Surgery of chagasic megacolon

Chagas' disease is an endemic clinical entity caused by Trypanosoma cruzi,a parasite that is transmitted to humans by the hematophagic Triatominae insects. It affects several million persons in Latin America, mostly in Brazil, Argentina, Chile, Paraguay, and Bolivia. Megacolon, the most common complication of intestinal trypanosomiasis, results in severe constipation, for which surgery is indicated. A variety of procedures have been proposed for the correction of this disabling condition including sigmoidectomy, abdominal rectosigmoidectomy, left colectomy, and subtotal colectomy. On long-term follow-up, however, these operations have proved to be inadequate in a significant number of cases, apparently due to preservation of the dyskinetic rectum which continues to act as a functional obstacle to the progression of the fecal bolus. On the other hand, pull-through operations, which include the removal of all or almost all of the dyskinetic rectum, or the exclusion of the rectum, as in the Duhamel-Haddad operation, have been demonstrated to be superior. The abdominoperineal endoanal pull-through resection with delayed colorectal anastomosis and the Duhamel-Haddad operation are the most accepted procedures in Brazil and other Latin American countries; their technical details are illustrated. Functional results are satisfactory. Anal continence is normal in the vast majority of cases and sexual disturbances are rare. Routine treatment of 2 main complications—fecaloma and volvulus of the sigmoid colon—are discussed.

---

Resumen La enfermedad de Chagas es una entidad clínica de carácter endémico transmitida al ser humano por insectos triatomídeos. Afecta a varios millones de personas en América Latina, principalmente en Brasil, Argentina, Chile, Paraguay, y Bolivia. El megacolon es una de las complicaciones más comunes de esta enfermedad. La cirugia esta indicada en la gran mayoría de los casos y tiene como propósito principal curar el severo estreñimiento que afecta a la mayoría de los pacientes. Entre los procedimientos quirúrgicos que han sido propuestos, la sigmoidectomía, la rectosigmoidectomía abdominal, la colectomía izquierda, y la colectomía total han demostrado ser ineficaces, en un número significativo de casos, en el seguimiento a largo plazo, ciertamente porque en estos procedimientos se preserva el recto disquinético, el cual continúa actuando como un obstáculo funcional al avance del bolo fecal. Por el contrario, las operaciones de tipo pull-through han demostrado mayor efectividad, en virtud de que incluyen la resección de la totalidad o de la casi totalidad del recto disquinético, o su exclusión, como en la operación de Duhamel-Haddad. La resección abdominoperineal con pull-through endoanal y la operación de Duhamel-Haddad son los 2 procedimientos de preferencia en Brasil y en las naciones latinoamericanas. Se ilustran sus detalles técnicos. La continencia anal queda normal en la mayoría de los casos operados y la disfunción sexual es rara. Se discute el tratamiento rutinario de otras 2 complicaciones—el fecaloma y el vólvulos del sigmoide.

---

Résumé La maladie de Chagas est une entité clinique endémique provoquée par le Trypanosome cruzi, parasite transmis aux hommes par les insectes Triatominae hématophagi. Elle affecte plusieurs millions d'individus en Amérique Latine, surtout au Brésil, en Argentine, au Chile, au Paraguay, et au Bolivie. Le mégacôlon, complication la plus courante de la trypanosomiase intestinale se traduit par une constipation grave pour laquelle la chirurgie est indiquée. Différents procédés ont été proposés pour corriger cet état invalidant comprenant sigmoïdectomie, rectosigmoïdectomie, colectomie gauche, et colectomie subtotale. Un bon nombre de ces interventions se sont avérées inadaptées dans les suites à long terme ce qui est apparemment dû à la conservation du rectum dyskinétique qui continue à agir comme obstacle fonctionnel à la progression des selles. Par ailleurs, les interventions par retournement qui comprennent l'ablation soit totale soit subtotale du rectum dyskinétique ou son exclusion comme dans l'intervention de Duhamel-Haddad, se sont avérées meilleures. La résection abdominopérinéale par retournement avec anastomose colorectale retardée et l'intervention de Duhamel-Haddad sont les processus les plus couramment employés au Brésil et dans les autres pays d'Amérique Latine; les détails techniques sont illustrés. Les résultats fonctionnels sont satisfaisants. La continence est normale dans la plus grande majorité des cas et les troubles sexuels sont rares. Le traitement systématique des 2 complications principales, fécalome et volvulus du côlon sigmoïde, sont discutées.

