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Campos MAG, de Sousa PMB, Lages JS, Silva GEB, Santos RF. Postrenal acute kidney injury. J Am Coll Emerg Physicians Open 2024; 5:e13139. [PMID: 38883692 PMCID: PMC11177016 DOI: 10.1002/emp2.13139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 02/19/2024] [Indexed: 06/18/2024] Open
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Danziger G, Xu TO, Russell TL, Tiusaba L, Yun J, Levitt MA, Badillo A. Colonic Resection in an 8-Year-Old Girl with Intractable Functional Constipation and Diffuse Colonic Dysmotility and Failed Antegrade Flushes. European J Pediatr Surg Rep 2024; 12:e23-e25. [PMID: 38298568 PMCID: PMC10830246 DOI: 10.1055/a-2212-0411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/21/2023] [Indexed: 02/02/2024] Open
Abstract
Optimal surgical management of patients with intractable constipation and diffuse colonic motility is not well defined. We present a patient with such a history, who ultimately achieved successful surgical management of constipation through a stepwise approach. An 8-year-old female presents with longstanding constipation and diffuse colonic dysmotility demonstrated with colonic manometry. She initially underwent sigmoid resection and cecostomy which failed and required diverting ileostomy. We initially proceeded with an extended resection, colonic derotation (Deloyers procedure), and neo-appendicostomy (neo-Malone) which resulted in successful spontaneous stooling for 1 year. Her constipation recurred and she subsequently underwent completion colectomy with ileorectal anastomosis given that she previously demonstrated ability to stool independently. Six months from surgery the patient continues to stool daily with assistance of fiber and loperamide. This case highlights a stepwise surgical approach to managing constipation due to diffuse colonic dysmotility and demonstrates that diffuse dysmotility may benefit from an upfront subtotal resection; however, it is crucial to assess a patient's ability to empty their rectum prior.
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Affiliation(s)
- Gabriella Danziger
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Thomas O. Xu
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Teresa Lynn Russell
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Laura Tiusaba
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Jennie Yun
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Marc A. Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Andrea Badillo
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
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Alsaawy SM, Gauci CM, Khalessi A, Phan-Thien KC. Robotic ultra-low anterior resection for idiopathic megarectum. ANZ J Surg 2023; 93:2241-2242. [PMID: 37095589 DOI: 10.1111/ans.18371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/23/2023] [Accepted: 02/25/2023] [Indexed: 04/26/2023]
Affiliation(s)
- Saad Mohammed Alsaawy
- Department Colorectal Surgery, St George Hospital, Sydney, New South Wales, Australia
- Department of Surgery, College of Medicine, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
- St George & Sutherland Campus, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Chahaya Marc Gauci
- Department Colorectal Surgery, St George Hospital, Sydney, New South Wales, Australia
- St George & Sutherland Campus, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Amirala Khalessi
- Department of Surgery, Hurstville Private Hospital, Sydney, New South Wales, Australia
| | - Kim-Chi Phan-Thien
- Department Colorectal Surgery, St George Hospital, Sydney, New South Wales, Australia
- St George & Sutherland Campus, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, New South Wales, Australia
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Wu K, Little RD, Long A, Khera A, Kamm MA, Basnayake C. Clinical features and outcomes of adult idiopathic megarectum. Eur J Gastroenterol Hepatol 2023; 35:550-552. [PMID: 36966769 DOI: 10.1097/meg.0000000000002545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
OBJECTIVE Idiopathic megarectum is characterized by abnormal, pronounced rectal dilatation in the absence of identifiable organic pathology. Idiopathic megarectum is uncommon and under-recognized. This study aims to describe the clinical features and management of idiopathic megarectum. METHODS A retrospective review was undertaken on patients diagnosed with idiopathic megarectum with or without idiopathic megacolon over a 14-year period until 2021. Patients were identified from the hospital's International Classification of Diseases codes, and pre-existing clinic patient databases. Patient demographics, disease characteristics, healthcare utilization and treatment history data were collected. RESULTS Eight patients with idiopathic megarectum were identified; half of the patients were female, with the median age of symptom onset being 14 years (interquartile range [IQR] 9-24). The median rectal diameter measured was 11.5 cm (IQR 9.4-12.1). The most common presenting symptom was constipation, bloating and faecal incontinence. All patients required prior sustained periods of regular phosphate enemas and 88% were using ongoing oral aperients. Concomitant anxiety and or depression were found in 63% of patients and 25% were diagnosed with an intellectual disability. Healthcare utilization was high with a median of three emergency department presentations or ward admissions related to idiopathic megarectum per patient over the follow-up period; 38% of patients required surgical intervention during the period of follow-up. CONCLUSION Idiopathic megarectum is uncommon and associated with significant physical and psychiatric morbidity and high healthcare utilization.
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Affiliation(s)
- Kyle Wu
- St Vincent's Hospital Melbourne, Melbourne, Australia
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Potor M, Tuech JJ, Bridoux V. Surgical technique of vertical reduction rectoplasty for idiopathic megarectum - A video vignette. Colorectal Dis 2023; 25:341-342. [PMID: 36059086 DOI: 10.1111/codi.16325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/01/2022] [Accepted: 08/08/2022] [Indexed: 02/08/2023]
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Beji H, Najib F, Zaiem A, Guelbi M, Rebai W, Kacem M. Idiopathic megabowel causing acute bowel obstruction: A case report. Ann Med Surg (Lond) 2022; 77:103665. [PMID: 35638050 PMCID: PMC9142543 DOI: 10.1016/j.amsu.2022.103665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Hazem Beji
- Department of General Surgery A, Hospital La Rabta, Tunis, Tunisia
- University Tunis El Manar, Faculty of Medicine of Tunis, Tunisia
- Corresponding author. 52 - Street of roses - 8050 Hammamet – Tunisia, University of Tunis El Manar, Faculty of Medicine of Tunis, Department of general surgery A Hospital La Rabta, Tunis, Tunisia.
| | - Fatma Najib
- Department of General Surgery A, Hospital La Rabta, Tunis, Tunisia
- University Tunis El Manar, Faculty of Medicine of Tunis, Tunisia
| | - Asma Zaiem
- Department of General Surgery A, Hospital La Rabta, Tunis, Tunisia
- University Tunis El Manar, Faculty of Medicine of Tunis, Tunisia
| | - Mohamed Guelbi
- Department of General Surgery A, Hospital La Rabta, Tunis, Tunisia
- University Tunis El Manar, Faculty of Medicine of Tunis, Tunisia
| | - Wael Rebai
- Department of General Surgery A, Hospital La Rabta, Tunis, Tunisia
- University Tunis El Manar, Faculty of Medicine of Tunis, Tunisia
| | - Montassar Kacem
- Department of General Surgery A, Hospital La Rabta, Tunis, Tunisia
- University Tunis El Manar, Faculty of Medicine of Tunis, Tunisia
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Disorders of anorectal motility: Functional defecation disorders and fecal incontinence. J Visc Surg 2022; 159:S40-S50. [DOI: 10.1016/j.jviscsurg.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Constantin A, Achim F, Spinu D, Socea B, Predescu D. Idiopathic Megacolon-Short Review. Diagnostics (Basel) 2021; 11:diagnostics11112112. [PMID: 34829459 PMCID: PMC8622596 DOI: 10.3390/diagnostics11112112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/02/2021] [Accepted: 11/08/2021] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Idiopathic megacolon (IM) is a rare condition with a more or less known etiology, which involves management challenges, especially therapeutic, and both gastroenterology and surgery services. With insufficiently drawn out protocols, but with occasionally formidable complications, the condition management can be difficult for any general surgery team, either as a failure of drug therapy (in the context of a known case, initially managed by a gastroenterologist) or as a surgical emergency (in which the diagnostic surprise leads additional difficulties to the tactical decision), when the speed imposed by the severity of the case can lead to inadequate strategies, with possibly critical consequences. METHOD With such a motivation, and having available experience limited by the small number of cases (described by all medical teams concerned with this pathology), the revision of the literature with the update of management landmarks from the surgical perspective of the pathology appears as justified by this article. RESULTS If the diagnosis of megacolon is made relatively easily by imaging the colorectal dilation (which is associated with initial and/or consecutive clinical aspects), the establishing of the diagnosis of idiopathic megacolon is based in practice almost exclusively on a principle of exclusion, and after evaluating the absence of some known causes that can lead to the occurrence of these anatomic and clinical changes, mimetically, clinically, and paraclinically, with IM (intramural aganglionosis, distal obstructions, intoxications, etc.). If the etiopathogenic theories, based on an increase in the performance of the arsenal of investigations of the disease, have registered a continuous improvement and an increase of objectivity, unfortunately, the curative surgical treatment options still revolve around the same resection techniques. Moreover, the possibility of developing a form of etiopathogenic treatment seems as remote as ever.
