[Conjoined twins: an experience of a tertiary hospital in Southeast Brazil]

PURPOSE

to analyze the occurrence of conjoined twins at a tertiary perinatology reference university hospital over a period of 25 years (January 1982 to January 2007) and to describe the successful separation of one of the pairs.

METHODS

we consulted retrospectively the database of the University Hospital of the Medical School of Ribeirão Preto, University of São Paulo, Brazil, in order to determine the number of pairs of conjoined twins, their frequency, classification, gender, type of pregnancy resolution, attempted surgical separation, prenatal diagnosis and survival.

RESULTS

we detected 14 pairs of conjoined twins (1/22,284 live births and 1/90 pairs of twin live births) born during this period (six males, seven females and one of indeterminate sex). The prenatal diagnosis was performed in all twins and all births were accomplished by cesarean section. The separation was possible in only one pair, which survives in excellent health conditions after eight years. Of the remaining 13, ten died on the day of birth and three survived only a few months (less than one year).

CONCLUSION

Although our study revealed an abnormally high number of conjoined twins, this is a rare phenomenon, with a poor perinatal prognosis depending on the organs shared by the twins and associated malformations, especially those related to the fetal heart. Due to the poor prognosis of these pairs and to the maternal reproductive impairment caused by the need to perform body cesareans, we suggest that, based on these numbers, early interruption of these pregnancies be legally granted, as in the case of other diseases incompatible with fetal survival outside the uterus. Thus, the confirmation of a diagnosis of conjoined twins and the resolution of pregnancy should be performed at a tertiary obstetric and perinatal care center, and an authorization for the interruption of pregnancy should be obtained by judicial means.

An alternative approach for management of abdominal cerebrospinal fluid pseudocysts in children

BACKGROUND

Cerebrospinal fluid (CSF) abdominal pseudocyst is an uncommon but important complication of ventriculoperitoneal shunts. From the collected series, several features about the etiology and management become apparent. Retrospective data were obtained from 12 children treated with cerebrospinal fluid abdominal pseudocyst defined an alternative approach for management of these patients.

METHODS

There were eight girls and four boys who ranged in age from 12 days to 18 years old (mean 7.7 months). The most frequent etiology of the hydrocephalus was Chiari type II malformation in six cases. Initial presentation with shunt malfunction was detected in nine cases. Abdominal distention and/or pain were the most frequent finding in our series (10/12). In only one case, infection was detected for all cerebrospinal fluid abdominal pseudocysts (8.3%). Ventriculoperitoneal shunt (VPS) externalization, antibiotics, and cyst aspiration was performed in 8/12 cases as initial management of abdominal pseudocyst. Ventriculoperitoneal shunt reinsertion in abdominal cavity and/or endoscopic third ventriculostomy (ETV) was performed as final management in 9/12. Ventriculoatrial shunt was used only in three cases. Recurrence of the abdominal cyst was observed in two cases.

DISCUSSION

Based on the success rate (75%) in our series submitted to this management, a ventriculoperitoneal shunt can be safely reinserted in the majority of the patients. Endoscopic third ventriculostomy could be performed in selected cases as an alternative approach. Although infection has been reported as responsible for pseudocyst formation, it was only exceptionally found in our series.

Anorectal manometry in children with chronic functional constipation

BACKGROUND: The anorectal manometry is a very utilized and well recognized examination in children with chronic funcional constipation. The major manometric findings in these children are: anal hypotonia, anal hypertonia, paradoxal contraction of the external anal sphincter, decreased ability of internal anal sphincter to relax during rectal distension and alterations in rectal contractility, sensibility and compliance. AIMS: To evaluate the anal basal pressure and the relaxation reflex before and after standard treatment for a better understanding of the physiopathologic mechanisms involved in pediatric chronic functional constipation. METHODS: Anorectal manometry was performed before treatment on 20 children with chronic functional constipation aged 4 to 12 years and the results were compared to those obtained after standard treatment, with a good outcome. RESULTS: There was a reduction in anal basal pressure after treatment, but no differences were detected between the anorectal manometries performed before and after treatment in terms of amplitude and duration of relaxation, residual pressure, latency time, or descent and ascent angle. CONCLUSIONS: We conclude that the anal basal pressure decreased in children recovering from chronic functional constipation, but the standard treatment did not provide all the conditions necessary for the relaxation reflex of constipated children to return to the values described in normal children.