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Rentea RM, Bokova E, Frischer JS, Gosain A, Langer JC, Levitt MA, Nandivada P, Rialon KL, Rollins MD, Segura B, Wood RJ, Lim IIP. Evaluation and Management of Total Colonic Hirschsprung Disease: A Comprehensive Review From the American Pediatric Surgical Association (APSA) Hirschsprung Disease Interest Group. J Pediatr Surg 2024:161677. [PMID: 39217005 DOI: 10.1016/j.jpedsurg.2024.08.017] [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] [Received: 01/25/2024] [Revised: 07/24/2024] [Accepted: 08/04/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Children with total colonic Hirschsprung disease (TCHD) are a unique group of patients with pre- and postoperative management challenges. This review provides a rational, expert-based approach to diagnosing and managing TCHD. METHODS The guidelines were developed by the Hirschsprung Disease Interest Group members established by the American Pediatric Surgical Association (APSA) Board of Governors. Group discussions, literature review, and expert consensus were used to summarize the current knowledge regarding diagnosis, staged approach, the timing of pull-through, and pre-and postoperative management in children with TCHD. RESULTS This paper presents recommendations for managing TCHD before and after reconstruction, including diagnostic criteria, surgical approaches, bowel management, diet, antibiotic prophylaxis, colonic irrigations, and post-surgical considerations. CONCLUSIONS A clear understanding of the unique challenges posed by TCHD and consensus on its treatment are lacking in the literature. This review standardizes this patient group's pre- and postoperative management. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Rebecca M Rentea
- Comprehensive Colorectal Center, Section of Colorectal and Pelvic Reconstructive Surgery, Department of Pediatric Surgery, Children's Mercy Kansas City, Kansas City, MO, 64108, USA; Department of Surgery, University of Missouri-Kansas City, Kansas City, MO, 64108, USA.
| | - Elizaveta Bokova
- Comprehensive Colorectal Center, Section of Colorectal and Pelvic Reconstructive Surgery, Department of Pediatric Surgery, Children's Mercy Kansas City, Kansas City, MO, 64108, USA
| | - Jason S Frischer
- Colorectal Center for Children, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ankush Gosain
- Department of Pediatric Surgery, Children's Hospital of Colorado, University of Colorado, Aurora, CO, USA
| | - Jacob C Langer
- Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, DC, 20001, USA
| | - Prathima Nandivada
- Colorectal and Pelvic Malformation Center, Department of Surgery, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Kristy L Rialon
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Texas, USA
| | - Michael D Rollins
- Department of Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Bradley Segura
- University of Minnesota, Department of Pediatric Surgery, MHealth Fairview Masonic Children's Hospital, Minneapolis, MN, USA
| | - Richard J Wood
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Irene Isabel P Lim
- Comprehensive Colorectal Center, Section of Colorectal and Pelvic Reconstructive Surgery, Department of Pediatric Surgery, Children's Mercy Kansas City, Kansas City, MO, 64108, USA; Department of Surgery, University of Missouri-Kansas City, Kansas City, MO, 64108, USA
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Bokova E, Elhalaby I, Saylors S, Lim IIP, Rentea RM. Utilization of Indocyanine Green (ICG) Fluorescence in Patients with Pediatric Colorectal Diseases: The Current Applications and Reported Outcomes. CHILDREN (BASEL, SWITZERLAND) 2024; 11:665. [PMID: 38929244 PMCID: PMC11202280 DOI: 10.3390/children11060665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/14/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024]
Abstract
In pediatric colorectal surgery, achieving and visualizing adequate perfusion during complex reconstructive procedures are paramount to ensure postoperative success. However, intraoperative identification of proper perfusion remains a challeng. This review synthesizes findings from the literature spanning from January 2010 to March 2024, sourced from Medline/PubMed, EMBASE, and other databases, to evaluate the role of indocyanine green (ICG) fluorescence imaging in enhancing surgical outcomes. Specifically, it explores the use of ICG in surgeries related to Hirschsprung disease, anorectal malformations, cloacal reconstructions, vaginal agenesis, bladder augmentation, and the construction of antegrade continence channels. Preliminary evidence suggests that ICG fluorescence significantly aids in intraoperative decision-making by improving the visualization of vascular networks and assessing tissue perfusion. Despite the limited number of studies, initial findings indicate that ICG may offer advantages over traditional clinical assessments for intestinal perfusion. Its application has demonstrated a promising safety profile in pediatric patients, underscoring the need for larger, prospective studies to validate these observations, quantify benefits, and further assess its impact on clinical outcomes. The potential of ICG to enhance pediatric colorectal surgery by providing real-time, accurate perfusion data could significantly improve surgical precision and patient recovery.