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Affiliation(s)
- Adrian Constantin
- General and Esophageal Clinic, Sf. Maria Clinical Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, 011172 Bucharest, Romania; (A.C.); (F.A.)
| | - Florin Achim
- General and Esophageal Clinic, Sf. Maria Clinical Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, 011172 Bucharest, Romania; (A.C.); (F.A.)
| | - Dan Spinu
- Department of Urology, Central Military Emergency University Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, 010825 Bucharest, Romania;
| | - Bogdan Socea
- Department of Surgery, Sf. Pantelimon Emergency Clinical Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, 021659 Bucharest, Romania;
| | - Dragos Predescu
- General and Esophageal Clinic, Sf. Maria Clinical Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, 011172 Bucharest, Romania; (A.C.); (F.A.)
- Correspondence:
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Villanueva MEP, Lopez MPJ, Onglao MAS. Idiopathic megacolon and megarectum in an adult treated with laparoscopic modified Duhamel procedure. BMJ Case Rep 2021; 14:e240209. [PMID: 34187804 PMCID: PMC8245436 DOI: 10.1136/bcr-2020-240209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2021] [Indexed: 11/04/2022] Open
Abstract
Idiopathic megacolon (IMC) and idiopathic megarectum (IMR) describe an abnormality of the colon or rectum, characterised by a permanent dilatation of the bowel diameter in the absence of an identifiable cause. We present a 23-year-old woman with chronic constipation and excessive straining during defecation who presented at the emergency department in partial gut obstruction with a palpable fecaloma. Manual faecal disimpaction and a sigmoid loop colostomy was initially done. A full thickness rectal biopsy was positive for ganglion cells. Further workup led to the diagnosis of chronic IMC and IMR. The patient underwent laparoscopic modified Duhamel procedure, with an uneventful postoperative course.
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Affiliation(s)
| | - Marc Paul Jose Lopez
- Division of Colorectal Surgery, Department of Surgery, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Mark Augustine S Onglao
- Division of Colorectal Surgery, Department of Surgery, University of the Philippines-Philippine General Hospital, Manila, Philippines
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Martin JE, English W, Kendall JV, Sheshappanavar V, Peroos S, West M, Cleeve S, Knowles C. Megarectum: systematic histopathological evaluation of 35 patients and new common pathways in chronic rectal dilatation. J Clin Pathol 2021; 75:jclinpath-2021-207413. [PMID: 34035078 PMCID: PMC9510396 DOI: 10.1136/jclinpath-2021-207413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/29/2021] [Accepted: 04/24/2021] [Indexed: 11/15/2022]
Abstract
AIMS Megarectum is well described in the surgical literature but few contemporary pathological studies have been undertaken. There is uncertainty whether 'idiopathic' megarectum is a primary neuromuscular disorder or whether chronic dilatation leads to previously reported and unreported pathological changes. We sought to answer this question. METHODS Systematic histopathological evaluation (in accord with international guidance) of 35 consecutive patients undergoing rectal excision surgery for megarectum (primary: n=24) or megarectum following surgical correction of anorectal malformation (secondary: n=11) in a UK university hospital with adult/paediatric surgical and gastrointestinal neuropathology expertise. RESULTS We confirmed some previously reported observations, notably hypertrophy of the muscularis propria (27 of 35, 77.1% of patients) and extensive fibrosis (30 of 35, 85.7% of patients). We also observed unique and previously unreported features including elastosis (19 of 33, 57.6%) and the presence of polyglucosan bodies (15 of 32, 46.9% of patients). In contrast to previous literature, few patients had any strong evidence of specific forms of visceral neuropathy (5 of 35, including 3 plexus duplications) or myopathy (6 of 35, including 3 muscle duplications). All major pathological findings were common to both primary and secondary forms of the disease, implying that these may be a response to chronic rectal distension rather than of primary aetiology. CONCLUSIONS In the largest case series reported to date, we challenge the current perception of idiopathic megarectum as a primary neuromuscular disease and propose a cellular pathway model for the features present. The severe morphological changes account for some of the irreversibility of the condition and reinforce the need to prevent ongoing rectal distension when first identified.
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Affiliation(s)
- Joanne E Martin
- Department of Cellular Pathology, Blizard Institute, Queen Mary University of London, London, UK
- Department of Cellular Pathology, Barts Health NHS Trust, London, UK
| | - William English
- Department of Colorectal Surgery, Barts Health NHS Trust, London, UK
- Department of Colorectal Surgery, Blizard Institute, Queen Mary University of London, London, UK
| | - John V Kendall
- Department of Cellular Pathology, Barts Health NHS Trust, London, UK
| | | | - Sara Peroos
- Department of Cellular Pathology, Blizard Institute, Queen Mary University of London, London, UK
| | - Milly West
- Department of Cellular Pathology, Blizard Institute, Queen Mary University of London, London, UK
| | - Stewart Cleeve
- Department of Paediatric Surgery, Barts Health NHS Trust, London, UK
| | - Charles Knowles
- Department of Colorectal Surgery, Blizard Institute, Queen Mary University of London, London, UK
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Mahmood F, Ajayi O, Ahmed M, Akingboye AA. Unusual case of cholecystocolonic fistula secondary to megabowel. BMJ Case Rep 2020; 13:13/12/e237836. [PMID: 33370988 PMCID: PMC7757503 DOI: 10.1136/bcr-2020-237836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Cholecystocolonic fistula with associated idiopathic megabowel (megacolon and megarectum) is a rare presentation as acute large bowel obstruction. Frequently presenting with chronic constipation, acute bowel obstruction is rarely encountered in the presence of concomitant cholecystocolonic fistula. This presents diagnostic and management difficulties with no consensus on appropriate surgical approach. This case highlights the outcomes following emergency total colectomy and subtotal cholecystectomy as a single-stage procedure for a 68-year-old man presenting with cholecystocolonic fistula secondary to idiopathic megabowel as acute large bowel obstruction.
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Affiliation(s)
- Fahad Mahmood
- General Surgery, Dudley Group NHS Foundation Trust, Dudley, UK
| | | | - Marriam Ahmed
- General Surgery, Dudley Group NHS Foundation Trust, Dudley, UK
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12
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Treatment of megarectum in anorectal malformation with emphasis on preventive aspects: 17 years experience. Pediatr Surg Int 2020; 36:933-940. [PMID: 32488402 DOI: 10.1007/s00383-020-04687-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Megarectum in anorectal malformation (ARM) causes severe morbidity. To compare conservative management (CM) of megarectum with excision (EX), to propose a new classification and to analyse management strategies. METHODS Between 2000-2016, we reviewed all ARM to identify megarectum, defined by radiological recto-pelvic ratio > 0.61. A new classification was proposed: primary megarectum (PM) pre-anorectoplasty, and secondary megarectum (SM) post-anorectoplasty, with sub-types. Complications and Krickenbeck bowel function were compared between CM and EX. RESULTS Of 124 ARM, 22 (18%) developed megarectum; of these, 7 underwent EX. There was no difference in functional outcomes when comparing CM vs EX-voluntary bowel movement (both 86%), soiling (40% vs. 57%) and constipation (both 86%). However, EX was associated with major complications (43%) and the requirement for invasive bowel management, compared to CM (85% vs. 27%, P = 0.02). 6/7 EX needed antegrade continence enema (ACE), one of these has a permanent ileostomy. With strategic changes, incidence of megarectum reduced from 20/77 (26%) to 2/47 (4%) after 2013 (P = 0.002). CONCLUSION EX did not confer benefit in the functional outcome but carried a high risk of complications, often needing ACE or stoma. By adhering to strategies discussed, we reduced the incidence of megarectum and have avoided EX since 2013.
