Refractory functional constipation: clinical management or appendicostomy? / Constipação intestinal funcional refratária: manejo clínico ou apendicostomia?

Abstract Objective: To compare the clinical evolution in patients with refractory functional constipation undergoing different therapeutic regimens: oral laxatives and antegrade enemas via appendicostomy or clinical treatment with oral laxatives and rectal enemas. Methods: Analysis of a series of 28 patients with a mean age of 7.9 years (2.4-11), followed-up in a tertiary outpatient clinic. Refractory functional constipation was defined as continuous retentive fecal incontinence after at least a 12-month period of consensus therapy. After the diagnosis of refractory condition, appendicostomy was proposed and performed in 17 patients. Outcomes: (1) persistence of retentive fecal incontinence despite the use of enemas, (2) control of retentive fecal incontinence with enemas, and (3) control of retentive fecal incontinence, spontaneous evacuations, with no need for enemas. Results: Six and 12 months after the therapeutic option, control of retentive fecal incontinence was observed only in patients who underwent surgery, 11/17 and 14/17, p = 0.001 and p = 0.001, respectively. At 24 months, control of retentive fecal incontinence was also more frequent in operated patients: 13/17 versus 3/11 with clinical treatment, p = 0.005. In the final evaluation, the median follow-up times were 2.6 and 3 years (operated vs. clinical treatment, p = 0.40); one patient in each group was lost to follow-up and 9/16 operated patients had spontaneous bowel movements vs. 3/10 in the clinical treatment group, p = 0.043. Surgical complications, totaling 42 episodes, were observed 14/17 patients. Conclusion: Appendicostomy, although associated with a high frequency of complications, controlled retentive fecal incontinence earlier and more frequently than clinical treatment. The choice of one of the methods should be made by the family, after adequate information about the risks and benefits of each alternative.

Resumo Objetivo Comparar a evolução clínica em crianças com constipação intestinal funcional refratária sob diferentes regimes terapêuticos: laxativos orais e enemas anterógrados via apendicostomia ou tratamento clínico com laxativos orais e enemas via retal. Métodos Análise de uma série de 28 pacientes, 7,9 anos (2,4-11), acompanhados em ambulatório terciário. Constipação intestinal funcional refratária foi definida como manutenção da incontinência fecal retentiva, em terapia consensual, por pelo menos 12 meses. Após diagnóstico de refratariedade, era proposta apendicostomia. Dezessete pacientes realizaram o procedimento cirúrgico. Desfechos: 1. Manutenção de incontinência fecal retentiva em uso de enemas; 2. Controle da incontinência fecal retentiva em uso de enemas; e 3. Controle da incontinência fecal retentiva, evacuações espontâneas, sem necessidade de enemas. Resultados Seis e 12 meses após opção terapêutica, controle da incontinência fecal retentiva foi observado apenas nos pacientes operados, 11/17 e 14/17, p = 0,001 e p = 0,001. Aos 24 meses, controle da incontinência fecal retentiva também mais frequente nos operados 13/17 versus 3/11 tratamento clínico, p = 0,005. Na avaliação final, medianas de tempo de seguimento: 2,6 e 3 anos (operados versus tratamento clínico, p = 0,40), um paciente em cada grupo abandonou o seguimento e 9/16 operados apresentavam evacuações espontâneas versus 3/10 no tratamento clínico, p = 0,043. Complicações cirúrgicas, 42 episódios, acometeram 14/17 pacientes. Conclusão A apendicostomia, embora associada a elevada frequência de complicações, controlou a incontinência fecal retentiva de maneira mais precoce e frequente do que o tratamento clínico. A escolha de um dos métodos deverá caber à família, após adequada informação sobre riscos e benefícios de cada alternativa.

Refractory functional constipation: clinical management or appendicostomy?

