. Patient records were reviewed to determine the perforation frequency and management, postoperative recovery time and the frequency of an immunohistochemical abnormality.

Results

One hundred ninety-seven patients (118 boys) were investigated by laparoscopic biopsy during the period. The mean age was 8.0 ± 4.0 years (range, 1.4-22.4). The patients took 28.7 ± 13.6 hours (range, 8-120) to recover, with 37 (19%) having nausea and/or vomiting requiring antiemetics. Most patients (160/197, 81%) were discharged the following day. Six patients (3%) had a mucosal perforation recognised at operation (treated by an Endoloop) with no change in postoperative outcome. Two patients (1%) had an unrecognised mucosal perforation requiring laparoscopic reoperation and Endoloop closure (laparotomy/colostomy not required), with no further sequelae. Eight-six patients (44%) had a specific immunohistochemical neuropeptide anomaly (reduced substance P [84], reduced vasoactive intestinal peptide [2]).

Conclusions

Laparoscopic biopsy is a valuable tool to investigate chronic constipation in children, allowing a pathological diagnosis to be made in many cases. The complications of the procedure are acceptably low with this technique.     

Scintigraphic evaluation of colonic motility in patients with anorectal malformations and constipation

Background and Purpose

Constipation is one of the major sequelae in patients after correction of anorectal anomalies (ARAs). The aim of the present work has been to assess the colonic transit time, using radioisotope scintigraphy, in patients operated for ARA and experiencing constipation in the follow-up. The results were compared with transit time from children with true functional constipation.

Methods

Twelve or 32 patients operated for ARA during the period 1994-2003 experienced mild or severe constipation (6 with high or intermediate form of ARA and 6 with low type) at follow-up. The mean age of this group was 5.8 years. Eighteen patients, mean age 6.7 years, with true functional constipation were studied as well. Colonic transit times were investigated using radioisotope scintigraphy. Normal values for colonic transit time were derived from historical controls. Radioisotope diethylenetriamine pentaacetic acid labelled with indium 111 was administered orally to determine a segmental colonic transit. Images of the abdomen have been taken at 6, 24, 48, and again at 72 hours, if radioactivity was not cleared from the colon. To quantify colonic transit, we calculated the geometric centre (GC) dividing the colon into anatomic regions.

Results

According to normal controls, 2 different type of delayed transit can be observed: (a) slow-transit constipation if GC at 48 hours is less than 4.1; (b) functional rectosigmoid obstruction (FRSO) if GC at 48 hours is 4.1 or more but less than 6.1 at 72 hours. Patients with functional constipation were divided into 2 groups: (a) slow-transit constipation in 12 patients with a GC at 48 hours of 3.7 ± 0.5; (b) FRSO in 6 patients with a GC of 4.7 ± 0.04 and 5.02 at 48 and 72 hours, respectively. Patients operated for high ARA had values characteristic of FRSO with GC at 48 hours of 5.1 ± 0.8 and 4.75 ± 0.5 at 72 hours. In low ARA, the transit times were similar to the ones observed in patients with high ARA at 48 hours with a GC of 4.9 ± 0.5.

Conclusions

Patients with ARA frequently have functional sequelae in the postoperative period such as constipation. According to our results, constipation seems to be secondary to segmental motility disorders limited to the rectosigmoid area, similar to constipated children with FRSO. No evidence of more generalised motility disturbance, as previously postulated, could be recorded.     

An alternative management option for colonic atresia preventing loss of the ileocecal valve

Purpose

Management of colonic atresia is contentious, with primary anastomosis having a notable risk of anastomotic leak. In addition, resection of the terminal ileum and ileocecal (i-c) valve is frequently performed, risking side effects such as diarrhea, vitamin B₁₂ deficiency, and gall stone formation.

Methods

The hospital coding system was searched for all patients with a diagnosis of colonic atresia between July 2005 and July 2008. Four term neonates were managed by formation of an ileostomy, a “blow hole” stoma just proximal to the atresia, and a mucus fistula distal to the atresia.

