Midterm follow-up study of high-type imperforate anus after laparoscopically assisted anorectoplasty

Purpose

The aim of this study was to evaluate postoperative anal function of high-type imperforate anus after laparoscopically assisted anorectoplasty (LAARP).

Methods

Between 2000 and 2002, LAARP was performed in 13 patients with high-type imperforate anus. Clinical data of the LAARP group were compared with the posterior sagittal anorectoplasty (PSARP) group (n = 7) operated before 2000. All patients were treated with initial colostomy in the newborn period. After anorectoplasty, daily glycerin enemas were given for postoperative bowel management. Anorectal function of these patients was evaluated using the Kelly score and manometry at the age of 3 to 5 years (LAARP) and 5 to 6 years (PSARP).

Results

Age at evaluation in the LAARP group was younger than that in the PSARP group (51 ± 10 vs 73 ± 12 months, P < .01). Kelly score was 3.8 ± 1.3 vs 3.4 ± 0.8, respectively. Resting pressure of internal sphincter was 31 ± 11 vs 33 ± 10 cm H₂O, respectively. Relaxation reflex of the internal anal sphincter was observed in 62% (8/13) and 29% (2/7), respectively.

Conclusions

Midterm follow-up study revealed that satisfactory fecal continence can be achieved in patients with high-type imperforate anus after LAARP. Laparoscopically assisted anorectoplasty may be a good alternative in this patient population. However, long-term follow-up is necessary to compare the benefits of LAARP against PSARP.     

The effect of vitamin A deficiency during pregnancy on anorectal malformations

Objective

The aim of this study was to study the effect of vitamin A deficiency (VAD) on the embryological development of anorectal malformations (ARMs) and the enteric nervous system.

Materials and Methods

Female Sprague-Dawley rats were divided into 3 groups: VAD group, normal group (negative control), and ethylene thiourea (ETU) group (positive control) with a normal diet. On day 20 of pregnancy, cesarean section was performed on all rats. The incidence of ARMs in the fetal rats and Protein gene product 9.5 (PGP9.5) and S-100 protein expression by immunohistochemistry were determined.

Results

The incidence of ARMs in VAD and ETU groups was 64.8% (59/91) and 45.9% (61/133), respectively (P > .05). Anorectal malformations were not found in the normal group. Protein gene product 9.5 and S-100 protein expression in the non-ARM rectums of the VAD group was lower than the ETU (P = .0156 vs P = .0105) and normal groups (P = .0091 vs P = .0024). There was no significant difference in PGP9.5 and S-100 protein expression between ETU and normal groups. In the ARM rectums, PGP9.5 and S-100 protein expression in the VAD group was lower than the ETU group (P < .0001). Protein gene product 9.5 and S-100 protein expression was also lower in ARM than non-ARM rectums in the VAD and ETU groups (P < .0001, P = .0203, and P = .0122, respectively).

Conclusion

Vitamin A deficiency during pregnancy may result in the embryological development of ARMs. Enteric nervous system development may be related to ARMs.     

The treatment of high and intermediate anorectal malformations: one stage or three procedures?

Background/Purpose

The aim of this study was to examine the safety, feasibility, and the long-term outcome of complete 1-stage repair of high and intermediate anorectal malformation using posterior sagittal anorectoplasty (PSARP) in a neonate.

Methods

One hundred thirteen patients with high-type and intermediate-type anorectal malformations (ARM) underwent follow-up. Of 113 cases, 48 cases entailed a divided colostomy, definitive operation, and colostomy closure (group I); the other 65 patients underwent 1-stage PSARP (group II). Anorectal function was measured by the modified Wingspread scoring, including “excellent,” “good,” “fair,” and “poor.” In barium enema studies, anorectal angulation was judged as “clear,” “unclear,” and “not present,” and leakage of barium was observed in the meantime. For anorectal manometric studies, anal resting pressure (ARP), anal squeezing pressure (ASP), and positive anorectal reflex (PAR) were measured.