OBJECTIVE: To compare the clinical evolution in patients with refractory functional constipation undergoing different therapeutic regimens: oral laxatives and antegrade enemas via appendicostomy or clinical treatment with oral laxatives and rectal enemas. METHODS: Analysis of a series of 28 patients with a mean age of 7.9 years (2.4-11), followed-up in a tertiary outpatient clinic. Refractory functional constipation was defined as continuous retentive fecal incontinence after at least a 12-month period of consensus therapy. After the diagnosis of refractory condition, appendicostomy was proposed and performed in 17 patients. OUTCOMES: (1) persistence of retentive fecal incontinence despite the use of enemas, (2) control of retentive fecal incontinence with enemas, and (3) control of retentive fecal incontinence, spontaneous evacuations, with no need for enemas. RESULTS: Six and 12 months after the therapeutic option, control of retentive fecal incontinence was observed only in patients who underwent surgery, 11/17 and 14/17, p=0.001 and p=0.001, respectively. At 24 months, control of retentive fecal incontinence was also more frequent in operated patients: 13/17 versus 3/11 with clinical treatment, p=0.005. In the final evaluation, the median follow-up times were 2.6 and 3 years (operated vs. clinical treatment, p=0.40); one patient in each group was lost to follow-up and 9/16 operated patients had spontaneous bowel movements vs. 3/10 in the clinical treatment group, p=0.043. Surgical complications, totaling 42 episodes, were observed 14/17 patients. CONCLUSION: Appendicostomy, although associated with a high frequency of complications, controlled retentive fecal incontinence earlier and more frequently than clinical treatment. The choice of one of the methods should be made by the family, after adequate information about the risks and benefits of each alternative.

Colonic transit in children and adolescents with chronic constipation / Trânsito intestinal em crianças e adolescentes com constipação crônica

OBJECTIVE: The aim of this study was to assess clinical features and colonic transit patterns in Brazilian children with refractory constipation.METHODS: From 2010 to 2013, 79 constipated patients received follow-up care in a tertiary hospital. Of these patients, 28 (aged 8-14 years) were refractory to conventional therapy and underwent a simplified visual method of nuclear colonic transit study, by ingestion of a liquid meal containing 9.25 MBq/kg of 99mTc-phytate. Abdominal static images were taken immediately and at two, six, 24, 30, and 48 h after ingestion for qualitative analysis of the radio marker progression through the colon.RESULTS: Two patterns of colonic transit were found: slow colonic transit (SCT,n = 14), when images at 48 h showed a larger part of the tracer remained in proximal and transverse colon, and distal retention (DR, n = 14), when after 30 h, the radio isotope passed the transverse colon and was retained in the rectosigmoid up to 48 h. The SCT and DR group included, respectively, nine and ten males; median ages in the nuclear study of 11 and 10 years, p = 0.207; median duration of constipation of seven and six years, p = 0.599. Constipation appearing during first year age (p = 0.04) and report of soft stools (p = 0.02) were more common in SCT patients. Palpable abdominal fecal impaction was found only in DR group. Appendicostomy for antegrade continence enema was successful in 4/12 (30%) of SCT patients (median follow-up: 2.4 years).CONCLUSION: Nuclear transit study distinguished two colonic dysmotility patterns and was useful for guiding refractory patients to specific therapies.