Results

Average time to full feeds was 7.5 days (range, 3-12 days), and average length of stay was 23 days (range, 13-47 days). Stoma management, problematic in 2 infants, was individualized by a specialist stoma nurse. Ileostomy output was refed into the mucus fistula. Complications included 3 episodes of prolapse of the blow hole stoma in infant 2. All of the infants returned to the operating theater at 1 to 3 months of age for restoration of bowel continuity and closure of the ileostomy. The atretic segment was resected, and an end-to-end anastomosis was performed. Recovery was straightforward in all cases.

Conclusion

A procedure that retains the i-c valve and most of the colon through creation of a blow hole stoma in the distended proximal colon with a diverting ileostomy and mucus fistula is described. The technique is recommended in selected infants as bowel length and anatomy can be preserved, despite the use of multiple stomas.     

Colonic manometry as predictor of cecostomy success in children with defecation disorders

Purpose

The aim of this study was to define the predictive value of colonic manometry and contrast enema before cecostomy placement in children with defecation disorders.

Methods

Medical records, contrast enema, and colonic manometry studies were reviewed for 32 children with defecation disorders who underwent cecostomy placement between 1999 and 2004. Diagnoses included idiopathic constipation (n = 13), Hirschsprung's disease (n = 2), cerebral palsy (n = 1), imperforate anus (n = 6), spinal abnormality (n = 6), and anal with spinal abnormality (n = 4). Contrast enemas were evaluated for the presence of anatomic abnormalities and the degree of colonic dilatation. Colonic manometry was considered normal when high-amplitude propagating contractions (HAPC) occurred from proximal to distal colon. Clinical success was defined as normal defecation frequency with no or occasional fecal incontinence.

Results

Colonic manometry was done on 32 and contrast enema on 24 patients before cecostomy. At follow-up, 25 patients (78%) fulfilled the success criteria. Absence of HAPC throughout the colon was related to unsuccessful outcome (P = .03). Colonic response with normal HAPC after bisacodyl administration was predictive of success (P = .03). Presence of colonic dilatation was not associated with colonic dysmotility.

Conclusion

Colonic manometry is helpful in predicting the outcome after cecostomy. Patients with generalized colonic dysmotility are less likely to benefit from use of antegrade enemas via cecostomy. Normal colonic response to bisacodyl predicts favorable outcome.     

Manometric tests of anorectal function in 90 healthy children: a clinical study from Kuwait

Background/Purpose

Anorectal manometry is a noninvasive test used to evaluate conditions like slow-transit constipation, anorectal outlet obstruction, and Hirschsprung disease and to assess postoperative results after Hirschsprung and anorectal malformations. This cross section study was designed to have normal manometric values of anorectal function in healthy children of different ages in Kuwait so that control values are available for comparisons with various pathological states.

Method

Anorectal manometry was conducted in 90 children aged 3 days to 12 years without any symptoms related to lower gastrointestinal tract. They were divided in 3 age groups (group 1—neonates up to 1 month, group 2—infants from 1 month to 1 year, and group 3—children more than 1 year). Water perfused system with anorectal catheter with 4 side holes was used to record length of anal canal or high-pressure zone, resting pressure of anal canal, and rectoanal inhibitory reflex (RAIR).

Result

Anorectal manometry was successfully done in all 90 children of different age groups without any complications. High-pressure zone or anal canal length was 1.67 ± 0.34 cm in neonates, 1.86 ± 0.6 cm in infants, and 3.03 ± 0.52 cm in children. Mean resting pressure of anal canal was 31.07 ± 10.9 mm Hg in neonates, 42.43 ± 8.9 mm Hg in infants, and 43.43 ± 8.79 mm Hg in children. Rectoanal inhibitory reflex was present in all of them. Mean RAIR threshold volumes of 9.67 ± 3.6, 14.0 ± 9.5, and 25.0 ± 11.6 mL was required for noenates, infants, and children, respectively.

Conclusion

Resting pressure of the anal canal, manometic anal canal length, and RAIR volume varies with the age. Normal values anorectal manometry at different age groups should be obtained to compare with pathological states of anorectum.     

Effects of intestinal electrical stimulation on postprandial small-bowel motility and transit in dogs

Background

Intestinal electrical stimulation (IES) with long pulses has been reported to inhibit motility as well as accelerate transit of continuous infusion. However, it is unknown whether there is a correlation between the IES-induced alterations in motility and transit and whether there is a difference in transit during IES between continuous infusion and bolus infusion.

