Sigmoidoscopy-assisted colostomy--an adapted trephine stoma formation

BACKGROUND/AIM: The purpose of this article was to report an adapted colostomy procedure that can be used on patients with multiple morbidities requiring fecal diversion. METHODS: An adapted colostomy was performed on a patient needing fecal diversion who had multiple surgical and medical complications. RESULTS: Thirteen weeks after colostomy placement, the patient's colostomy functioned well and was viable throughout his course without related complications. CONCLUSION: The method of sigmoidoscopy-assisted colostomy described here can be beneficial to the complicated patient needing fecal diversion but unable to tolerate a laparotomy or laparoscopy.     

Surgical treatment of chronic constipation with megarectum in children

In this paper, a new operative procedure for patients with chronic constipation with megarectum and its results are presented. Nine cases of idiopathic chronic constipation and one case of short aganglionosis showing megarectum underwent this operation. An incision was placed on the dentate line at 6 o'clock and the internal sphincter muscle was identified. The incision was extended to this muscle. The blunt division between the internal and external sphincter muscles was orally advanced 5 cm from the dentate line. The all layers of anus and lower part of rectum in length of 5 cm were clamped by 2 forceps in width of 1 cm. The mucosal and muscular layers were bilaterally cut in the outer side of the forceps. The rectum on the top of the forceps was pulled through to the dentate line and was anastomosed there; i.e. the posterior part of the anus was replaced by the rectal wall. Bowel habits of operated patients were evaluated at 1 to 3 years after the operation. Complete cure was obtained in 7 cases (including 1 case with aganglionosis). Three cases improved but needed sometimes suppositories. This procedure, sphinctero-myectomy and-plasty may be an operation of choice for chronic constipation with megarectum.     

Long-term management of chronic constipation in children

A retrospective clinical study was conducted to determine the success of a strict regimen employing the prolonged use of daily enemas in 203 children with chronic constipation. This study confirmed that the use of long-term daily enemas did eliminate constipation as well as the primary complaint of fecal soiling. The majority of children treated had an excellent to good result (85.8%) over an extended period of time. Patients with a past medical history of imperforate anus or Hirschsprung's disease required longer treatment periods (32.6 and 20.1 months, respectively) than children with other medical problems (rectal prolapse, rectal stricture, malrotation, spina bifida, mental retardation, psychological; 13 months) or patients with functional constipation (5.9 months).     

Pathophysiology and treatment of idiopathic chronic constipation with megarectum in children

Anorectal manometry was carried out in 65 children with idiopathic chronic constipation. Forty-five had no megarectum, and 20 had megarectum. Patients without megarectum showed normal anorectal pressures, recto-anal reflex, rectal sensation and rectal compliance, but motility of the colon was disturbed in these patients. Patients with megarectum also had normal anorectal pressures, recto-anal reflex and rectal sensation, but they showed remarkably high rectal compliance, or excessive rectal reservoir. Patients without megarectum were treated with laxatives and all of them were cured within 6 months after institution of therapy. Patients with megarectum were treated with rectal washout and suppository and 14 out of 20 were cured within 10 months. Six out of 20 patients with megarectum, however, were resistant to conservative therapy and necessity of surgical treatment to reduce the excessive rectal reservoir was proposed for these patients.     

Colonoscopic polypectomy in children.

Between January 1984 and July 1990, a total of 129 colonoscopic snare polypectomies were performed during 77 sessions on 74 patients aged 2 to 12 years. Bleeding per rectum (mean duration, 10 months) was the chief presenting symptom and was present in all of these patients. In 89% of patients polypectomy was carried out without using general anesthesia. Ninety-six percent of patients had juvenile polyps. Two patients had familial polyposis coli and one patient had a solitary adenomatous polyp. The majority (98; 80%) of the polyps were located in the rectosigmoid region. Four patients developed complications, one needing emergency operation. There were no deaths in the series. It is concluded that colonoscopic snare polypectomy is a simple, effective, and safe procedure for treating colorectal polyps in children.     