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Affiliation(s)
- Elizaveta Bokova
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA (I.E.)
| | - Ismael Elhalaby
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA (I.E.)
- Tanta University Hospital, Faculty of Medicine, Tanta University, Tanta 31527, Egypt
| | - Seth Saylors
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA (I.E.)
| | - Irene Isabel P. Lim
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA (I.E.)
- Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Rebecca M. Rentea
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA (I.E.)
- Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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Bokova E, Svetanoff WJ, Lopez JJ, Levitt MA, Rentea RM. State of the Art Bowel Management for Pediatric Colorectal Problems: Anorectal Malformations. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050846. [PMID: 37238394 DOI: 10.3390/children10050846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/28/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023]
Abstract
Up to 79% of patients with anorectal malformations (ARMs) experience constipation and/or soiling after a primary posterior sagittal anoplasty (PSARP) and are referred to a bowel management program. We aim to report the recent updates in evaluating and managing these patients as part of the manuscript series on the current bowel management protocols for patients with colorectal diseases (ARMs, Hirschsprung disease, functional constipation, and spinal anomalies). The unique anatomic features of ARM patients, such as maldeveloped sphincter complex, impaired anal sensation, and associated spine and sacrum anomalies, indicate their bowel management plan. The evaluation includes an examination under anesthesia and a contrast study to exclude anatomic causes of poor bowel function. The potential for bowel control is discussed with the families based on the ARM index calculated from the quality of the spine and sacrum. The bowel management options include laxatives, rectal enemas, transanal irrigations, and antegrade continence enemas. In ARM patients, stool softeners should be avoided as they can worsen soiling.
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Affiliation(s)
- Elizaveta Bokova
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Wendy Jo Svetanoff
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Joseph J Lopez
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, DC 20001, USA
| | - Rebecca M Rentea
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
- Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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Bokova E, Svetanoff WJ, Levitt MA, Rentea RM. Pediatric Bowel Management Options and Organizational Aspects. CHILDREN 2023; 10:children10040633. [PMID: 37189882 DOI: 10.3390/children10040633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 03/30/2023]
Abstract
A bowel management program (BMP) to treat fecal incontinence and severe constipation is utilized for patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and functional constipation, decreasing the rate of emergency department visits, and hospital admissions. This review is part of a manuscript series and focuses on updates in the use of antegrade flushes for bowel management, as well as organizational aspects, collaborative approach, telemedicine, the importance of family education, and one-year outcomes of the bowel management program. Implementation of a multidisciplinary program involving physicians, nurses, advanced practice providers, coordinators, psychologists, and social workers leads to rapid center growth and enhances surgical referrals. Education of the families is crucial for postoperative outcomes, prevention, and early detection of complications, especially Hirschsprung-associated enterocolitis. Telemedicine can be proposed to patients with a defined anatomy and is associated with high parent satisfaction and decreased patient stress in comparison to in-person visits. The BMP has proved to be effective in all groups of colorectal patients at a 1- and 2-year follow-up with social continence achieved in 70–72% and 78% of patients, respectively, and an improvement in the patients’ quality of life. A transitional care to adult program is essential to maintain the same quality of care, and continuity of care and to achieve desired long-term outcomes as the patient reaches adult age.
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Ayub SS, Zeidan M, Larson SD, Islam S. Long-term outcomes of antegrade continence enema in children with chronic encopresis and incontinence: what is the optimal flush to use? Pediatr Surg Int 2019; 35:431-438. [PMID: 30426223 DOI: 10.1007/s00383-018-4416-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE Severe constipation and encopresis are significant problems in the pediatric population. Medical management succeeds in 50-70%; however, surgical considerations are necessary for the remainder such as the antegrade continence enema (ACE). The purpose of this study is to assess the long-term outcomes following the ACE procedure. METHODS All patients undergoing an ACE over a 14-year period were included. Data on clinical conditions, treatments, and outcomes were collected. A successful outcome was defined as remaining clean with ≤ 1 accident per week. Comparative data were analyzed using the Fisher's exact test, Mann-Whitney U test, or Student's t test. RESULTS There were 42 ACE patients, and overall, 79% had improvement in their bowel regimens. Encopresis rates decreased from 79 to 5% (P < 0.001). Admissions for cleanouts decreased from 52 to 19% (P = 0.003). All cases of Hirschsprung's, functional constipation and spina bifida were successful. Rates of success varied for other diseases such as slow-transit constipation (60%) and cerebral palsy (33%). A majority (85%) required a change in the enema composition for improvement. CONCLUSION In our study, ACE reduced soiling, constipation, and need for fecal disimpaction. Higher volume saline flushes used once a day was the optimal solution and most preferred option. LEVEL OF EVIDENCE Level 4 (retrospective case series or cohort).