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Ribas Y, Bargalló J, Lamas S, Aguilar F. Idiopathic Sigmoid Megacolon with Fecal Impaction and Giant Calcified Fecaloma. Am Surg 2020. [DOI: 10.1177/000313481307900219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Yolanda Ribas
- Department of Surgery Consorci Sanitari de Terrassa Terrassa, Spain
| | - Josep Bargalló
- Department of Surgery Consorci Sanitari de Terrassa Terrassa, Spain
| | - Susana Lamas
- Department of Surgery Consorci Sanitari de Terrassa Terrassa, Spain
| | - Francesc Aguilar
- Department of Surgery Consorci Sanitari de Terrassa Terrassa, Spain
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Wang L, Zheng H, Tian Y, Mou J, Zhang L, Liu B, Tong W. Laparoscopic-assisted colectomy with Duhamel procedure for idiopathic megacolon in adults: a retrospective study. ANZ J Surg 2020; 90:2285-2289. [PMID: 32267630 DOI: 10.1111/ans.15868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/26/2020] [Accepted: 03/01/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Idiopathic megacolon (IMC) is an uncommon disease in adults. To date, only a few laparoscopic experiences and functional outcomes of IMC have been reported. This study was to retrospectively analyse our 12 year surgical experience and functional outcomes in adult patients with IMC. METHODS A 12-year retrospective study from October 2006 to November 2018 was performed for patients with IMC who underwent surgical interventions. Patients who underwent laparoscopic-assisted colectomy and Duhamel procedure with ileorectal or colorectal anastomosis were collected. Clinical data of surgery and functional outcomes were analysed. RESULTS A total of 13 patients who underwent surgical interventions were included in the study. Seven patients underwent laparoscopic total colectomy with ileorectal anastomosis (Duhamel procedure), one patient underwent laparoscopic total colectomy with end ileostomy because of acute intestinal obstruction, while five other patients underwent laparoscopic segmental colectomy with colorectal anastomosis (Duhamel procedure). The mean operative time was 181.6 min (range 150-246). The mean estimated blood loss was 75.6 ml (range 40-200). The mean postoperative hospital stay was 8.2 days (range 6-13). There was no conversion to an open procedure and no surgical mortality. Postoperative diarrhoea was the most prominent complaint during the early period after total colectomy. All patients showed adaptation to the defaecation frequency 3-6 months postoperatively, and had a good quality of life in long-term follow-up. CONCLUSION Laparoscopic-assisted colectomy with Duhamel procedure is a safe and efficient technique for IMC in adults. The scope of colon resection and the type of anastomosis should be individually selected.
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Affiliation(s)
- Li Wang
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Huichao Zheng
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Yue Tian
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Jianghong Mou
- Department of Pathology, Daping Hospital, Army Medical University, Chongqing, China
| | - Lianyang Zhang
- Department of Trauma Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Baohua Liu
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - WeiDong Tong
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, China
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Surgical treatment of idiopathic megarectum in constipated children. J Pediatr Surg 2019; 54:1379-1383. [PMID: 30578018 DOI: 10.1016/j.jpedsurg.2018.10.103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 09/01/2018] [Accepted: 10/31/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Chronic constipation in children is associated with primary megarectum. This study investigated outcomes of surgical treatment of idiopathic megarectum in children. METHODS This retrospective comparative study included 52 children with idiopathic megarectum (mean age, 9.4 ± 1.7 years) treated from 2007 to 2016. Patients were divided into 2 groups. Group 1 included 23 patients who underwent a Soave pull-through operation. Group 2 included 29 children who underwent laparoscopic low anterior resection with endorectal stapled anastomosis using laparoscopic ultrasound guidance. All patients had clinical and laboratory evaluations with anorectal manometry, colonoscopy and contrast enema studies. RESULTS Six patients (26.1%) in Group 1 and one (3.5%) in Group 2 experienced anastomosis leakage requiring colostomy (χ2 = 3.867, P = 0.049). In long-term follow-up, 3 children (13.1%) in Group 1 and 2 (6.9%) in Group 2 had ongoing constipation; this difference was not significant. Frequent loose stools with soiling were significantly more common in Group 1 (14 patients; 60.9%) than in Group 2 (4 patients; 13.8%) (χ2 = 10.566, P = 0.001). CONCLUSIONS Our experience shows that laparoscopic video-assisted low anterior resection of the colon with endorectal stapled anastomosis under laparoscopic ultrasound guidance to determine the level of colon resection is the better operation then Soave for children with idiopathic megarectum and chronic constipation. This approach provides good functional results and reduces complications. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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16
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Megabowel and Giant Fecaloma: a Surgical Condition? J Gastrointest Surg 2019; 23:1269-1270. [PMID: 30187321 DOI: 10.1007/s11605-018-3919-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/06/2018] [Indexed: 01/31/2023]
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17
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Cheng LS, Goldstein AM. Surgical Management of Idiopathic Constipation in Pediatric Patients. Clin Colon Rectal Surg 2018; 31:89-98. [PMID: 29487491 DOI: 10.1055/s-0037-1609023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Constipation is a common childhood problem, but an anatomic or physiologic cause is identified in fewer than 5% of children. By definition, idiopathic constipation is a diagnosis of exclusion. Careful clinical evaluation and thoughtful use of imaging and other testing can help exclude specific causes of constipation and guide therapy. Medical management with laxatives is effective for the majority of constipated children. For those patients unresponsive to medications, however, several surgical options can be employed, including anal procedures, antegrade colonic enemas, colorectal resection, and intestinal diversion. Judicious use of these procedures in properly selected patients and based on appropriate preoperative testing can lead to excellent outcomes. This review summarizes the surgical options available for managing refractory constipation in children and provides guidance on how to choose the best procedure for a given patient.
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Affiliation(s)
- Lily S Cheng
- Department of General Surgery, University of California San Francisco, San Francisco, California
| | - Allan M Goldstein
- Department of Surgery, Harvard Medical School, Boston, Massachusetts.,Department of Pediatric Surgery, Massachusetts General Hospital, Boston, Massachusetts.,MassGeneral Hospital for Children, Boston, Massachusetts
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Cuda T, Gunnarsson R, de Costa A. Symptoms and diagnostic criteria of acquired Megacolon - a systematic literature review. BMC Gastroenterol 2018; 18:25. [PMID: 29385992 PMCID: PMC5793364 DOI: 10.1186/s12876-018-0753-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 01/23/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Acquired Megacolon (AMC) is a condition involving persistent dilatation and lengthening of the colon in the absence of organic disease. Diagnosis depends on subjective radiological, endoscopic or surgical findings in the context of a suggestive clinical presentation. This review sets out to investigate diagnostic criteria of AMC. METHODS The literature was searched using the databases - PubMed, Medline via OvidSP, ClinicalKey, Informit and the Cochrane Library. Primary studies, published in English, with more than three patients were critically appraised based on study design, methodology and sample size. Exclusion criteria were studies with the following features: post-operative; megarectum-predominant; paediatric; organic megacolon; non-human; and failure to exclude organic causes. RESULTS A review of 23 articles found constipation, abdominal pain, distension and gas distress were predominant symptoms. All ages and both sexes were affected, however, symptoms varied with age. Changes in anorectal manometry, histology and colonic transit are consistently reported. Studies involved varying patient numbers, demographics and data acquisition methods. CONCLUSIONS Outcome data investigating the diagnosis of AMC must be interpreted in light of the limitations of the low-level evidence studies published to date. Proposed diagnostic criteria include: (1) the exclusion of organic disease; (2) a radiological sigmoid diameter of ~ 10 cm; (3) and constipation, distension, abdominal pain and/or gas distress. A proportion of patients with AMC may be currently misdiagnosed as having functional gastrointestinal disorders. Our conclusions are inevitably tentative, but will hopefully stimulate further research on this enigmatic condition.