Results

In group I, the rate of excellent and good scores was 58.3% (28 of 48). In the barium enema examination, 85.4% (41 of 48) was clear and 14.6%(7 of 48) unclear or not present. The rate of barium leakage was 10.4% (5 of 48). In group II, the rate of excellent and good was 53.8% (35 of 65). Anorectal angulations were clear in 83.1% of patients (54 of 65). Barium leakage happened in 7.69% of patients (5 of 65). Early operative complications occurred in 56.3% (27 of 48) of patients in group I and 29.2% (19 of 65) in group II. The incidence of colostomy complications in group I was 39.6% (19 of 48). Soiling and constipation were the major complications after the PSARP operation. The respective rates of constipation in the 2 groups were 47.9% (23 of 48) and 44.6% (29 of 65), and the respective rates of soiling were 47.9% (23 of 48) and 50.8% (33 of 65). There was no significant difference in the mean ARP between the 2 groups.

Conclusions

The 1-stage PSARP procedure in the neonate not only achieves the same long-term outcome as the conventional PSARP procedure but also involves fewer short-term complications. Complete 1-stage repair using the PSARP to treat high-type and intermediate-type anorectal malformations is safe and feasible.     

Outcome of excision of megarectum in children with anorectal malformation

Background/Purpose

Megarectum in association with anorectal malformation contributes to chronic constipation and fecal incontinence. Resection of megarectum in anorectal malformation improves bowel function, but neuropathy and poor sphincter quality may affect the outcome of fecal continence adversely. The aim of this study was to evaluate the benefits of resection of megarectum in anorectal malformation and to ascertain the impact of anal sphincter quality and neuropathy on the outcome.

Methods

We studied 62 children with intractable fecal incontinence after repair of anorectal malformation between January 1991 and January 2005. All patients were investigated with anorectal manometry and anal endosonography under ketamine anesthesia. On endosonography, an intact or scarred internal anal sphincter (IAS) was classified as good and a fragmented or absent IAS as poor. On manometry, a resting anal sphincter pressure equal to or more than 30 mm Hg was classified as good and a lower pressure as poor. Functional assessment of fecal continence was done before and after excision of megarectum using a modified Wingfield scores.

Results

Sixteen children had excision of megarectum with median age of 9 years (range, 2-15 years) and postoperative follow-up of 5 years (range, 1-10 years). Seven had formation of antegrade continent enema stoma before excision of megarectum. Children were classified into three groups of anomalies: low (n = 6), intermediate (n = 4), and high (n = 6). All children were incontinent of feces. After excision of megarectum, of the 9 children with good IAS and no neuropathy, 7 became continent of feces. Of the remaining 7 children, 4 had poor IAS and 3 had neuropathy, 5 of whom required an antegrade continent enema stoma to be clean.

Conclusion

Excision of megarectum in children who had previous repair of anorectal malformation results in fecal continence in the presence of a good IAS and absence of neuropathy. Patients with a poor IAS or neuropathy will often require artificial means of fecal continence.     

Evaluation of the Nuss procedure using pre- and postoperative computed tomographic index

Background

Objective assessment of the chest in patients with pectus excavatum after the Nuss procedure has not been published. This study evaluated the results of the Nuss procedure using computed tomographic (CT) index (CTi).

Methods

We have performed the Nuss procedure in 382 patients since 1998, and 150 patients who underwent bar removal were included in this study. Computed tomographic scans were obtained before the Nuss procedure and after bar removal, and then preoperative CTi (pre-CTi) and postoperative CTi (post-CTi) were calculated. Computed tomographic scans of 62 age-matched patients without chest deformity were collected as controls. Patients were divided at 10 years of age into the younger and older groups, and groups with mild and severe deformity were defined using a pre-CTi value of 5 as border. These CT indices were compared and statistically analyzed.

Results

Mean pre-CTi in all cases was 5.97 ± 3.31 and improved to 3.08 ± 0.64. Postoperative CTi was not significantly different from that of the control (2.47 ± 0.32, P = .17). In the group with mild depression, pre-CTi was 4.15 ± 0.62, and post-CTi was 2.88 ± 0.50. Preoperative CTi in the group with severe deformity (7.44 ± 3.82) improved to 3.25 ± 0.69. Postoperative CTi values between the severe and mild groups were not significantly different (P = .75). Computed tomographic index of the young group improved from 6.20 ± 3.58 to 2.93 ± 0.49 and in older group from 5.50 ± 2.64 to 3.40 ± 0.79. These 2 post-CTi values were not significantly different (P = .73).

Conclusion

Postoperative CT scan could provide objective evaluation of sternal elevation. Mean CTi after the Nuss procedure was statically equivalent to that of the control cohort. Good sternal elevation can be achieved with the Nuss procedure regardless of the severity of chest depression or age.     