Methods

The study was performed in 2 postprandial sessions (control and stimulation) in dogs with 2 pairs of serosal electrodes and 2 intestinal cannulas. Intestinal motility and transit with and without IES were measured by manometry and phenol red, respectively.

Results

IES significantly decreased intestinal motility and increased transit time. There was a significant correlation between motility index and transit during IES.

Conclusions

IES inhibits both intestinal bolus motility and transit. There is correlation between motility and transit during IES.     

Mosaic trisomy 22 associated with total colonic aganglionosis and malrotation

Aims

Abnormalities of chromosome 22 karyotype have been reported to be associated with both malrotation and aganglionosis. However, although malrotation has been reported to occur in the rare mosaic trisomy 22, Hirschsprung's disease has not. We present a case of mosaic trisomy 22 that presented during the neonatal period with malrotation and total colonic aganglionosis, and we discuss the possible pathogenesis of both conditions in the light of this rare genetic abnormality. The association of total colonic aganglionosis and mosaic trisomy 22 has not previously been reported.

Results

A male neonate with an antenatal diagnosis of de novo mosaic trisomy 22 underwent a laparotomy with correction of malrotation and midgut volvulus on day 3 of life. Rectal biopsy was performed because he had not passed meconium. This revealed Hirschsprung's disease; an ileostomy was formed, and histology confirmed aganglionosis as far as the terminal ileum. At 6 months, a modified Lester Martin Duhamel pull-through was performed. He is showing normal development at follow-up.

Conclusions

We recommend an increased index of suspicion of Hirschsprung's disease and malrotation in patients with mosaic trisomy 22 until further evidence can establish or exclude a meaningful relationship.     

Use of anorectal manometry for evaluation of postoperative results of patients with anorectal malformation: a study from Kuwait

Purpose

The objective of this study is to use anorectal manometry for functional assessment of early postoperative results after corrective surgery for anorectal malformations (ARMs) in children and compare manometric observations with age-matched controls. Parents were counseled and management strategies were planned according to the manometric assessments.

Methods

From August 2005 to September 2009, 32 patients who underwent surgery for ARM were assessed postoperatively with anorectal manometry using a water-perfused anorectal motility catheter to record anal canal length or high-pressure zone, resting pressure of anal canal (RP), and rectoanal inhibitory reflex (RAIR). These patients were divided in 2 groups (infants, <1 year; children, >1 year) according to the age at the time of performance of anorectal manometry that was done at 6 months or later following stoma closure or anoplasty.

Results

Out of these 32 patients, high anomaly was present in 13, whereas 19 had low type of defect. Manometric anal canal length of the children with high and low ARM was 2.10 ± .44 and 2.25 ± .53 cm, respectively, which was significantly shorter than that of their age-matched controls(P < .05). In patients with high ARM, RP in infants (17 ± 7.7 mm of Hg) and children (21 ± 9.4 mm of Hg) was lower than that of controls (RP in infants = 42.43 ± 8.19 mm of Hg, RP in children = 43.43 ± 8.79 mm of Hg, P < .001). In patients with low ARM, RP in infants (34 ± 8.6 mm of Hg, P = .002) and children (26 ± 9.9 mm of Hg, P = .001) was lower than that in controls. Presence of RAIR was demonstrated in 5 (38.4%) of 13 patients with high ARM and in 11 (57.9%) of 19 cases with low ARM. Parental counseling was done after this early evaluation, and management strategies like bowel management program and biofeedback training were planned according to the results of the tests.

Conclusion

Our anorectal manometric results suggest that patients with ARM had short anal canal with lower RP and impaired RAIR, which could affect the ultimate functional outcome in these patients. Thus, postoperative anorectal manometric evaluation of the patients with ARM can give more realistic information about future continence and might help in planning future treatment strategies like bowel management program or biofeedback training.     

Experimental study of colonic anastomosis with a degradable stent in a porcine model

Background

Intestinal anastomosis is a major technical component of gastrointestinal procedures. We have developed a new procedure of colonic anastomosis with a degradable stent. This article evaluates this procedure.