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Affiliation(s)
- Tahleesa Cuda
- Cairns Clinical School, College of Medicine and Dentistry, James Cook University, 451 Draper Street, Cairns, QLD, 4870, Australia.
- Department of Surgery, Cairns Private Hospital, Cairns, QLD, Australia.
| | - Ronny Gunnarsson
- Cairns Clinical School, College of Medicine and Dentistry, James Cook University, 451 Draper Street, Cairns, QLD, 4870, Australia
- Research and Development Unit, Primary Health Care and Dental Care, Southern Älvsborg County, Cairns, Region Västra Götaland, Sweden
- Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Cairns, Sweden
| | - Alan de Costa
- Cairns Clinical School, College of Medicine and Dentistry, James Cook University, 451 Draper Street, Cairns, QLD, 4870, Australia
- Department of Surgery, Cairns Private Hospital, Cairns, QLD, Australia
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Glasser JG, Nottingham JM, Durkin M, Haney ME, Christensen S, Stroman R, Hammett T. Case series with literature review: Surgical approach to megarectum and/or megasigmoid in children with unremitting constipation. Ann Med Surg (Lond) 2017; 26:24-29. [PMID: 29326815 PMCID: PMC5760313 DOI: 10.1016/j.amsu.2017.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 12/13/2017] [Accepted: 12/21/2017] [Indexed: 11/26/2022] Open
Abstract
Background The role of surgery in treating children with functional constipation (FC) is controversial, because of the efficacy of bowel management programs. This case series is comprised of failures: 43 children, spanning 25 years' practice, who had megarectosigmoid (MRS) and unremitting constipation. Purpose To determine whether these children were helped by surgery, and to contribute to formulating a standard of care for children with megarectum (MR) and/or redundancy of the sigmoid colon (MS) who fail medical management. Method We describe our selection criteria and the procedures we utilized – mucosal proctectomy and endorectal pull-through (MP) or sigmoidectomy (SE) with colorectal anastomosis at the peritoneal reflection. The internet (social media) allowed us to contact most of these patients and obtain extremely long follow-up data. Results 30/43 patients had MP and 13/43 had SE. Follow-up was obtained in 83% MP and 70% SE patients. 60% of MP and 78% of SE patients reported regular evacuations and no soiling. 20% MP patients had occasional urgency or soiling or episodic constipation. 12% MP and 22% SE patients required antegrade continence enemas (ACE) or scheduled cathartics and/or stool softeners. 4% MP had no appreciable benefit, frequent loose stools and soiling, presumably from encopresis. Conclusion MR is characterized by diminished sensation, poor compliance and defective contractility. Patients with MR do better with MP, which effectively removes the entire rectum versus SE, where normal caliber colon is anastomosed to MR at the peritoneal reflection; furthermore, MP reliably preserves continence; whereas total proctectomy (trans-anal or trans-abdominal) may cause incontinence. Intestinal peristalsis stagnates in a dilated segment. Megarectosigmoid (MRS) may present during infancy or later in life. It may occur in association with anorectal malformations or as an isolated abnormality. Unlike dilatation secondary to outlet dysfunction, MRS persists even after a diverting colostomy. MRS does not respond to bowel management programs. Intestinal peristalsis improves following extirpation of MRS.
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Affiliation(s)
- James G Glasser
- Department of Surgery and Pediatrics, University of South Alabama, School of Medicine, Attending Surgeon, Children's and Women's Hospital, Mobile, AL, 36604, USA
| | - James M Nottingham
- University of South Carolina School of Medicine, 2 Richland Medical Park, Suite 300, Columbia, SC, 29203, USA
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Mercer-Jones M, Grossi U, Pares D, Vollebregt PF, Mason J, Knowles CH. Surgery for constipation: systematic review and practice recommendations: Results III: Rectal wall excisional procedures (Rectal Excision). Colorectal Dis 2017; 19 Suppl 3:49-72. [PMID: 28960928 DOI: 10.1111/codi.13772] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM To assess the outcomes of rectal excisional procedures in adults with chronic constipation. METHOD Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements with a summative Oxford Centre for Evidence-Based Medicine (2009) level. RESULTS Forty-seven studies were identified, providing data on outcomes in 8340 patients. Average length of procedures was 44 min and length of stay (LOS) was 3 days. There was inadequate evidence to determine variations in procedural duration or LOS by type of procedure. Overall morbidity rate was 16.9% (0-61%), with lower rates observed after Contour Transtar procedure (8.9%). No mortality was reported after any procedures in a total of 5896 patients. Although inconsistently reported, good or satisfactory outcome occurred in 73-80% of patients; a reduction of 53-91% in Longo scoring system for obstructive defecation syndrome (ODS) occurred in about 68-76% of patients. The most common long-term adverse outcome is faecal urgency, typically occurring in up to 10% of patients. Recurrent prolapse occurred in 4.3% of patients. Patients with at least 3 ODS symptoms together with a rectocoele with or without an intussusception, who have failed conservative management, may benefit from a rectal excisional procedure. CONCLUSION Rectal excisional procedures are safe with little major morbidity. It is not possible to advise which excisional technique is superior from the point of view of efficacy, peri-operative variables, or harms. Future study is required.
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Affiliation(s)
- M Mercer-Jones
- Queen Elizabeth Hospital, Gateshead NHS Trust, Gateshead, UK
| | - U Grossi
- National Bowel Research Centre, Blizard Institute, Queen Mary, University London, London, UK
| | - D Pares
- Hospital Germans Trías i Pujol, Barcelona, Spain
| | - P F Vollebregt
- National Bowel Research Centre, Blizard Institute, Queen Mary, University London, London, UK
| | - J Mason
- University of Warwick, Coventry, UK
| | - C H Knowles
- National Bowel Research Centre, Blizard Institute, Queen Mary, University London, London, UK
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- National Institute for Health Research: Chronic Constipation Treatment Pathway, London, UK
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- Affiliate section of the Association of Coloproctology of Great Britain and Ireland
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Knowles CH, Grossi U, Horrocks EJ, Pares D, Vollebregt PF, Chapman M, Brown SR, Mercer-Jones M, Williams AB, Hooper RJ, Stevens N, Mason J. Surgery for constipation: systematic review and clinical guidance: Paper 1: Introduction & Methods. Colorectal Dis 2017; 19 Suppl 3:5-16. [PMID: 28960925 DOI: 10.1111/codi.13774] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIM This manuscript provides the introduction and detailed methodology used in subsequent reviews to assess the outcomes of surgical interventions with the primary intent of treating chronic constipation in adults and to develop recommendations for practice. METHOD PRISMA guidance was adhered to throughout. A literature search was performed in public databases between January 1960 and February 2016. Studies that fulfilled strictly-defined PICOS (patients, interventions, controls, outcome, and study design) criteria were included. The process involved two groups of participants: (i): 'a clinical guidance group' of 18 UK experts (including junior support) who performed the systematic reviews and produced summary evidence statements (SES) based strictly on data synthesis in each review. The same group then produced prototype graded practice recommendations (GPRs) based on coalescence of SES and expert opinion; (ii): a European Consensus group of 18 ESCP (European Society of Coloproctology) nominated experts from nine European countries evaluated the appropriateness of each prototype GPR based on published RAND/UCLA methodology. RESULTS An overview of the search results is provided in this manuscript. A total of 156 studies from 307 full text articles (from 2551 initially screened records) were included, providing data on procedures characterized by: (i) colonic resection (n = 40); (ii) rectal suspension (n = 18); (iii) rectal wall excision (n = 44); (iv) rectovaginal septum reinforcement (n = 47); (v) sacral nerve stimulation (n = 7). The overall quality of evidence was poor with 113/156 (72.4%) studies providing only Oxford level IV evidence. The best evidence was extracted for rectal excisional procedures, where the majority of studies were Oxford level I or II. The five subsequent reviews provide a total of 99 SES (reflecting perioperative variables, efficacy, harms and prognostic variables) that contributed to 100 prototype GPRs covering patient selection, procedural considerations and patient counselling. The final manuscript details the 85/100 GPRs that were deemed appropriate by European Consensus (remaining 15 were all uncertain) and future research recommendations. CONCLUSION This manuscript and the following 6 papers suggest that the evidence base for surgical management of chronic constipation is currently poor although some expert consensus exists on best practice. Further studies are required to inform future commissioning of treatments and of research funding.