Clinicopathologic assessment of prenatally diagnosed lung diseases

Purpose

To investigate the clinical features and pathologic diagnosis of prenatally diagnosed lung diseases.

Materials and Methods

The medical records of 28 fetuses with prenatally diagnosed lung diseases were reviewed with regard to perinatal courses, ultrasonographic measurement of the lesion volume ratio, and the histopathology of lung tissue.

Results

Of the 23 fetuses with a prenatal diagnosis of congenital cystic adenomatoid malformation (CCAM), 4 required an emergency lobectomy (1 prenatally and 3 postnatally), whereas the other 14 showed uneventful courses after birth. The pathologic diagnosis of the resected lungs included CCAM (n = 4), lobar emphysema (n = 2), intralobar sequestration (n = 2), and bronchial atresia (n = 1). The peak value of the lesion volume ratio was significantly higher in the CCAM cases that required urgent surgery than in the non-CCAM cases (2.29 ± 0.46 vs 1.20 ± 0.21, P < .001). The ratio decreased after the 25th to the 30th week to less than 1.0 in the 5 non-CCAM cases, but remained higher than 2.0 in the 4 CCAM cases. Prenatally diagnosed extralobar pulmonary sequestration caused massive pleural effusion requiring a fetal intervention in 4 of the 5 fetuses.

Conclusions

The prenatally diagnosed lung lesions include various kinds of pulmonary diseases. Regardless of the diseases, sequential ultrasonographic assessment may predict perinatal risks.     

Normal and abnormal embryonic development of the anorectum in rats

Background

The embryologic and pathologic aspect of anorectal malformation (ARM) remains poorly understood. There is no universally accepted theory to explain anorectal embryology and the abnormal development that produces ARM. The aim of this study was to observe the developmental processes of anorectum in rats and to explore the abnormal embryonic development that leads to ARM.

Methods

Rat embryos with ARM were obtained by treating pregnant rats with administration of ethylenethiourea (ETU). Normal rat embryos and embryos with ARM from gestational days 12.5 to 20 were sectioned serially and sagittally and stained with H & E. The relevant structure including cloaca and urorectal septum (URS) were examined in a temporospatial sequence.

Results

Characteristics of anorectum development in ARM rat embryos treated by ETU were as follows: (1) URS never fused with cloaca membrane. (2) Dorsal cloacal membrane was maldeveloped. (3) Cloacal configuration was abnormal. (4) Tail groove never appeared. All type of ARM was the rectourethal fistula and common cloaca in ETU-treated rat embryos and was discernible on gestation day 16.

Conclusions

Absence of the tail groove and maldevelopment of the dorsal cloacal membrane, cloacal configuration, and urorectal septum are likely to be responsible for the formation of ARM. Failure of fusion of the URS with cloacal membrane is the immediate reason for rectourethral fistula or common cloaca in ETU-treated rats.     

Preparing medical students to enter surgery residencies

Background

This study was designed to develop and evaluate an integrated cognitive and proficiency-based skills curriculum based on American College of Surgeons Graduate Medical Education Committee (ACGME) competencies to prepare students for surgery internships.

Methods

Course content included cadaver dissections, didactic sessions, team training, and training in clinical and technical skills. Using previously validated skills curricula (12 open and 5 Fundamental Laparoscopic Surgery [FLS] tasks), trainees underwent pretest, self-practice to proficiency, and post-test. Surveys regarding confidence levels and skills were administered.

Results

Mean course evaluation score was 4.5 ± .6 on a 5-point Likert scale. Trainees (n = 9) achieved proficiency on open tasks and FLS tasks 2-5. The mean confidence self-rating on 51 skills increased on a 5-point Likert scale from 2.4 ± .6 to 4.0 ± .6 (P < .001).

Conclusions

This integrated curriculum did improve confidence levels, and skills proficiency can be achieved in an abbreviated time. The anticipated result would be enhanced baseline abilities for internship.     

Fetal tracheal occlusion for severe congenital diaphragmatic hernia in humans: a morphometric study of lung parenchyma and muscularization of pulmonary arterioles

Objective

The aim of this study is to examine structure of lung parenchyma (Pp) and muscularization of pulmonary arterioles (PAs) in human fetuses that underwent tracheal occlusion (TO) therapy for severe congenital diaphragmatic hernia (CDH).