The ileocoecal valve changes in chronic constipation in children

There were analyzed the results of treatment of 574 children, suf fering anatomic anomalies of a large bowel, in whom a chronic constipation was revealed. In 61 patients the ileoceocal valve (IV) insufficiency was noted. To all the patients together with complex conservative treatment there was prescribed a preparation, containing magnesium orotat, for restoration of the IV insufficiency. In 56 (91.8%) patients conservative treatment was effective and in 5--surgical intervention was conducted as a consequence of ineffective conservative treatment. Negative correlation dependence was established between a patient age and results of treatment.     

An improved means of faecal diversion: the trephine stoma.

Twenty-four patients in whom trephine stoma formation was performed over a 4-year period are described. This procedure permits the formation of an end ileostomy or colostomy without laparotomy. It is simple, rapid, safe and allows speedy recovery. It is widely applicable and previous abdominal surgery is no contraindication. The procedure was impossible in two patients who required laparotomy and in a third in whom a loop colostomy was created. Operation time was shorter and postoperative opiate requirements less than when laparotomy was undertaken for stoma formation. Follow-up (median 1 year) of 17 patients confirmed a low incidence of complications (two prolapses, one parastomal hernia) after trephine stoma formation. This procedure is recommended as the preferred method of ileostomy or colostomy formation when laparotomy is not otherwise indicated.     

The usefulness of olive oil enema in children with severe chronic constipation

PurposeFew reports have determined the efficacy of olive oil enemas for severe constipation. Here, we review our experience with olive oil enemas in children with severe chronic constipation.MethodsIn our outpatient pediatric surgery department, the charts of 118 patients prescribed with olive oil enemas between January 2010 and November 2019 were retrospectively reviewed. A 1–2 ml/kg olive oil enema was given either alone or followed several hours later by a glycerin enema. Ratings included “very effective (VE),” “effective (E),” “limited (L),” “ineffective (I),” and “unknown (U).”ResultsOne hundred and fifteen (97.5%) patients were able to use olive oil enemas at home. Forty-nine had functional constipation; 43 had anorectal malformation; 40 had Hirschsprung disease; 12 had spina bifida; and 10 had other maladies.Used as an enema, olive oil was effective in treating fecal impaction in 77.6% of patients; as a lubricant, it was effective in treating 76.9% of patients. Efficacy for fecal disimpaction was similar among patients with different underlying disorders.ConclusionOlive oil enemas are useful for more than three-quarters of children with severe chronic constipation. Further study is warranted to add olive oil enemas as an adjunctive treatment in the management of severe constipation.     

Outcome of the antegrade colonic enema procedure in children with chronic constipation

BACKGROUND: Chronic constipation and fecal incontinence in children related to pelvic trauma, congenital anomalies, or malignancy will eventually lead to significant social and psychologic stress. Maximal medical treatment (daily enemas and laxatives) can also be difficult to maintain in many children. METHODS: At our children's hospital, 11 children with chronic constipation or fecal incontinence or both underwent the antegrade colonic enema (ACE) procedure. The operation involved constructing a conduit into the cecum using either the appendix (n = 8) or a "pseudo-appendix" created from a cecal flap (n = 3). We report our surgical results. RESULTS: Mean child age was 9.6 (5 to 18) years. With a mean follow-up of 14 (6 to 24) months, 10 of the children (91%) had significant improvement and 7 children (64%) are completely clean with no soiling and controlled bowel movements after irrigation. CONCLUSIONS: Regular colonic lavage after the ACE procedure allows children with chronic constipation and fecal incontinence to regain normal bowel habits and a markedly improved lifestyle. This procedure should be considered before colostomy in children and adults for the treatment of fecal incontinence from a variety of causes.     

How large should a skin trephine be for an end stoma?

BACKGROUND: Although much has been written about techniques for making a good stoma, little has been described regarding how to excise a trephine that will perfectly fit a given end stoma. METHODS: A reproducible technique for making a stomal trephine to a precise fit for each stoma is described. RESULTS: More than 20 stomas have been made with good results. CONCLUSION: The skin trephine should have a diameter approximately two-thirds of the width of the crushed bowel end.     

