Near-total intestinal aganglionosis: long-term follow-up of a morbid condition

PURPOSE

The aim of this study was to understand the long-term outcome of near-total intestinal aganglionosis (NTIA).

METHODS

The study was an institutional review of all patients with NTIA between 1974 and 1999, inc!usive. Seven full-term babies were identified (4 boys, 3 girls). Mean birth weight was 3.2 kg (range, 2.7 to 4.1). Patients included 1 pair of siblings and 1 Down's syndrome baby. All 7 had obstruction within 5 days of life. One patient experienced bowel perforation. All 7 had NTIA diagnosed within the first 2 months of life. In 2 of 7, aganglionosis began 10 cm distal to the ligament of Treitz (LOT). The longest segment of normal small bowel was 130 cm from the LOT. Five of 7 babies underwent a stoma between day of life (DOL) 1 and 15.

RESULTS

Two of three "long-term" survivors (>2 years) had corrective surgery by 13 months. The first received extended jejuno-ileal myotomy and myectomy with multiple postoperative problems. She died at 8 years of age of complications of total parenteral nutrition (TPN). The second underwent myotomy, resection and patch graft to jejunum, and several jejunostomy revisions. All of the involved bowel eventually was resected. The 3 of 7 who lived more than 1 year all took some nutrition orally. Three died, between 3 months and 8 years of age, of complications of TPN. There are 2 survivors at 3 and 7 years of age. Survival has not correlated with the length of aganglionic bowel.

CONCLUSIONS

Aganglionosis involving most of the bowel has a high morbidity and mortality rate. Since 1990 a more aggressive surgical approach has resulted in improved survival rates but with significant morbidity. For children surviving beyond 3 months of age, outcome was less dismal. Some patients may benefit from extended jejunal myotomy or myectomy. However, postoperative complications are the rule, not the exception.

Identification of nucleoside transport binding sites in the human myocardium

The role of nucleoside transport in ischemia-reperfusion injury and arrhythmias has been well documented in various animal models using selective blockers. However, clinical application of nucleoside transport inhibitors remains to be demonstrated in humans. It is not known whether human heart has nucleoside transport similar to that of animals. The aim of this study is to pharmacologically identify the presence of nucleoside transport binding sites in the human myocardium compared to animals. Myocardial tissue was obtained from guinea pig left and right ventricle, canine left ventricle, human intraoperative right atrium and human cadaveric right atrium and right and left ventricles. Myocardial preparations were obtained from tissue samples after homogenized and a differential centrifugation. Equilibrium binding assays were performed using [3H]-p-nitrobenzylthioinosine (NBMPR) at room temperature in the presence or absence of non-radioactive NBMPR or other nucleoside transport blockers such as p-nitrobenzylthioguanosine dipyridamole, lidoflazine, papaverin, adenosine and doxorubcine. From saturation curves and inhibition kinetics, we determined the relative maximal binding (Bmax) and dissociation constant (Kd) of [3H]-NBMPR binding of human myocardial preparations. Results demonstrated that the fresh human myocardial preparations have a specific binding site for NBMPR with a Bmax of 283+/-32 fmol/mg protein and Kd of 0.56+/-0.12 nM. These values are lower than those obtained from guinea pigs (Bmax = 1440+/-187 fmol/mg protein and Kd = 0.21+/-0.03 nM) and canine atrium (Bmax 594+/-73 fmol/mg protein, and Kd = 1.12+/-0.22 nM). Displacement kinetics studies revealed the relative potencies (of certain unrelated drugs as follow: p-nitrobenzylthioguanosine > dipyridamole > lidoflazine > pavaverine > Diltazam > adenosine > doxyrubicin. It is concluded that human myocardium contains an active nucleoside transport site which may play a crucial role in post-ischemic reperfusion-mediated injury in a wide spectrum of ischemic syndromes.

Rehbein's anterior resection in Hirschsprung's disease, using a circular stapler

The results of 30 patients with Hirschsprung's disease, operated by Rehbein's anterior resection, have been evaluated. In 26 children the anastomosis was constructed with a circular stapler (Ethicon Proximate ILS) and in 4 it was handsutured. When a stapler was used, technical problems in 4, with a defect in the rings of bowel after firing the instrument, necessitated reinforcing sutures. The level of the anastomosis was significantly lower in the children in which a stapler was used. Eight children were operated by dorsal myectomy (DRM) prior to and 4 after anterior resection. The children with DRM prior to anterior resection had a significantly lower requirement for postoperative dilations. Early postoperative complications included 3.3% mortality, 6.7% enterocolitis, 3.3% anastomotic insufficiency, 3.3% early ileus and 10.0% wound infection. Three patients (10.0%) were operated for postoperative anastomotic stricture, one requiring anastomotic revision and two requiring DRM. At follow-up two children (7.4%) reported constipation with regular requirement for enemas and two (7.4%) reported daily encopresis. Twenty-three patients had 1-5 bowel movements per day and 4 patients had more than 5. In our experience the use of a circular stapler makes it possible to perform a lower anastomosis. We believe that this technique gives a wider and more elastic anastomosis and is technically less difficult to handle than a handsutured anastomosis.