Material

Fifteen fetuses underwent TO, with 5 survivors (Am J Obstet Gynecol. 2000:183;1059-1066). Paraffin-embedded lung specimens from 7 of 10 nonsurvivors (CDH-TO) and 6 age-matched fetuses (CDH) were available for morphometric analysis, which included measurements of point fraction of lung Pp and surface density. The PAs were categorized according to external diameter (<70 μm and 70 ≤ 140 μm). Percent medial wall thickness (%MWT) was calculated by dividing raw measurements of MWT by external diameter.

Results

Gestational age at TO was 27.6 ± 0.9 weeks with a mean duration of TO of 32.6 ± 6.8 days. Gestational age at delivery (CDH-TO 31.9 ± 0.9 vs CDH 35.4 ± 1.8 weeks; P = .18) and postnatal survival time (CDH-TO 20.5 ± 6.0 vs CDH 18.6 ± 7.8 days; P = .85) were not significantly different between groups. Tracheal occlusion significantly increased the lung-to-body weight ratio (CDH-TO 13.0 ± 2.2 vs CDH 6.6 ± 0.9; P = .02). Tracheal occlusion tended to decrease right-lung Pp (CDH-TO 54.6% ± 2.6% vs CDH 65.7% ± 5.9%; P = .05), whereas left-lung Pp was not different between groups (CDH-TO 63.0% ± 3.5% vs CDH 66.7% ± 4.1%; P = .51). Surface density of airspaces was not different between groups in either left (CDH-TO 171.3 ± 16.1 cm⁻¹ vs CDH 151.1 ± 8.1 cm⁻¹; P = .34) or right (CDH-TO 172.0 ± 10.6 cm⁻¹ vs CDH 160.8 ± 3.6 cm⁻¹; P = .33) lungs. The %MWT in small and large PA was similar between groups.

Conclusions

Open prenatal TO in human fetuses increased lung growth, as evidenced by an increase in lung weight, but did not improve parenchymal structure or muscularization of PAs.     

Las hepatectomías mayores en pacientes con colangiocarcinoma e ictericia son seguras

Background

Surgical resection is the only possibility of long term survival in patients with Klatskin tumours. However, surgical resection is a challenging problem and hepatic resection is often necessary.

Objective

The aim of our study was to assess the need for biliary drainage, resection rate and outcome of hilar cholangiocarcinoma in a single tertiary referral centre.

Patients and methods

From 2005 to 2008, 26 patients with Klatskin tumours were identified and assessed prospectively with multidetector CT and MR cholangiography in special cases. Seven patients (27%) were deemed to be unresectable in pre-operative staging. A total of 19 surgical procedures were performed, 8 left hepatectomies, 5 right hepatectomies and 6 resections exclusively of the biliary tree.

Results

Resection rate was 73%, transfusion rate 53% and preoperative biliary drainage was performed only in 7 cases (37%). Major complications occurred in 11 (58%), including two post-operative deaths (10%).There were no differences in the epidemiological data, when we separately analysed the outcomes of the 9 patients with bilirubin <15 mg/dL and the 10 patients with bilirubin >15 mg/dL. Biliary drainage was required in 6 (67%) patients in the group with low bilirubin levels vs. 1(10%) in the other group (P=0.02). The mean bilirubin level in the jaundiced group was 22.1±3.9 vs. 4.7±4.3 (P<0.001) in the other group. There were no differences in the postoperative outcome between both groups.

Conclusion

Resection and survival rates have increased recently but still carries the risk of significant morbidity and mortality. Major hepatectomies in selected patients without percutaneous biliary drainage are safe.     

The Currarino triad: the variable expression

Background

The Currarino triad is a relatively unknown hereditary disorder linked to the 7q36 region and characterized by an anorectal malformation, sacrococcygeal defect, and a presacral mass.

Purpose

The aim of the study was to report the highly variable expression in patients with the Currarino triad and provide a guideline for the clinician if the Currarino triad is suspected.

Methods

We examined the symptoms and associated anomalies in 5 families with the Currarino triad by retrospective chart review.

Results

Fifteen patients had Currarino-associated anomalies. This included anorectal malformation in 9, a presacral mass in 9, and a sacral bone defect in 15. Tethered cord was present in 4 patients. There were 12 symptomatic patients. Constipation was diagnosed in all of them. Other symptoms included recurrent urinary tract infections caused by bladder dysfunction in 5, abnormal gait in 1, and another patient who initially presented with meningitis. Two carriers of the genetic defect had no symptoms or anomalies.