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Affiliation(s)
- Suniah S Ayub
- Department of Surgery, Division of Pediatric Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, Room 6130, PO Box 100119, Gainesville, FL, 32610-0287, USA
| | - Michelle Zeidan
- Department of Surgery, Division of Pediatric Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, Room 6130, PO Box 100119, Gainesville, FL, 32610-0287, USA
| | - Shawn D Larson
- Department of Surgery, Division of Pediatric Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, Room 6130, PO Box 100119, Gainesville, FL, 32610-0287, USA
| | - Saleem Islam
- Department of Surgery, Division of Pediatric Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, Room 6130, PO Box 100119, Gainesville, FL, 32610-0287, USA.
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Abstract
The surgical approach to treating fecal incontinence is complex. After optimal medical management has failed, surgery remains the best option for restoring function. Patient factors, such as prior surgery, anatomic derangements, and degree of incontinence, help inform the astute surgeon regarding the most appropriate option. Many varied approaches to surgical management are available, ranging from more conservative approaches, such as anal canal bulking agents and neuromodulation, to more aggressive approaches, including sphincter repair, anal cerclage techniques, and muscle transposition. Efficacy and morbidity of these approaches also range widely, and this article presents the data and operative considerations for these approaches.
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Affiliation(s)
- Joshua I S Bleier
- Division of Colon and Rectal Surgery, Pennsylvania Hospital/Hospital of the University of Pennsylvania, University of Pennsylvania, 800 Walnut Street, 20th Floor, Philadelphia, PA 19106, USA.
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González Jiménez D, Díaz Martin J, Bousoño García C, Jiménez Treviño S. Patología gastrointestinal en niños con parálisis cerebral infantil y otras discapacidades neurológicas. An Pediatr (Barc) 2010; 73:361.e1-6. [DOI: 10.1016/j.anpedi.2010.03.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Revised: 02/07/2010] [Accepted: 03/07/2010] [Indexed: 12/27/2022] Open
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How did the surgeons treat neonates with imperforate anus in the eighteenth century? Pediatr Surg Int 2010; 26:1149-58. [PMID: 20706726 DOI: 10.1007/s00383-010-2672-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2010] [Indexed: 10/19/2022]
Abstract
Anorectal malformations (ARMS) are one of those challenging topics of pediatric surgery. The developments in assessing and approaching patients with these anomalies have been made in the last decades and the methods described in older textbooks functioned as a guide in planning these attempts (Kiely and Peña in Pediatric surgery, Mosby, Missouri, pp 1425-1449, 1998; Grosfeld in Anorectal malformations in children, Springer-Verlag, Berlin, pp 3-15, 2006). The aim of this study is to present the attitude of a surgeon of eighteenth century to the treatment of anorectal malformations, and the evolution in the history of the anomaly. The part about imperforate anus in a textbook of surgery, found in a second-hand bookstore, was translated. The description and the classification of the anomaly, the methods of approaching these cases together with some case reports were presented and compared with today's practice. The historical background of the anomaly was evaluated not only with regard to the book of Heister specifically but also to the other data obtained in the literature. The anomaly was reported to be "not rarely" observed. The obstetricians were warned to examine a newborn baby completely for early diagnosis. The classification of the anomaly was made according to the properties of the membrane covering the anus but prompt treatment, initiating with its simple excision, was suggested in all types. Better results in cases whose anus was covered with a thin, delicate membrane were reported. The results show that routine neonatal examination for all babies was recommended in this Textbook of Surgery which had been published 260 years ago. The physical deterioration due to delay was well described. A broad classification of imperforate anus was made and successful outcome in low-type anomalies of today was reported with some case samples. It is clear that all the efforts starting from Soranus until today improved the understanding of the anomaly. Combining previous information with today's practice in the meetings focused totally on anorectal malformations, where the leading surgeons shared their experiences and re-evaluated the problems encountered, enlightened the future status of this interesting topic of pediatric surgery.