Rectal myectomy in the treatment of chronic constipation in children

Rectal myectomy was used with the positive result in 22 children. In patients with the supra-anal form of the Hirschsprung's disease, rectal myectomy was performed as an independent intervention. In patients with the residual zone of agangliosis after radical intervention, idiopathic constipation after radical myectomy, the pressure in the anal canal reduced, rectal emptying improved.     

Abnormalities in visceral evoked potentials from the anal canal in children with chronic constipation

The integrity of the sensory nervous system in the anal canals of chronically constipated children was investigated using evoked potential techniques examining cerebral and spinal evoked potentials from the lower extremities and anal canal. Stimulation of the posterior tibial nerve produced no significant difference in the parameters of spinal and cerebral evoked potentials between 18 controls and 12 chronically constipated chidren. However, stimulation of the anal canal resulted in evoked potentials related to the age and/or consciousness level of the control children. Reproducible cerebral responses were obtained only from nine of these control children, all aged over 4 years, who were examined while awake without sedatives. A typical response was characterized by a polyphasic wave occurring with an onset latency of 79.4± 27.7ms (mean ±SD). In the 12 chronically constipated children, the 5 sedated patients examined while asleep did not show any reproducible potential, as in the controls. However, in the remaining 7 children examined while awake, the occurrence of the anal canal evoked potential was significantly reduced, and only two exhibited a cerebral response. These findings suggest that rectal mucosal perception of the intraluminal stimuli might be disturbed in some children with chronic constipation.     

Electrorectography in chronic constipation

The rectal electrical activity recorded by electrorectogram (ERG) was studied in 22 chronically constipated subjects and 16 healthy colunteers. The latter had a mean (±SD) age of 42.6±8.5 years; 10 were men and 6 women. Of the 22 constipated patients, 14 had inertia-type age 38.4±12.2 years. The rectal electrical activity was recorded by a silver-silver chloride electrode situated 1 cm from the tip of a 6 F catheter, which was applied to the rectal mucosa by suction. At least four recording sessions of 120 minutes each were performed for each individual. In normal volunteers, regular and reproducible pacesetter potentials (PPs) were recorded with a mean frequency of 2.8±0.8 cycles/min (cpm), amplitude 2.1±0.8 mV, and velocity 4.6±0.8 cm/sec. They were followed randomly by action potentials (APs). In IC patients the PPs were so infrequent that in most cases half an hour would have elapsed without recording a PP; the mean frequency was 2.4±0.2 cycle/60 min, amplitude 0.92±0.02 mV, and velocity 4.1±0.6 cm/sec. APs were not recorded in 10 patients during the recording time; in two patients they were occasional. In OC subjects regular and reproducible PPs were recorded with a higher frequency (p<0.01) and velocity (p<0.05) than normal. Two ERG patterns were identified in those with chronic constipation: bradyrectia and tachyrectia. The former was recorded in the IC subjects and the latter in OC subjects. It is concluded that ERG is a technique by which electromechanical activity is recorded. It is noninvasive and nonradiologic, and it can be included as an investigative tool for rectal detrusor disorders.

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Resumen La actividad eléctrica rectal medida por electrorectograma (ERG) fue estudiada en 22 individuos con estreñimiento crónico y en 16 voluntarios normales. Estos últimos tenían edad promedio de 42.6±8.5 años, 10 eran hombres y 6 mujeres. De los 22 pacientes con estreñimiento, 14 tenían estreñimiento del tipo inercia (IC, edad media 44.6±10.2 años) y 8 estreñimiento del tipo obstructivo (OC, edad media 38.4±12.2 años). La actividad eléctrica rectal fue registrada mediante un electrodo situado a 1 cm de la punta de un catéter 6F que fue adherido a la mucosa rectal mediante succión. Se hicieron no menos de 4 sesiones de registro de 120 minutos cada una en cada individuo. En los voluntarios normales se registraron potenciales con una frecuencia media de 2.8±0.7 ciclos/min, amplitud de 2.1±0.8 mV y velocidad de 4.6±0.8 cm/segundo. Estos fenómenos fueron seguidos, al azar, por potenciales de acción (PA). En los pacientes con IC, los potenciales fueron tan infrecuentes que en la mayoría de los casos se observó que pasaba media hora sin registro alguno; la frecuencia media fue 2.4±0.2 ciclos/60 min, la amplitud 0.92 ±0.02 mV y la velocidad 4.1±0.6 cm/segundo. No se registraron PA en 10 pacientes en el curso de la sesión de registro; en 2 pacientes aparecieron en forma ocasional. En los OC, se registraron potenciales regulares y reproducibles con mayor frecuencia (P<0.01) y velocidad (P<0.05) que en los normales. Se identificaron dos patrones de ERG en el estreñimiento crónico: bradirrectia y taquirrectia. La primera modalidad fue registrada en los IC y la última en los OC. En conclusión, la electrorectografía es una técnica que permite registrar la actividad electromecánica rectal. Es un procedimiento no invasor y no radio-lógico y puede ser incluido como un instrumento de diagnóstico en las alteraciones de la evacuación rectal.