Conclusions

The phenotypical expression of the gene mutations causing the Currarino triad can vary from asymptomatic to patients presenting with the complete triad. Presence of a crescent-shaped defect of the sacral bone may be used as initial screening method. As the penetration of the genetic defect is variable, DNA screening is the only method to fully exclude the triad.     

Large fetal congenital cystic adenomatoid malformations: growth trends and patient survival

Purpose

The prognosis for fetuses with large congenital cystic adenomatoid malformations (CCAMs) remains uncertain. This study examined the natural history of large fetal CCAMs managed expectantly at a major referral center.

Methods

A 5-year retrospective review was conducted on fetuses diagnosed with a thoracic lesion (n = 59). Large CCAMs were identified on prenatal imaging and followed longitudinally. Perinatal outcomes were assessed.

Results

Twelve (20.3%) fetuses had large CCAMs in the absence of other congenital anomalies. Peak CCAM size occurred at 25.3 ± 3.6 weeks' gestation. Serial magnetic resonance volumetry demonstrated a trend toward decreasing CCAM mass volume relative to thoracic cavity volume over time. Overall, 6 patients, including 3 with signs of early hydrops, showed a marked regression of their lesions relative to estimated fetal weight. Five fetuses required an emergent intervention postnatally, including extracorporeal membrane oxygenation support (n = 1), cyst aspiration (n = 1), and lung resection (n = 5). Overall survival was 75%, with severe hydrops before 30 weeks seen in all 3 deaths.

Conclusion

Large fetal CCAMs tend to peak in size at 25 weeks' gestation and are characterized by in utero diminution relative to overall fetal growth. The prognosis for most fetuses with large CCAMs remains quite favorable under careful perinatal management.     

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.     

Surgical experimental jejunoileal atresia in rat embryo

Purpose

Jejunoileal atresia represents about 40% of intestinal atresia. After surgical repair, intestinal motility disorders are burdened with the postoperative outcome, and the origin of these troubles remains unclear. To specify the physiopathologic feature of jejunoileal atresia, we developed an experimental surgical model in fetal rat.

Methods

Time-dated pregnant rats were operated on at 18 days of gestational age. Hysterotomy was performed, followed by fetal wall incision. The exteriorization of the bowel loop was obtained by saline injection; the intestine was ligated and returned to the abdominal cavity before incisions were closed. Fetal intestine was excised at day 21, after cesarean delivery.

Results

Twenty-one pregnant rats underwent operation with 90% maternal survival rate. Among the 56 fetuses successfully operated on, 49 survived (87%). In fetuses with atresia, the mean birth weight (4.5 ± 0.6 g) and the mean intestinal length (12.8 ± 1.3 cm) were significantly lower compared to sham fetuses and controls.

Conclusion

The rat model offers the advantage of a low-expense mammal model with a wide panel of probes and reagents available for the study of the gut. This model of jejunoileal atresia could be used to study the consequences of prenatal intestinal obstruction on fetal gut.     

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.     

Psychosocial liaison-consultation for the children who have undergone repair of imperforate anus and Hirschsprung disease

Objective

The aim of this study was to investigate the psychological status of Japanese children with congenital anorectal malformation and their mothers to develop appropriate psychiatric interventions.

Method

The subjects comprised 50 children with congenital anorectal malformation aged 0 to 16 years and their mothers. The psychology of children aged 7 to 16 years was investigated by Kovacs' Children's Depression Inventory (CDI). The psychology of their mothers was assessed by Spielberger's State-Trait Anxiety Index (STAI) and Zung's Self-rating Depression Scale (SDS).

Results

Depression was more marked in the children aged 12 to 16 years than in those aged 7 to 11 years according to the CDI. The mothers of preschool children showed higher levels of anxiety and depression than those of school-aged children, according to the STAI and SDS. Significant correlations between the CDI score of the children and the STAI or SDS score of the mothers were observed only among children aged 7 to 11 years.

Conclusions

The frequency of depression and anxiety among children with congenital anorectal malformation and that among their mothers was associated with the age of the child. Long-term postoperative psychosocial support for the children and their mothers may be required, taking into account the age of the child.     