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Abstract
The gastrointestinal tract responds to significant mechanical or functional obstruction by dilatation and hypertrophy of the segment proximal to the obstruction. Excessive dilatation compromises motility, and absorption and is associated with considerable morbidity (intraluminal stasis, sepsis) such that bowel dilatation represents a major liability that predisposes the patient to intestinal failure. The dilated bowel proximal to an obstruction provides valuable autologous material for reconstruction with "tissue appropriate to the part." Bowel elongation and dilatation are integral to the natural intestinal adaptation response to loss of small bowel and can also be induced through a structured "Bowel Expansion" program. The additional absorptive tissue that is progressively generated is essential for reconstruction of the bowel (tailoring and lengthening), to restore gastrointestinal dynamics (effective propulsion and absorption), and to reduce morbidity (intraluminal stasis, sepsis). In enhancing the prospects for enteral autonomy, dilatation and elongation of the residual autologous bowel are crucial to long-term survival and good quality life, and represent a most welcome asset. This paper reviews the impact and management of bowel dilatation along the gastrointestinal tract.
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Affiliation(s)
- A Bianchi
- Royal Manchester Children's Hospital, Department of Paediatric Reconstructive Surgery-Urology, Manchester, United Kingdom.
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Griffin SJ, Parkinson EJ, Malone PSJ. Bowel management for paediatric patients with faecal incontinence. J Pediatr Urol 2008; 4:387-92. [PMID: 18790425 DOI: 10.1016/j.jpurol.2008.01.211] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2007] [Accepted: 01/10/2008] [Indexed: 12/17/2022]
Abstract
This review assesses the incidence and aetiology of faecal incontinence in childhood. We then systematically address the presentation, clinical assessment, investigation and management of these children. Under management, both medical and surgical approaches and their complications are discussed.
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Affiliation(s)
- S J Griffin
- Department of Paediatric Nephro-Urology, G Level, Southampton University Hospitals NHS Trust, Tremona Road, Southampton SO16 6YD, UK
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Abstract
Continent stoma rectus sheath tunnel (CSRST) has been used in antegrade colonic enema (ACE) and urinary continent cutaneous diversion (UCCD) stomas to reduce leakage and to support a straight track for the continent conduit. All patients that underwent CSRST between 1995 and 2005 were identified and their case notes retrospectively reviewed. Patients were divided into two groups: the ACE group and the UCCD group. Demographic data, age at surgery and complications including stenosis and leakage were recorded. Forty patients underwent CSRST between 1995 and 2005. The mean age and standard deviation (SD) at surgery was 6.8 (2.1) years. Eighteen patients underwent ACE with a mean (SD) follow-up of 7.6 (3.1) years. No patient has faecal leakage. No patient had stomal revision, but one patient (5.5%) required an indwelling gastrostomy button to maintain patency. Twenty-two patients underwent UCCD with a mean (SD) follow-up of 8.1 (2.8) years. No patient developed urinary leakage. Two patients (9%) required revision of the stoma and one (4.5%) required an indwelling catheter because of recurring stomal stenosis. CSRST prevents stoma leakage. Revision surgery rate after CSRST is low, particularly after ACE reconstruction.
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Sullivan PB. Gastrointestinal disorders in children with neurodevelopmental disabilities. ACTA ACUST UNITED AC 2008; 14:128-36. [DOI: 10.1002/ddrr.18] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Tobias N, Mason D, Lutkenhoff M, Stoops M, Ferguson D. Management principles of organic causes of childhood constipation. J Pediatr Health Care 2008; 22:12-23. [PMID: 18174085 DOI: 10.1016/j.pedhc.2007.01.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Constipation is extremely common in the pediatric population; however, it is a symptom and not a disease. Organic causes of constipation include Hirschprung's disease, anorectal malformation, and spina bifida. This article also discusses constipation and urinary tract pathology and dysfunction. The function of the gastrointestinal and urinary tracts are intertwined, and this concept will assist the practitioner in managing patients accordingly. Children and adolescents who experience bowel dysfunction require patience and sensitive support from their health care providers so that they can live productive and emotionally healthy lives.
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Affiliation(s)
- Nan Tobias
- Cincinnati Children's Hospital, Division of Urology, 3333 Burnet Ave, MLC 5037, Cincinnati, Ohio 45229, USA.