     

改良Duhmel手术治疗先天性巨结肠126例

目的:总结用改良Duhamel手术治疗先天性巨结肠的经验,提高临床疗效.方法:采用改良Duhamel手术治疗先天性巨结肠126例,将张氏手术和Ikeda手术结合应用,发挥各自的优点.结果:126例手术无死亡,远期疗效满意,近期并发症有:盆腔感染2例,肛门缘感染4例,肛门污粪6例,排便不规则8例,经治疗均痊愈.结论:改良Duhamel手术是一种损伤小,比较符合生理的手术方法,只要操作得当,可避免盲袋及"闸门症候群"等并发症.     

Surgery of the immunodeficient child

A great deal has been learned about the surgery of immunodeficient patients. If one assesses the problem and follows the surgical principles described, in most instances one can solve the problem and be a great help to the oncologist and immunotherapist. A team approach is most important.     

Toxic megacolon

Toxic Megacolon (TM) is a rare life-threatening clinical entity characterized by total or segmental colonic distension in the setting of acute colitis and signs of systemic toxicity. It arises in a setting of almost any colitis, however ulcerative colitis (UC) and clostridium difficile-associated disease (CDAD) are the most common causes. The mainstays of diagnosis are clinical and laboratory assessment of systemic toxicity and underlying colitis as well as abdominal imaging demonstrating colonic distension. Medical therapy including resuscitation, electrolyte repletion, antibiotics, discontinuation of antimotility agents, and treatment of the underlying colitis is warranted in the absence of severe toxicity, perforation, or severe hemorrhage. However, 25–50% of patients with TM ultimately require colectomy, typically in the form of total abdominal colectomy with end ileostomy.     

Toxic megacolon

Toxic megacolon is a serious complication of inflammatory bowel disease, thus its prevention should be performed thoroughly. In patients with severe colitis refractory to maximal oral and topical therapy or who presents with toxicity, intravenous steroids are obligatory. If there is failure to achieve significant improvement within 7-10 days colectomy or treatment with intravenous cyclosporine or azathioprine are mandatory. In addition to maximal medical therapy as for severe colitis including broad spectrum antibiotics, patients with toxic megacolon should be kept nil per os, with small bowel decompression tube (if a small bowel ileus is present) and rotated into the prone or knee-elbow position frequently (evacuation of bowel gas). Any clinical, laboratory, or radiological deterioration require immediate colectomy. The duration of medical treatment of megacolon is controversial if no significant improvement is noted. Some experts support surgery within 72 hours, others take a more observing position if no toxic symptoms are present, but some advocate surgery within 24 hours.     

Toxic megacolon]

Reference to the literature dealing with idiopathic rectocolitis and its complications, with particular attention to megacolon, is followed by the presentation of two cases of ulcerous colitis complicated by toxic megacolon and a picture of acute abdomen. Emphasis is placed on the clinical features of such complications and the surgical treatment required in accordance with the degree of seriousness of the case.     

腹腔镜辅助Soave根治术治疗小儿先天性巨结肠的手术并发症及防治措施

目的:探讨腹腔镜辅助Soave根治术治疗小儿先天性巨结肠的手术并发症及防治措施。方法:回顾分析2002～2012年为625例先天性巨结肠患儿行腹腔镜辅助Soave根治术的临床资料。其中男506例,女119例;9天～8岁3个月,平均(41.13±4.85)个月;体重2.3～23.4 kg,平均(8.34±0.86)kg。常见型334例,长段型216例,全结肠型75例。结果:625手术均获成功,手术时间70～210 min,平均(102.76±16.43)min;术中出血量3～10 ml,平均(4.58±0.62)ml。术后近期大便4～15次/d,6～12个月后大便接近正常,大便2～5次/d。术后发生小肠结肠炎56例(8.96%),肛周皮炎98例(15.68%),污粪35例(5.6%),便秘复发4例(0.64%),吻合口漏、结肠回缩3例(0.48%),结肠扭转4例(0.64%),肛门狭窄8例(1.28%),吻合口出血5例(0.8%)。结论:腹腔镜辅助Soave根治术治疗小儿先天性巨结肠具有创伤小、操作简单、安全、有效、美观等优点;但也具有一些并发症,尤其长段型、全结肠型巨结肠。术前诊断及术中、术后规范处理,可减少术后并发症的发生。