Long-term outcomes of individualized biofeedback training based on the underlying dysfunction for patients with imperforate anus

Background

The aim of this study was to design an individualized biofeedback program based on the underlying dysfunctions and to assess the short-term and long-term clinical and quality-of-life outcomes for patients with imperforate anus.

Methods

Thirty-one patients were treated using an individualized biofeedback program according to their different dysfunctions after having completed the assessment of the anorectal function. Many special biofeedback training methods that consist of strengthening the perianal muscles biofeedback, sensory discrimination biofeedback, synchronizing external sphincter contraction biofeedback, and improving defecation dynamic biofeedback were selected to make up the individualized biofeedback training program. The clinical scores and quality-of-life scores were assessed in the short-term and long-term follow-up.

Results

The clinical scores and quality-of-life scores of patients before training, after biofeedback training, at short-term follow-up, and at long-term follow-up were 3.2 ± 1.1 and 8.7 ± 1.1, 5.2 ± 0.6 and 11.0 ± 0.8, 5.1 ± 0.6 and 10.8 ± 0.9, and 4.6 ± 0.7 and 10.1 ± 0.7, respectively. After biofeedback training, the strength of the perianal muscles were increased significantly, the abnormal rectal threshold sensation and defecation dynamic reverted to normal in all patients, and 82% patients who have no external anal sphincter reflex acquired the new reflex. In the short-term follow-up, 12 (57%) patients maintained the clinical outcome, and only 9 (43%) patients have regressions slightly. At long-term follow-up, 7 (33%) patients maintained the clinical outcome very well, and 14 (67%) patients had regressed. Although the clinical and quality-of-life scores have decreased slightly at follow-up, they were still significantly increased compared with those before biofeedback training.

Conclusions

The individualized biofeedback is more suitable for improvement of the clinical outcome and the quality of life, and maintained a good clinical outcome and quality of life on the short-term and long-term follow-ups.     

Deficient motor innervation of the sphincter mechanism in fetal rats with anorectal malformation: a quantitative study by fluorogold retrograde tracing

Background/purpose: Deficiency of motoneuron innervation to the sphincter mechanism has been described in patients with anorectal malformation. Whether this event is primary or secondary remains unclear.Methods: The authors quantified the motoneuron innervation of the sphincter mechanism by Fluorogold (FG) retrograde tracing experiment in fetal rats with anorectal malformation. Anorectal malformation was induced in rat fetuses by ethylenethiourea (ETU). Serial longitudinal sections encompassing the whole width of lumbosacral spinal cord were examined. The number of FG-labelled motoneurons were scored and compared between male fetuses with or without malformation in the ETU-fed group and normal controls.Results: The number of FG-labelled motoneurons in the fetuses without defect, with imperforate anus (IA), with neural tube anomalies (NTA), with combined IA and NTA, and normal controls were determined to be (mean ± SEM) 109.13 ± 37.88, 55.05 ± 25.85, 48.20 ± 30.34, 54.43 ± 28.55, and 135.22 ± 28.78, respectively. FG-labelled motoneurons in the fetuses with IA, NTA, and combined IA and NTA are significantly fewer than that in fetuses without defects (P < .05) and in normal controls (P < .005).Conclusions: These findings suggest that defective motoneuron innervation to the sphincter mechanism is a primary anomaly that coexists with the alimentary tract anomaly in anorectal malformation during fetal development. The intrinsic neural deficiency is an important factor likely to contribute to poor postoperative anorectal function despite surgical correction of anorectal malformation.     

Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program

Background

The purpose of this study was to examine the outcomes of checklist-driven preoperative briefings and postoperative debriefings during the Veterans Health Administration (VHA) medical team training program.

Methods

A briefing score (1, never started; 2, started then discontinued; 3, maintained on original targeted cases; 4, expanded to other services; 5, briefing all cases, all services) was established at 10.1 ± .3 months after introduction of the checklist. Outcomes included antibiotic and deep venous thrombosis prophylaxis compliance rates before and after use of the checklist.

Results

Antibiotic (97.0% ± .1% vs 92.1% ± 1.5%; P = .01) and deep venous thrombosis (95.7% ± .8% vs 85.1% ± 4.6%; P = .05) prophylaxis compliance rates were higher after initiation of a surgical checklist.

Conclusions

Checklist-driven preoperative briefings and postoperative debriefings are associated with improvements in patient safety for surgical patients.