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Affiliation(s)
- C H Knowles
- National Bowel Research Centre, Blizard Institute, Queen Mary University London, London, UK
| | - U Grossi
- National Bowel Research Centre, Blizard Institute, Queen Mary University London, London, UK
| | - E J Horrocks
- National Bowel Research Centre, Blizard Institute, Queen Mary University London, London, UK
| | - D Pares
- Hospital Germans Trías i Pujol, Barcelona, Spain
| | - P F Vollebregt
- National Bowel Research Centre, Blizard Institute, Queen Mary University London, London, UK
| | - M Chapman
- Good Hope Hospital, Heart of England NHS Trust, Birmingham, UK
| | - S R Brown
- Sheffield Teaching Hospitals, Sheffield, UK
| | - M Mercer-Jones
- Queen Elizabeth Hospital, Gateshead NHS Trust, Gateshead, UK
| | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - R J Hooper
- Pragmatic Clinical Trials Unit, Blizard Institute, Queen Mary University of London, London, UK
| | - N Stevens
- Pragmatic Clinical Trials Unit, Blizard Institute, Queen Mary University of London, London, UK
| | - J Mason
- University of Warwick, Coventry, UK
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- National Institute for Health Research: Chronic Constipation Treatment Pathway, UK
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- Affiliate section of the Association of Coloproctology of Great Britain and Ireland, London, UK
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Tan YW, Borrelli O, Lindley K, Thapar N, Curry J. Duhamel operation for children with distal colonic dysmotility. Pediatr Surg Int 2017; 33:861-868. [PMID: 28616722 DOI: 10.1007/s00383-017-4108-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To report outcomes of children with constipation refractory to medical management and manometrically proven distal colonic dysmotility, managed with rectosigmoidectomy followed by Duhamel operation (Duhamel). METHODS Children who underwent a Duhamel from 2009 onwards for intractable constipation and left colonic dysmotility were retrospectively reviewed. The primary end point was resolution of constipation, and secondary end point was postoperative complications. Continuous data were median (range). RESULTS 11 patients (4 males) had Duhamel at 11 years (5-16) with constipation started from 2 years (1-8). Hirschsprung's disease was excluded. All Duhamels were performed with a covering ileostomy: 9 following a Hartmann procedure, one following a previously failed reversal of Hartmann, and one Duhamel performed with a pre-existing ileostomy. All ileostomies were subsequently closed. Median resection length was 22 cm (11-31). Length of stay was 8 days (5-23). Follow-up was 5 years (0.5-7). Age at final review was 15 years (10-18). Resolution of constipation occurred in nine patients (4 required antegrade continence enemas (ACE), 5 with laxative); two had persistent constipation and faecal incontinence despite ACE, ultimately requiring an ileostomy. Two postoperative small bowel obstructions required laparotomy. CONCLUSION Duhamel performed in children with manometrically proven distal colonic dysmotility yielded 82% resolution of refractory constipation; half of them subsequently needed ACE.
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Affiliation(s)
- Yew-Wei Tan
- Specialist Neonatal and Paediatric Surgery Department, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK.
| | - Osvaldo Borrelli
- Neurogastroenterology and Motility Unit, Department of Gastroenterology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Keith Lindley
- Neurogastroenterology and Motility Unit, Department of Gastroenterology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Nikhil Thapar
- Neurogastroenterology and Motility Unit, Department of Gastroenterology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Joe Curry
- Specialist Neonatal and Paediatric Surgery Department, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
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Fürst A. [Differential indications for ileoanal pouch anastomosis : Ulcerative colitis, familial adenomatous polyposis, synchronous colorectal cancer - Crohn's disease, constipation]. Chirurg 2017; 88:555-558. [PMID: 28405717 DOI: 10.1007/s00104-017-0421-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Ileoanal pouch anastomosis is the procedure of choice for patients with drug refractory ulcerative colitis, indeterminate colitis and familial adenomatous polyposis (FAP). In selected patient groups this procedure is a treatment option for patients with Crohn's disease, hereditary nonpolyposis colorectal cancer (HNPCC), synchronous colorectal cancer and for severe colorectal constipation refractory to conservative drug treatment. The pouch procedure provides the opportunity to avoid a permanent ileostomy. The majority of surgeons prefer the ileal J‑pouch as the construction is the easiest to perform and complications and dysfunction rates are low. Due to functional reasons most pouch surgeons favor a circular stapled ileoanal pouch anastomosis. The more radical proctocolectomy can produce sensory defects in the anal canal with subsequent soiling and incontinence. Studies have shown that even after proctocolectomy residual rectal mucosa was found in the anal canal. Therefore, the functionally important anorectal transitional zone should be preserved if possible. Ulcerative colitis can be "healed" with proctocolectomy; however, pouchitis can still occur in one third of the patients. Patients must be informed about the risk of pouchitis and a multidisciplinary monitoring and treatment strategy must be available. In Crohn's disease the ileoanal pouch survival rate of 80% in the long-term follow-up is surprisingly good despite an increased postoperative complication rate. The anal pouch anastomosis is the standard operation in patients with drug refractory ulcerative colitis, indeterminate colitis and FAP. Synchronous colorectal cancer, HNPCC and severe therapy refractive constipation represent rare indications for proctocolectomy where decisions must be made on an individual basis.
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Affiliation(s)
- A Fürst
- Klinik für Allgemein-, Viszeral-, Thoraxchirurgie, Adipositasmedizin, Caritas-Krankenhaus St. Josef, Landshuterstr. 65, 93052, Regensburg, Deutschland.
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Koppen IJN, Yacob D, Di Lorenzo C, Saps M, Benninga MA, Cooper JN, Minneci PC, Deans KJ, Bates DG, Thompson BP. Assessing colonic anatomy normal values based on air contrast enemas in children younger than 6 years. Pediatr Radiol 2017; 47:306-312. [PMID: 27896373 PMCID: PMC5316394 DOI: 10.1007/s00247-016-3746-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 09/22/2016] [Accepted: 10/31/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Contrast enemas with barium or water-soluble contrast agents are sometimes performed in children with severe intractable constipation to identify anatomical abnormalities. However there are no clear definitions for normal colonic size or abnormalities such as colonic dilation or sigmoid redundancy in children. OBJECTIVE To describe characteristics of colonic anatomy on air contrast enemas in children without constipation to provide normal values for colonic size ratios in children. MATERIALS AND METHODS We performed a retrospective chart review of children aged 0-5 years who had undergone air contrast enemas for intussusception. The primary outcome measures were the ratios of the diameters and lengths of predetermined colonic segments (lengths of rectosigmoid and descending colon; diameters of rectum, sigmoid, descending colon, transverse colon and ascending colon) in relation to the L2 vertebral body width. RESULTS We included 119 children (median age 2.0 years, range 0-5 years, 68% boys). Colonic segment length ratios did not change significantly with age, although the differences for the rectosigmoid/L2 ratio were borderline significant (P = 0.05). The ratios that involved the rectal and ascending colon diameters increased significantly with age, while diameter ratios involving the other colonic segments did not. Differences by gender and race were not significant. CONCLUSION These data can be used for reference purposes in young children undergoing contrast studies of the colon.