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Resumé L'activité électrique du rectum, enregistrée par l'électrorectogramme (ERG) a été étudiée chez 22 sujets présentant une constipation chronique et chez 16 sujets volontaires sains. Ces derniers avaient un âge moyen de 42.6±8.5 ans, et comprenant 10 hommes et 6 femmes. Des 22 patients constipés, 14 avaient une constipation du type «inertie» (CI),(âge moyen 44.6±10.2 ans) et huit avaient une constipation du type «obstructive» (CO),(âge moyen 38.4±12.2 ans). L'activité électrique rectale a été enregistrée par une électrode argent/chlorure d'argent, située à 1 cm de l'extrémité d'un cathéter 6 F, appliqué sur la muquese rectale par aspiration. Au moins quatre séances d'enregistrement de 120 minutes chacune, ont été réalisées. Chez le sujet volontaire sain, les potentiels du pacemaker (PP), réguliers et reproductibles, ont été enregistrés avec une fréquence moyenne de 2.8±0.7 cycles/min (cpm), d'une amplitude moyenne de 2.1±0.8 mV et d'une vitesse moyenne de 4.6±0.8 cm/sec. Ces PP ont été suivis de façon inconstante de potentiels d'action (PA). Chez les patients ayant une CI, les PP étaient peu fréquents: leur fréquence moyenne était de 2.4±0.2 cycles/heure si bien qu'une séance d'enregistrement avait très peu de chance de les capter, leur amplitude moyene a été de 0.92±0.02 mV et leur vitesse de 4.1±0.6 cm/sec. Chez 10 patients, il n'y avait aucun PA et chez 2, les PA se produisaient occasionnellement. Chez les patients ayant une CO, les PP réguliers et reproductibles avaient une fréquence (p<0.01) et une vitesse (p<0.05), plus importantes que chez le sujet sain. On a identifié deux types de constipation chronique: la bradyrectie et la tachyrectie. Le premier a été enregistré en cas de constipation de type «inertie» et le deuxième en cas de constipation de type «obstructif». L'électorectographie est une technique qui permet d'enregistrer l'activité électromé-canique. Elle est non-invasive et non radiologique et pourraient être un outil important dans les investigations des désordres du détrusor rectal.

     