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Casale AJ, Metcalfe PD, Kaefer MA, Dussinger AM, Meldrum KK, Cain MP, Rink RC. Total Continence Reconstruction: A Comparison to Staged Reconstruction of Neuropathic Bowel and Bladder. J Urol 2006; 176:1712-5. [PMID: 16945629 DOI: 10.1016/j.juro.2006.04.086] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2005] [Indexed: 10/24/2022]
Abstract
PURPOSE Surgical treatment for neuropathic bowel and bladder has become an essential tool in maximizing the quality of life in patients with myelomeningocele. We present our results comparing results in patients who underwent total continence reconstruction of the urinary and gastrointestinal tracts to patients who underwent a separate or single operation. MATERIALS AND METHODS We performed a retrospective chart review of all patients with myelomeningocele at our institution who underwent reconstruction with a cutaneous catheterizable urinary channel or Malone antegrade continence enema. We compared outcomes with regard to surgical revisions of the channel between patients who underwent the construction of each simultaneously, that is total continence reconstruction, to outcomes in those with a single channel or who underwent reconstruction at 2 or more operations. RESULTS Most of our patients underwent genitourinary and gastrointestinal reconstruction, and few desired surgical intervention for only a single system. We were unable to find any differences in the continence rate or stomal complications. However, patients who underwent staged reconstruction usually had significant secondary reasons for repeat surgery. CONCLUSIONS Surgical success for urinary and fecal continence can be safely and effectively achieved through single or multiple procedures. However, because of shared pathophysiology, we believe that most patients benefit from intervention in the gastrointestinal and the genitourinary tract. Therefore, a major advantage of total continence reconstruction is avoidance of the morbidity of a second major surgical procedure.
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Affiliation(s)
- A J Casale
- Department of Pediatric Urology, James Whitcomb Riley Hospital for Children, Indiana University School of Medicine, 702 Barnhill Drive, Indianapolis, IN 46202, USA
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Chung EAL, Emmanuel AV. Gastrointestinal symptoms related to autonomic dysfunction following spinal cord injury. PROGRESS IN BRAIN RESEARCH 2006; 152:317-33. [PMID: 16198710 DOI: 10.1016/s0079-6123(05)52021-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The impact of spinal cord injury on an individual's gastrointestinal tract function is often poorly understood by the general public and also by those involved with persons with spinal cord injury. This chapter reviews the anatomy, physiology and function of the gastrointestinal tract, with particular emphasis on neurological control mechanisms. In turn, it relates the effect that spinal cord injury has on the neurological control of the gastrointestinal tract. The symptoms that are encountered by patients in the acute phase following injury, and by individuals in the months/years after injury, with particular reference to the effect of altered autonomic nervous system control of the gastrointestinal tract, are discussed. Together with a following summary of current bowel management regimens and techniques, this chapter aims to provide an overall view of the effect that autonomic dysfunction due to spinal cord injury has on gastrointestinal function.
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Affiliation(s)
- Eric A L Chung
- St Mark's Hospital, Northwick Park, Watford Road, Harrow, Middlesex, HA1 3UJ, UK
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Pensabene L, Nurko S. Management of Fecal Incontinence in Children Without Functional Fecal Retention. ACTA ACUST UNITED AC 2004; 7:381-390. [PMID: 15345209 DOI: 10.1007/s11938-004-0051-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The management of the fecal incontinence in children is difficult, and its social consequences are usually devastating. The general objectives of any bowel program are to produce social continence, predictability, and eventually independence. How to achieve those goals depends in part on the underlying condition. In children, fecal incontinence can occur from a variety of conditions. The most common is overflow incontinence from functional fecal retention, but it can also occur in otherwise healthy children with functional nonretentive fecal soiling or in children with organic causes of fecal incontinence, such as congenital malformations, or any other condition affecting the anorectum, anal sphincters, or the spinal cord. The therapeutic regimen that is recommended in patients with nonretentive fecal soiling consists of explanation and support for the child and parents, a nonaccusatory approach, and a toilet training program with a rewarding system. Biofeedback does not play an important role, and laxatives need to be used with caution, as they may exacerbate the incontinence. For those patients with congenital/neuropathic incontinence a combination of maneuvers to change stool consistency, colonic transit, anorectal function, and rectosigmoid evacuation is used. Stool consistency can be changed with the use of dietary interventions or medications. Stool transit can be slowed (antimotility agents) or accelerated (laxatives) with the use of medications. Anorectal function can be improved with the use of biofeedback or procedures to alter sphincter pressure, and the production of a bowel movement can be induced with maneuvers to empty the sigmoid (suppositories, enemas). With the recent advent of the Antegrade Colonic Enema (ACE), the patient is then able to be predictable and independent. This procedure creates a continent conduit from the skin to the cecum that can be catheterized or accessed for self-administration of enemas. The ACE has revolutionized the treatment of children with fecal incontinence.
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Affiliation(s)
- Licia Pensabene
- Department of Gastroenterology and Nutrition, Hunnewell Ground, 300 Longwood Avenue, Boston, MA 02115, USA.
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