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Affiliation(s)
- Ilan J. N. Koppen
- Division of Pediatric Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, OH USA ,Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital/Academic Medical Center, H7-250, PO Box 22700, 1100DD Amsterdam, The Netherlands
| | - Desale Yacob
- Division of Pediatric Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, OH USA
| | - Carlo Di Lorenzo
- Division of Pediatric Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, OH USA
| | - Miguel Saps
- Division of Pediatric Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, OH USA
| | - Marc A. Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital/Academic Medical Center, H7-250, PO Box 22700, 1100DD Amsterdam, The Netherlands
| | - Jennifer N. Cooper
- Center for Surgical Outcomes Research, Research Institute Nationwide Children’s Hospital, Columbus, OH USA
| | - Peter C. Minneci
- Center for Surgical Outcomes Research, Research Institute Nationwide Children’s Hospital, Columbus, OH USA ,Division of Pediatric Surgery, Department of Surgery, Nationwide Children’s Hospital, Columbus, OH USA
| | - Katherine J. Deans
- Center for Surgical Outcomes Research, Research Institute Nationwide Children’s Hospital, Columbus, OH USA ,Division of Pediatric Surgery, Department of Surgery, Nationwide Children’s Hospital, Columbus, OH USA
| | - D. Gregory Bates
- Department of Radiology, Nationwide Children’ Hospital, Columbus, OH USA
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Abstract
BACKGROUND Diverticulosis and redundant colon are colonic conditions for which underlying pathophysiology, management and prevention are poorly understood. Historical papers suggest an inverse relationship between these two conditions. However, no further attempt has been made to validate this relationship. This study set out to assess the correlation between diverticulosis and colonic redundancy. METHODS Redundant colon, diverticulosis and patient demographics were recorded during colonoscopy. Multivariate binary logistic regression was performed with redundant colon as the dependent variable and age, gender and diverticulosis as independent variables. Nagelkerke R 2 and a receiver operator curve were calculated to assess goodness of fit and internally validate the multivariate model. RESULTS Redundant colon and diverticulosis were diagnosed in 31 and 113 patients, respectively. The probability of redundant colon was increased by female gender odds ratio (OR) 8.4 (95% CI 2.7-26, p = 0.00020) and increasing age OR 1.7 (95% CI 1.1-2.6, p = 0.017). Paradoxically, diverticulosis strongly reduced the probability of redundant colon with OR of 0.12 (95% CI 0.42-0.32, p = 0.000039). The Nagelkerke R 2 for the multivariate model was 0.29 and the area under the curve at ROC analysis was 0.81 (95% CI 0.73-0.90 p-value 3.1 × 10-8). CONCLUSIONS This study found an inverse correlation between redundant colon and diverticulosis, supporting the historical suggestion that the two conditions rarely occur concurrently. The underlying principle for this relationship remains to be found. However, it may contribute to the understanding of the aetiology and pathophysiology of these colonic conditions.
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Goldstein AM, Thapar N, Karunaratne TB, De Giorgio R. Clinical aspects of neurointestinal disease: Pathophysiology, diagnosis, and treatment. Dev Biol 2016; 417:217-28. [PMID: 27059882 DOI: 10.1016/j.ydbio.2016.03.032] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/21/2016] [Accepted: 03/31/2016] [Indexed: 02/07/2023]
Abstract
The enteric nervous system (ENS) is involved in the regulation of virtually all gut functions. Conditions referred to as enteric neuropathies are the result of various mechanisms including abnormal development, degeneration or loss of enteric neurons that affect the structure and functional integrity of the ENS. In the past decade, clinical and molecular research has led to important conceptual advances in our knowledge of the pathogenetic mechanisms of these disorders. In this review we consider ENS disorders from a clinical perspective and highlight the advancing knowledge regarding their pathophysiology. We also review current therapies for these diseases and present potential novel reparative approaches for their treatment.
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Affiliation(s)
- Allan M Goldstein
- Department of Pediatric Surgery, Center for Neurointestinal Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Nikhil Thapar
- Division of Neurogastroenterology and Motility, Department of Gastroenterology, UCL Institute of Child Health and Great Ormond Street Hospital, London, UK
| | - Tennekoon Buddhika Karunaratne
- Department of Medical and Surgical Sciences and Gastrointestinal System, University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy; Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Roberto De Giorgio
- Department of Medical and Surgical Sciences and Gastrointestinal System, University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy; Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy
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Quigley EMM, Neshatian L. Advancing treatment options for chronic idiopathic constipation. Expert Opin Pharmacother 2015; 17:501-11. [PMID: 26630260 DOI: 10.1517/14656566.2016.1127356] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Chronic constipation is a global problem affecting all ages and associated with considerable morbidity and significant financial burden for society. Though formerly defined on the basis of a single symptom, infrequent defecation; constipation is now viewed as a syndrome encompassing several complaints such as difficulty with defecation, a sense of incomplete evacuation, hard stools, abdominal discomfort and bloating. AREAS COVERED The expanded concept of constipation has inevitably led to a significant change in outcomes in clinical trials, as well as in patient expectations from new therapeutic interventions. The past decades have also witnessed a proliferation in therapeutic targets for new agents. Foremost among these have been novel prokinetics, a new category, prosecretory agents and innovative approaches such as inhibitors of bile salt transport. In contrast, relatively few effective therapies exist for the management of those anorectal and pelvic floor problems that result in difficult defecation. EXPERT OPINION Though constipation is a common and often troublesome disorder, many of those affected can resolve their symptoms with relatively simple measures. For those with more resistant symptoms a number of novel, effective and safe options now exist. Those with defecatory difficulty (anismus, pelvic floor dysfunction) continue to represent a significant management challenge.
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Affiliation(s)
- Eamonn M M Quigley
- a Lynda K. and David M. Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology , Houston Methodist Hospital, Weill Cornell Medical College , Houston , TX , USA
| | - Leila Neshatian
- a Lynda K. and David M. Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology , Houston Methodist Hospital, Weill Cornell Medical College , Houston , TX , USA
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Zhang P, Yang Y, Wu ZJ, Zhang N, Zhang CH, Zhang XD. Should simultaneous ureteral reimplantation be performed during sigmoid bladder augmentation to reduce vesicoureteral reflux in neurogenic bladder cases? Int Urol Nephrol 2015; 47:759-64. [PMID: 25822616 DOI: 10.1007/s11255-015-0958-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 03/21/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the necessity of performing simultaneous collateral reimplantation during sigmoid bladder augmentation (SBA) to reduce vesicoureteral reflux (VUR) in low-compliance neuropathic bladder with associated VUR. METHODS We retrospectively identified 31 patients who underwent SBA alone or with simultaneous ureteral reimplantation at our hospital. The video urodynamics data, VUR status, renal function, and clinical symptoms were studied during follow-up. RESULTS The mean follow-up time was 57 months (range 12-117). All patients displayed significantly increased safe cystometric capacity (P < 0.001) and bladder compliance (P < 0.001) and decreased creatinine (P < 0.01) and urea nitrogen (P < 0.05) compared with preoperative levels. High-grade VUR was resolved in only 7 of 15 patients (47%) in Group A (simultaneous ureteral reimplantation), whereas low-grade VUR was resolved in 13 of 16 patients (81%) in Group B (SBA alone). The other 11 patients still displaying VUR after SBA had larger safe bladder volumes due to augmentation. The patients' improving renal function benefited most from the enlarged bladder and partly from increased antireflux resistance of vesico-ureter anastomosis. Twelve (38.7%) had recurrent febrile urinary tract infection after SBA, and one (3.2%) suffered from vesico-ureter anastomosis contracture after ureteral reimplantation. CONCLUSIONS A preoperative intravesical VUR pressure of 20 cmH2O is not an effective cutoff point for whether ureteral reimplantation should be simultaneously performed during SBA. Augmentation appears to be more important than reimplantation for protecting kidney from damage due to febrile urinary tract infection after SBA. Simultaneous reimplantation may be not necessary during SBA in neurogenic bladder.
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Affiliation(s)
- Peng Zhang
- Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China,
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Russell KW, Barnhart DC, Zobell S, Scaife ER, Rollins MD. Effectiveness of an organized bowel management program in the management of severe chronic constipation in children. J Pediatr Surg 2015; 50:444-7. [PMID: 25746705 DOI: 10.1016/j.jpedsurg.2014.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Revised: 08/09/2014] [Accepted: 08/10/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Chronic constipation is a common problem in children. The cause of constipation is often idiopathic, when no anatomic or physiologic etiology can be identified. In severe cases, low dose laxatives, stool softeners and small volume enemas are ineffective. The purpose of this study was to assess the effectiveness of a structured bowel management program in these children. METHODS We retrospectively reviewed children with chronic constipation without a history of anorectal malformation, Hirschsprung's disease or other anatomical lesions seen in our pediatric colorectal center. Our bowel management program consists of an intensive week where treatment is assessed and tailored based on clinical response and daily radiographs. Once a successful treatment plan is established, children are followed longitudinally. The number of patients requiring hospital admission during the year prior to and year after initiation of bowel management was compared using Fisher's exact test. RESULTS Forty-four children with refractory constipation have been followed in our colorectal center for greater than a year. Fifty percent had at least one hospitalization the year prior to treatment for obstructive symptoms. Children were treated with either high-dose laxatives starting at 2mg/kg of senna or enemas starting at 20ml/kg of normal saline. Treatment regimens were adjusted based on response to therapy. The admission rate one-year after enrollment was 9% including both adherent and nonadherent patients. This represents an 82% reduction in hospital admissions (p<0.001). CONCLUSIONS Implementation of a structured bowel management program similar to that used for children with anorectal malformations, is effective and reduces hospital admissions in children with severe chronic constipation.