Methods

Forty pigs were assigned randomly to a stent group (n = 20) and a control group (n = 20). A colonic anastomosis with a degradable stent was performed in the stent group, and hand-sewn anastomosis was performed in the control group. Pigs of each group were divided evenly into 4 subgroups according to time of death (days 3, 7, and 14, and month 10 postoperatively) to evaluate the healing of anastomosis.

Results

All procedures were completed successfully. The surgical time of the stent group was significantly less than the control group. No complications occurred in either group. Bursting pressure of the stent group was significantly higher than the control group on postoperative days 3 and 7. No significant difference of hydroxyproline content or microvessel density was found between the 2 groups.

Conclusions

The procedure of colonic anastomosis with a degradable stent is a simple, feasible, and safe procedure in this porcine model.     

Transabdominal electrical stimulation increases colonic propagating pressure waves in paediatric slow transit constipation

Background and aims

In slow-transit constipation (STC) pancolonic manometry shows significantly reduced antegrade propagating sequences (PS) and no response to physiological stimuli. This study aimed to determine whether transcutaneous electrical stimulation using interferential current (IFC) applied to the abdomen increased colonic PS in STC children.

Methods

Eight children (8–18 years) with confirmed STC had 24-h colonic manometry using a water-perfused, 8-channel catheter with 7.5 cm sidehole distance introduced via appendix stomas. They then received 12 sessions (20 min/3 × per week) of IFC stimulation (2 paraspinal and 2 abdominal electrodes), applied at a comfortable intensity (< 40 mA, carrier frequency 4 kHz, varying beat frequency 80–150 Hz). Colonic manometry was repeated 2 (n = 6) and 7 (n = 2) months after IFC.

Results

IFC significantly increased frequency of total PS/24 h (mean ± SEM, pre 78 ± 34 vs post 210 ± 62, p = 0.008, n = 7), antegrade PS/24 h (43 ± 16 vs 112 ± 20, p = 0.01) and high amplitude PS (HAPS/24 h, 5 ± 2:10 ± 3, p = 0.04), with amplitude, velocity, or propagating distance unchanged. There was increased activity on waking and 4/8 ceased using antegrade continence enemas.

Conclusions and inferences

Transcutaneous IFC increased colonic PS frequency in STC children with effects lasting 2–7 months. IFC may provide a treatment for children with treatment-resistant STC.     

Intratracheal pulmonary ventilation improves gas exchange during laparoscopy in a pediatric lung injury model

Background/Purpose

This study was aimed at determining whether intraoperative intratracheal pulmonary ventilation (ITPV) could prevent/treat respiratory complications of laparoscopy in a model of pediatric pulmonary insufficiency.

Methods

Severe lung injury was induced in 0- to 2-month-old lambs (n = 5) by endotracheal saline lavage. Animals then underwent establishment of CO₂ pneumoperitoneum. Intraperitoneal pressures were progressively raised from 0 to 15 mm Hg, at intervals of 5 mm Hg. At each interval, blood gas and hemodynamic data were recorded, 20 minutes after initiation of both conventional ventilation and pure ITPV. All ventilatory parameters were constant and identical on both modes of ventilation.

Results

On conventional ventilation, severe respiratory acidosis and hypoxemia ensued at intraperitoneal pressures of 5 mm Hg and 10 mm Hg or more, respectively. Compared with conventional ventilation, ITPV led to statistically significant decreases in Pco₂ at intraperitoneal pressures of 5 mm Hg (43.2 ± 5.2 vs 56.1 ± 6.6 mm Hg) and 10 mm Hg (45.1 ± 3.2 vs 61 ± 6.3 mm Hg) and to significant increases in Po₂ at 10 mm Hg (92 ± 10.2 vs 61 ± 8.1 mm Hg), resolving the acidosis and hypoxemia at those pressure levels.

Conclusions

Compared with conventional ventilation, ITPV improves both CO₂ removal and oxygenation during CO₂ pneumoperitoneum in a pediatric lung injury model. Intratracheal pulmonary ventilation may be a safer intraoperative mode of ventilation for neonates and children with respiratory failure who require laparoscopy.     

The risk factors to predict acute rejection in liver transplantation

Purpose

The aim of this study was to evaluate risk factors for an acute cellular rejection episode (ARE) among adult liver transplant (OLT) patients.