OBJETIVO: Avaliar as características clínicas e os padrões de trânsito intestinal em crianças brasileiras com constipação refratária.MÉTODOS: De 2010 a 2013, 79 pacientes constipados receberam acompanhamento em um hospital terciário. Desses pacientes, 28 (entre 8-14 anos) foram identificados como terapia refratária a convencional e passaram por um método visual simplificado de estudo nuclear do trânsito intestinal, com ingestão de uma refeição líquida contendo 9,25 MBq/Kg de fitato-99mTc. Imagens estáticas abdominais foram tiradas imediatamente e em duas, seis, 24, 30 e 48 horas após a ingestão para uma análise qualitativa da progressão do marcador radioativo pelo cólon.RESULTADOS: Foram encontrados dois padrões de trânsito intestinal: trânsito intestinal lento (STC, n = 14), quando as imagens de 48 horas mostraram que grande parte do marcador permaneceu no cólon proximal e transversal; e retenção distal (DR, n = 14), quando, após 30 horas, o radioisótopo havia passado o cólon transverso e estava retido no retossigmoide até 48 horas. O grupo STC e o grupo DR incluíram, respectivamente, nove e 10 meninos; idade média no momento do NTS: 11 e 10 anos, p = 0,207; duração média de constipação: sete e seis anos, p = 0,599. Sintomas de constipação durante o primeiro ano de idade (p = 0,04) e relatos de fezes moles (p = 0,02) foram mais comuns em pacientes com STC. Observou-se impactação fecal abdominal palpável apenas no grupo DR. A apendicostomia para enema anterógrado para continência foi bem-sucedida em 4/12 (305) pacientes com STC (acompanhamento médio: 2,4 anos).CONCLUSÃO: O estudo nuclear do trânsito diferenciou dois padrões de dismotilidade intestinal e foi útil para orientar pacientes refratários a terapias específicas.

Colonic transit in children and adolescents with chronic constipation.

OBJECTIVE: The aim of this study was to assess clinical features and colonic transit patterns in Brazilian children with refractory constipation. METHODS: From 2010 to 2013, 79 constipated patients received follow-up care in a tertiary hospital. Of these patients, 28 (aged 8-14 years) were refractory to conventional therapy and underwent a simplified visual method of nuclear colonic transit study, by ingestion of a liquid meal containing 9.25 MBq/kg of (99m)Tc-phytate. Abdominal static images were taken immediately and at two, six, 24, 30, and 48h after ingestion for qualitative analysis of the radio marker progression through the colon. RESULTS: Two patterns of colonic transit were found: slow colonic transit (SCT, n=14), when images at 48h showed a larger part of the tracer remained in proximal and transverse colon, and distal retention (DR, n=14), when after 30h, the radio isotope passed the transverse colon and was retained in the rectosigmoid up to 48h. The SCT and DR group included, respectively, nine and ten males; median ages in the nuclear study of 11 and 10 years, p=0.207; median duration of constipation of seven and six years, p=0.599. Constipation appearing during first year age (p=0.04) and report of soft stools (p=0.02) were more common in SCT patients. Palpable abdominal fecal impaction was found only in DR group. Appendicostomy for antegrade continence enema was successful in 4/12 (30%) of SCT patients (median follow-up: 2.4 years). CONCLUSION: Nuclear transit study distinguished two colonic dysmotility patterns and was useful for guiding refractory patients to specific therapies.

Postoperative vomiting in pediatric oncologic patients: prediction by a fuzzy logic model.

OBJECTIVE: To report a fuzzy logic mathematical model to predict postoperative vomiting (POV) in pediatric oncologic patients and compare with preexisting scores. BACKGROUND: Although POV has a high incidence in children and may decrease parental satisfaction after surgeries, there is only one specific score that predicts POV in children: the Eberhart's score. In this study, we report a fuzzy model that intends to predict the probability of POV in pediatric oncologic patients. Fuzzy logic is a mathematical theory that recognizes more than simple true and false values and takes into account levels of continuous variables such as age or duration of the surgery. The fuzzy model tries to account for subjectiveness in the variables. METHODS: Preoperative potential risk factors for POV in 198 children (0-19 year old) with malignancies were collected and analyzed. Data analysis was performed with the chi-square test and logistic regression to evaluate probable risk factors for POV. A system based on fuzzy logic was developed with the risk factors found in the logistic regression, and a computational interface was created to calculate the probability of POV. RESULTS: The model showed a good performance in predicting POV. After the analysis, the model was compared with Eberhart's score in the same population and showed a better performance. CONCLUSIONS: The fuzzy score can predict the chance of POV in children with cancer with good accuracy, allowing better planning for postoperative prophylaxis of vomiting. The computational interface is available for free download at the internet and is very easy to use.