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Affiliation(s)
- Katie W Russell
- University of Utah, Division of Pediatric Surgery, Primary Children's Hospital, 100 North Mario Capecchi Drive, Suite 2600, Salt Lake City, UT 84113.
| | - Douglas C Barnhart
- University of Utah, Division of Pediatric Surgery, Primary Children's Hospital, 100 North Mario Capecchi Drive, Suite 2600, Salt Lake City, UT 84113
| | - Sarah Zobell
- University of Utah, Division of Pediatric Surgery, Primary Children's Hospital, 100 North Mario Capecchi Drive, Suite 2600, Salt Lake City, UT 84113
| | - Eric R Scaife
- University of Utah, Division of Pediatric Surgery, Primary Children's Hospital, 100 North Mario Capecchi Drive, Suite 2600, Salt Lake City, UT 84113
| | - Michael D Rollins
- University of Utah, Division of Pediatric Surgery, Primary Children's Hospital, 100 North Mario Capecchi Drive, Suite 2600, Salt Lake City, UT 84113
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Chronic severe constipation: current pathophysiological aspects, new diagnostic approaches, and therapeutic options. Eur J Gastroenterol Hepatol 2015; 27:204-14. [PMID: 25629565 DOI: 10.1097/meg.0000000000000288] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic constipation is a considerable problem because it significantly affects the quality of a patient's life. Constipation can be diagnosed at every age and is more frequent in women and among the elderly. In epidemiological studies, its incidence is estimated at 2-27% in the general population. Chronic constipation may be primary or secondary. However, primary constipation (functional or idiopathic) can be classified into normal transit constipation, slow transit constipation, and pelvic outlet obstruction. In this review we make an attempt to present the current pathophysiological aspects and new therapeutic options for chronic idiopathic constipation, particularly highlighting the value of patient assessment for accurate diagnosis of the cause of the problem, thus helping in the choice of appropriate treatment.
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Long-term follow-up of sigmoid bladder augmentation for low-compliance neurogenic bladder. Urology 2014; 84:697-701. [PMID: 25168554 DOI: 10.1016/j.urology.2014.05.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 05/17/2014] [Accepted: 05/21/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To assess the clinical and urodynamic outcomes of patients with low-compliance neurogenic bladder who were treated with sigmoid bladder augmentation (SBA) over a long-term follow-up. MATERIALS AND METHODS We retrospectively reviewed 52 patients with low-compliance neurogenic bladder who underwent SBA alone or with antireflux techniques in our hospital from 2006 to 2014. Clinical outcomes regarding bladder function, incontinence, medications, catheterization schedules, subsequent interventions, bowel function, and patient satisfaction were addressed. RESULTS The mean follow-up was 49 months. All patients experienced significant increases in safe cystometric capacity from 113.8 ± 65.9 mL to 373.1 ± 66.7 mL (P <.001), bladder compliance from 2.96 ± 1.55 mL/cm H2O to 14.07 ± 5.45 mL/cm H2O (P <.001), and decreases in creatinine from 88.1 ± 38.6 μmol/L to 77.1 ± 30.4 μmol/L (P <.001) compared with those before surgery. Six patients (11.5%) required anticholinergic medicine to control neurogenic detrusor overactivity, and 11 (21.1%) had recurrent febrile urinary tract infections after SBA. Among 47 prehydronephrosis patients (grade I-II in 10 and III-V in 37), 16 still had minor hydronephrosis after SBA, but the hydronephrosis had been improved significantly (all posthydronephroses were grade I-II instead). All patients reported significant improvements in constipation, and no patient had obvious metabolic acidosis or bladder perforation after SBA. All patients expressed extreme satisfaction with the operation. CONCLUSION SBA provided durable clinical and urodynamic improvement for patients with low-compliance neurogenic bladder and constipation. SBA alone, without ureteral reimplantation, seemed sufficient for neurogenic bladder. Furthermore, there was a high level of patient satisfaction with SBA.
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González-Calatayud M, Gutiérrez-Uvalle GE. Pseudo Intestinal Occlusion: Case Report and Literature Review. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2014. [DOI: 10.1016/j.hgmx.2014.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Hong SM, Hong J, Kang G, Moon SB. Ultrashort-segment Hirschsprung's disease complicated by megarectum: A case report. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2014. [DOI: 10.1016/j.epsc.2014.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Abstract
Faecal incontinence is a common condition and is associated with considerable morbidity and economic cost. The majority of patients are managed with conservative interventions. However, for those patients with severe or refractory incontinence, surgical treatment might be required. Over the past 20 years, numerous developments have been made in the surgical therapies available to treat such patients. These surgical therapies can be classified as techniques of neuromodulation, neosphincter creation (muscle or artificial) and injection therapy. Techniques of neuromodulation, particularly sacral nerve stimulation, have transformed the management of these patients with a minimally invasive procedure that offers good results and low morbidity. By contrast, neosphincter procedures are characterized by being more invasive and associated with considerable morbidity, although some patients will experience substantial improvements in their continence. Injection of bulking agents into the anal canal can improve symptoms and quality of life in patients with mild-to-moderate incontinence, and the use of autologous myoblasts might be a future therapy. Further research and development is required not only in terms of the devices and procedures, but also to identify which patients are likely to benefit most from such interventions.
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Management of pediatric patients with refractory constipation who fail cecostomy. J Pediatr Surg 2013; 48:1931-5. [PMID: 24074670 DOI: 10.1016/j.jpedsurg.2012.12.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Revised: 12/16/2012] [Accepted: 12/18/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Antegrade continence enema (ACE) is a recognized therapeutic option in the management of pediatric refractory constipation. Data on the long-term outcome of patients who fail to improve after an ACE-procedure are lacking. PURPOSE To describe the rate of ACE bowel management failure in pediatric refractory constipation, and the management and long term outcome of these patients. METHODS Retrospective analysis of a cohort of patients that underwent ACE-procedure and had at least 3-year-follow-up. Detailed analysis of subsequent treatment and outcome of those patients with a poor functional outcome was performed. RESULTS 76 patients were included. 12 (16%) failed successful bowel management after ACE requiring additional intervention. Mean follow-up was 66.3 (range 35-95 months) after ACE-procedure. Colonic motility studies demonstrated colonic neuropathy in 7 patients (58%); abnormal motility in 4 patients (33%), and abnormal left-sided colonic motility in 1 patient (9%). All 12 patients were ultimately treated surgically. Nine patients (75%) had marked clinical improvement, whereas 3 patients (25%) continued to have poor function issues at long term follow-up. CONCLUSIONS Colonic resection, either segmental or total, led to improvement or resolution of symptoms in the majority of patients who failed cecostomy. However, this is a complex and heterogeneous group and some patients will have continued issues.
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Bove A, Bellini M, Battaglia E, Bocchini R, Gambaccini D, Bove V, Pucciani F, Altomare DF, Dodi G, Sciaudone G, Falletto E, Piloni V. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment). World J Gastroenterol 2013. [PMID: 23049207 DOI: 10.3748/wjg.v] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.
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Affiliation(s)
- Antonio Bove
- Gastroenterology and Endoscopy Unit, Department of Gastroenterology, AORN "A. Cardarelli", 80131 Naples, Italy.