Materials and methods

We retrospectively reviewed 110 consecutive patients who underwent OLT between May 2007 and December 2010. The diagnosis of ARE was based upon clinical and biochemical data; liver biopsy was only performed when clinical presentation was equivocal. We recorded donor and recipient characteristics, perioperative immune status, and postoperative laboratory data. Forty patients (36.4%) who suffered a clinical rejection episode and received pulsed or recycled steroid therapy (R group), were compared with 70 (63.6%) free of rejection (N group).

Results

The mean age of R recipients was 46.61 ± 9.97 years, which was younger than the N group (51.86 ± 8.37, P = .005). R group patients displayed a lower pre-OLT creatinine (P = .016) and higher alanine aminotransferase (P = .048). Cox regression model showed recipient age to be the only significant factor to predict ARE (odds ratio = 1.071, P = .003). The cutpoint of age was 46 years by receiver operating characteristic analysis. Patients younger than 46 years showed higher initial CD8⁺ T-cell counts (P = .038).

Conclusion

Recipient age was significantly associated with ARE; younger patients showed higher CD8⁺ lymphocyte counts than older patients. More aggressive immunosuppression should be considered for younger recipients to prevent ARE.     

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.     

Evaluating long-term results of modified Heller limited esophagomyotomy in children with esophageal achalasia

Background/Purpose

Modified Heller esophagomyotomy has become the initial treatment of choice for esophageal achalasia in children. However, only limited and not objective data are currently available on the long-term results of modified Heller limited esophagomyotomy (LEM). This retrospective study was undertaken to objectively assess the long-term results of LEM in childhood esophageal achalasia.

Methods

Medical records of 15 patients with a median age of 9.5 years (range, 6-13 years) who underwent an LEM without an antireflux procedure from January 1991 to December 2005 were reviewed. Clinical scores, barium esophagogram, flexible upper alimentary endoscopy, 24-hour esophageal pH monitoring, and esophageal manometry before and 0.5 to 15 years after surgery were analyzed.

Results

An excellent to good outcome was observed in 14 (93.3%) patients. One patient (6.7%) required reoperation 8 months after surgery because of persistent dysphagia. The late barium esophagogram showed a significant decrease (from 4.2 ± 0.95 to 2.4 ± 1.1 cm, P < .01) of esophageal diameter, as compared with preoperative values. Only 1 patient had grade II esophagitis on flexible upper alimentary endoscopy. Twenty-four- hour esophageal pH monitoring showed an abnormal acid exposure in 1 patient. The late esophageal manometry showed a significant decrease (from 31.7 ± 7.9 to 7.8 ± 3.7 mm Hg; < .05) of lower esophageal sphincter (LES) pressure, and only insignificant increase (from 18.8 ± 6.2 to 21.4 ± 8.4 mm Hg; NS) of amplitude of esophageal contractions over preoperative values.

Conclusions

Transabdominal LEM without an antireflux procedure is an effective and safe treatment of esophageal achalasia in children because of its long-term high rate of symptoms relief and low incidence of postoperative complications, despite the lack of esophageal motility restoration to normal.     

Colonic transit time--what is normal?

Background

Constipation is a common problem in childhood, and various radiologic methods have been advocated for investigation. Colonic transit time (CTT) has been used in adults to investigate colonic motility, but few studies evaluate this method in children. Data on CTT in the normal paediatric population are scarce.

Methods

The colonic transit time was measured in 22 healthy children (median age, 10 years; range, 4 to 15 years) by Abrahamsson’s method. Children took bolus ingestions of radiopaque markers on 6 consecutive days, and on day 7 a single abdominal x-ray was performed. This was evaluated for total and segmental colonic transit time.

Results

The mean total CTT was 40 hours, and the upper limit of normal (95th percentile) was 84 hours. The upper limit of normal for segmental transit time was as follows: 14 hours for the ascending, 33 hours for the transverse, 21 hours for the descending, and 41 hours for the rectosigmoid colon.

Conclusions

CTT provides an objective measure to assess childhood constipation. To date, 6 studies using 5 different methods have been published reporting values for healthy children. Comparing these, Abrahamson’s method has low radiation exposure and is well tolerated. This study contributes additional normal values in children.