Intestinal stoma complications in immunocompromised children

BACKGROUND/PURPOSE: When performing an urgent gastrointestinal operation on an immunocompromised child, the pediatric surgeon may have to decide between performing an intestinal anastomosis (and risk leakage or sepsis) or creating an intestinal stoma. This study evaluates the postoperative course of those patients treated with intestinal stomas and the long-term survival rate of such patients. METHODS: A 13-year retrospective review of immunocompromised children with intestinal stomas was performed. Patients were assessed as to their diagnosis, indication for surgery, stoma type, postoperative complications (within 30 days of surgery), ostomy-related complications, and survival. RESULTS: 19 stomas (8 ileostomies and 11 colostomies) were created in 18 patients. Six children had immunodeficiency disorders; 12 were immunosuppressed from chemotherapy treatment for cancer. Indications for surgery included infectious complications (n = 8); neoplasm-induced bowel obstruction, perforation, or invasion (n = 10); and Hirschsprung's disease (n = 1). Postoperative complications occurred in 13 cases (68%); two warranted reoperation. Four of six patients with neutropenia had serious postoperative infectious complications. Stoma complications occurred in 6 cases (32%); 1 required revision. All 3 patients in whom bleeding developed from their stoma site were thrombocytopenic. Nine of 18 patients (50%) died, yet no patient died of complications attributable to their stomas. Of the surviving 9 children, 6 underwent stoma takedown at a mean of 19 months after creation; 1 has a permanent colostomy, and 2 currently are undergoing chemotherapy. CONCLUSION: Although immunocompromised children who require intestinal stomas frequently die of their underlying illnesses and their stomas often produce considerable morbidity, stoma creation does not jeopardize their chance of survival.     

小儿便秘结肠动力学机制的初步探讨

目的探讨慢性便秘患儿的结肠动力学变化特点和规律。方法 2 5例便秘儿童接受结肠传输时间测定和直肠肛管向量测压检查 ,根据结肠传输时间将便秘儿童分为传输时间正常型便秘组和传输时间延长型便秘组 ,探讨直肠肛管向量测压对于不同类型便秘的意义。结果便秘组的全胃肠传输时间 (TGITT)、左半结肠传输时间 (LCTT)和直肠乙状结肠传输时间 (RSTT)较对照组显著延长 [(92± 5 6 )h比 (2 9± 8)h ,P <0 0 1;(17± 13)h比 (7± 4 )h ,P <0 0 1;(6 2± 2 9)h比 (13±6 )h ,P <0 0 1]。肛管最大收缩压显著升高 [(2 36± 4 4 )mmHg比 (190± 38)mmHg ,P <0 0 5 ],对称指数显著降低 [(0 71± 0 0 6 )比 (0 84± 0 0 8) ,P <0 0 5 ]。传输时间正常型便秘组和传输时间延长型便秘组的肛管最大压力、向量容积和对称指数之间差异无显著意义。结论便秘儿童的TGITT、LCTT和RSTT比正常儿童显著延长 ,肛管最大收缩压升高 ,对称指数降低。便秘儿童的结肠传输功能和 (或 )直肠肛管动力存在不同程度异常。     

Long term outcome of antegrade colonic enema (ACE) stoma for treatment of constipation and fecal incontinence in children

AimTo determine the long term outcome of antegrade colonic enema (ACE) stoma for treatment of chronic constipation and soiling in children.MethodWe reviewed patients prospectively who underwent formation of ACE stoma after failure of maximum medical treatment of chronic constipation and soiling from September 2008 to October 2020. All patients had anorectal manometry, endosonography and colonic transit study. A validated symptom severity (SS) score questionnaire was used pre operatively and during follow up. The sum of SS score ranged between 0 (best) and 65 (worst). Data was expressed as median(range) and Wilcoxon rank sum test was used and p value < 0.05 was considered significant.Results58 patients had formation of ACE stoma, laparoscopic appendicostomy 56, cecostomy 1, and open procedure 1. The main indications for the ACE stoma were chronic functional constipation (FC) 50(86%), anorectal malformations (ARM) 6(11%) and Hirschsprung disease (HD) 2(3%). 41(71%) of patients had previous intrasphincteric botulinum toxin (BT) treatment. Age at operation was 11(range 4–15) years and follow up was 36(3–84) months. 47(81%) patients were continent of stool within three months postoperatively. The preoperative SS score improved from 34/65 (26–47) to 8/65 (4–12) at 12 months and 5/65 (2–11) at 24 months follow up, p ≤ 0.05.Overallcomplication rate was 15(26%), wound infection 5, granulation tissue 4, stoma prolapse 4, retraction 1, abscess formation and fistula 1. 15 (26%) adolescents had transition of their care to adult services.ConclusionThere is a significant improvement of constipation, soiling and general health of patients following formation of ACE stoma. Adolescents benefits an orderly transition of their care to adult services.Level of evidenceLevel 2, Therapeutic study.