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Abstract
Patients presenting with megacolon and megarectum require extensive specialized testing to distinguish underlying Hirschsprung's disease from other secondary causes. Diagnostic testing and long-term treatment are best initiated after disimpaction has been achieved, by large-volume tap water enemas and/or oral colonic lavage with polyethylene glycol. With intensive treatment (including biofeedback if pelvic floor dysfunction is present), at lease one half of patients can avoid surgery. Maintenance therapy relies on daily use of osmotic laxatives. Stimulant laxatives are used intermittently as rescue treatments if there has not been a satisfactory bowel movement in 3 days. Patients with idiopathic megacolon or megarectum may require surgery if they have refractory symptoms. Depending on age, pelvic floor, and anal sphincter function, patients who have isolated megacolon can be treated with either subtotal colectomy with ileorectostomy or diverting loop ileostomy. Patients with isolated megarectum can be treated with either proctectomy and coloanal anastomosis or vertical reduction rectoplasty. Patients who have combined megacolon and megarectum can be offered diverting loop ileostomy or, if pelvic floor function is normal and they wish to avoid stoma, total proctocolectomy with ileal pouch-anal anastomosis.
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Affiliation(s)
- Lawrence A Szarka
- Colon and Rectal Surgery, Mayo Clinic College of Medicine and Mayo Foundation, 200 First Street SW, Gonda 9-S, Rochester, MN 55905, USA.
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39
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Bove A, Bellini M, Battaglia E, Bocchini R, Gambaccini D, Bove V, Pucciani F, Altomare DF, Dodi G, Sciaudone G, Falletto E, Piloni V. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (Part II: Treatment). World J Gastroenterol 2012; 18:4994-5013. [PMID: 23049207 PMCID: PMC3460325 DOI: 10.3748/wjg.v18.i36.4994] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 11/17/2011] [Accepted: 08/15/2012] [Indexed: 02/06/2023] Open
Abstract
The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.
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40
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Bove A, Bellini M, Battaglia E, Bocchini R, Gambaccini D, Bove V, Pucciani F, Altomare DF, Dodi G, Sciaudone G, Falletto E, Piloni V. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment). World J Gastroenterol 2012. [PMID: 23049207 PMCID: PMC3460325 DOI: 10.3748/wjg.v18.i36.4994;] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.
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Affiliation(s)
- Antonio Bove
- Gastroenterology and Endoscopy Unit, Department of Gastroenterology, AORN "A. Cardarelli", 80131 Naples, Italy.
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Rigamonti F, Bucher P, Nguyen-Tang T, Merlani P. Images in emergency medicine. Elderly male with respiratory failure. Chronic idiopathic intestinal pseudo-obstruction. Ann Emerg Med 2012; 60:423, 430. [PMID: 23010179 DOI: 10.1016/j.annemergmed.2012.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 04/21/2012] [Accepted: 04/24/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Fabio Rigamonti
- Service of Cardiology, University Hospitals of Geneva, Geneva, Switzerland
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Yik YI, Leong LCY, Hutson JM, Southwell BR. The impact of transcutaneous electrical stimulation therapy on appendicostomy operation rates for children with chronic constipation--a single-institution experience. J Pediatr Surg 2012; 47:1421-6. [PMID: 22813807 DOI: 10.1016/j.jpedsurg.2012.01.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Revised: 01/13/2012] [Accepted: 01/15/2012] [Indexed: 12/27/2022]
Abstract
PURPOSE Appendicostomy for antegrade continence enema is a minimally invasive surgical intervention that has helped many children with chronic constipation. At our institution, since 2006, transcutaneous electrical stimulation (TES) has been trialed to treat slow-transit constipation (STC) in children. This retrospective audit aimed to determine if TES use affected appendicostomy-formation rates and to monitor changes in practice. We hypothesized that appendicostomy rates have decreased for STC but not for other indications. METHODS Appendicostomy-formation rate was determined for the 5 years before and after 2006. Children were identified as STC or non-STC from nuclear transit scintigraphy and patient records. RESULTS Since 1999, 317 children were diagnosed with STC using nuclear transit scintigraphy with 121 during 2001 to 2005 (24.2/year) and 147 during 2006 to 2010 (29.4/year). Seventy-four children had appendicostomy formation. For 2001 to 2005, appendicostomy-formation rates for STC and non-STC children were similar: 5.4 per year (n = 27) and 4.8 per year (n = 24), respectively. For 2006 to 2010, appendicostomy-formation rates were 1.2 per year (n = 6) for STC and 3.2 per year (n = 16) for non-STC (χ(2), P = .04). CONCLUSION Since 2006, appendicostomy-formation rates have significantly reduced in STC but not in non-STC children at our institute, coinciding with the introduction of TES as an alternative treatment for STC. Transcutaneous electrical stimulation has not been tested on non-STC children in this period.
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Affiliation(s)
- Yee Ian Yik
- F Douglas Stephens Surgical Research and Gut Motility Laboratories, Murdoch Children's Research Institute, Melbourne, Australia
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Yucel AF, Akdogan RA, Gucer H. A giant abdominal mass: fecaloma. Clin Gastroenterol Hepatol 2012; 10:e9-e10. [PMID: 21749849 DOI: 10.1016/j.cgh.2011.06.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 06/24/2011] [Accepted: 06/30/2011] [Indexed: 02/07/2023]
Affiliation(s)
- Ahmet Fikret Yucel
- Department of Surgery, School of Medicine, Rize University, Rize, Turkey
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Dos Santos CHM, Fonseca O. Idiopathic megacolon associated with ulcerative colitis: a rare association. Inflamm Bowel Dis 2011; 17:E92-3. [PMID: 21604330 DOI: 10.1002/ibd.21754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Kabeer S, Dvorkin L, Carrannante J, Linehan I. A life-threatening complication of undiagnosed congenital idiopathic megacolon. BMJ Case Rep 2010; 2010:2010/aug24_1/bcr0420102888. [PMID: 22767475 DOI: 10.1136/bcr.04.2010.2888] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A case of undiagnosed congenital idiopathic megacolon in a 16-year-old boy who presented with toxic megacolon and cardiovascular instability with a background of longstanding constipation is presented. He underwent life-saving subtotal colectomy from which he made a full recovery.
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Affiliation(s)
- Syed Kabeer
- Department of Surgery, Basildon & Thurrock University Hospitals NHS Foundation Trust, Basildon, UK.
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46
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Abstract
The operative management of pediatric colorectal diseases has improved significantly in recent years through the development of innovative approaches for operative exposure and a better understanding of colorectal anatomy. Advances in transanal and minimal access techniques have formed the cornerstone of this innovation, leading to improved functional outcomes, earlier recovery, and superior cosmetic results for a number of colorectal diseases. In this regard, we have witnessed a significant evolution in the way that many of these conditions are managed, particularly in the areas of anorectal malformations and Hirschsprung disease. Furthermore, a more thorough understanding of the pathophysiology underlying encopresis and true fecal continence has led to novel and less invasive approaches to the operative management of these conditions. The goal of this review is to describe the evolution of operative management pertaining to these diseases, with an emphasis on technical aspects and relevant clinical pitfalls.
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Affiliation(s)
- Shawn J Rangel
- Department of Surgery, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02210, USA.
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47
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Gurland B, Zutshi M. Overview of Pelvic Evacuation Dysfunction. SEMINARS IN COLON AND RECTAL SURGERY 2010. [DOI: 10.1053/j.scrs.2009.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Affiliation(s)
- Marc A Levitt
- Colorectal Center for Children, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Christison-Lagay ER, Rodriguez L, Kurtz M, St Pierre K, Doody DP, Goldstein AM. Antegrade colonic enemas and intestinal diversion are highly effective in the management of children with intractable constipation. J Pediatr Surg 2010; 45:213-9; discussion 219. [PMID: 20105606 DOI: 10.1016/j.jpedsurg.2009.10.034] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 10/06/2009] [Indexed: 01/16/2023]
Abstract
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.
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Affiliation(s)
- Emily R Christison-Lagay
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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50
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Averboukh F, Kariv Y. Ileal Pouch Rectal Anastomosis: Technique, Indications, and Outcomes. SEMINARS IN COLON AND RECTAL SURGERY 2009. [DOI: 10.1053/j.scrs.2009.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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