Kidney safety during surgical pneumoperitoneum: an experimental study in rats.

BACKGROUND: Elevations of intraabdominal pressure during laparoscopic procedures may lead to oliguria or anuria in mammals. Despite this, previous research has not been able to confirm an associated kidney injury. This study aimed to investigate the occurrence of an early kidney lesion secondary to surgical pneumoperitoneum in a rat model using the expression of neutrophil gelatinase-associated lipocalin (N-GAL) as a biomarker for early kidney injury. METHODS: In this study, 20 male Sprague-Dawley rats under general anesthesia and mechanically ventilated were allocated to one of five experimental time-dependent groups: group 1 (1-h control), group 2 (1-h pneumoperitoneum), group 3 (2-h control), group 4 (2-h pneumoperitoneum), and group 5 (positive kidney injury group induced by intravenous administration of cisplatin 7.5 mg/kg). To evaluate the renal expression of N-GAL 24 h after the procedure, all the rats underwent a 2-h urine output evaluation as well as laparotomy and bilateral nephrectomy performed sequentially to investigate the presence of renal injury using immunofluorescence qualification and western blotting. RESULTS: Urine output was reduced and N-GAL expression was increased in the animals from the cisplatin group. The animals undergoing 1- or 2-h pneumoperitoneum displayed urine output and N-GAL expression similar to that of the animals from the matching control groups. CONCLUSIONS: Under the experimental conditions of this study, the animals with normal preoperative renal function did not show any type of acute kidney injury associated with the presence of a stabilized surgical pneumoperitoneum.

Evaluation of a simple valve mechanism used to stabilize intraabdominal pressure during surgically induced pneumoperitoneum in small animals.

BACKGROUND: Preventing sudden changes in intraabdominal pressure (IAP) during surgical pneumoperitoneum may reduce adverse events. This study aimed to describe a valve system that stabilizes intraabdominal pressure, minimizing complications of erratic fluctuations in IAP. METHODS: Five male Sprague-Dowley rats were submitted to pneumoperitoneum, with the insufflator set sequentially at 5, 10, and 15 mmHg for each rat. Measures of IAP were taken initially without the valve and then using the same insufflator levels with the valve system regulated to three different pressures (5, 10, and 15 mmHg). The mean of the three highest registered pressures during a 15-min observation was used as the maximal pressure, and the mean of the three lowest registered pressures was used as the minimal pressure for each experimental setting. RESULTS: Without the valve system, the pressure level set by the insufflator correlated poorly with the actual IAP. When the valve system was used, the IAP pressure was limited by the valve settings regardless of the insufflator settings. Also, the variability of IAP was significantly higher when no valve was used than in all situations that had implementation of the system. CONCLUSIONS: The valve system was very effective in stabilizing IAP, allowing a reproducible and reliable estimate of IAP and greatly reducing the variability resulting from the cycling mechanism of the insufflator. Due to the small dimensions of intracorporeal cavities in the newborn, this mechanism may help to improve safety when neonatal video-assisted surgery is performed.

Babies with brain damage who can not swallow: surgical management.

BACKGROUND: Neonates with severe neurological impairment are often unable to swallow, necessitating gastrostomy for feeding. Because of the risk of developing severe reflux, this procedure is often associated with fundoplication. OBJECTIVE: To assess the safety and efficacy of gastrostomy and Nissen fundoplication in 22 neonates with swallowing difficulties due to serious neurological impairment. METHOD: All children underwent an initial period of nasogastric feeding and after informed consent underwent gastrostomy and Nissen fundoplication. RESULTS: There were no significant intraoperative complications. There were two cases of postoperative periostomy leakage. Of the 22 neonates 16 were alive four months after surgery. Six neonates died of complications due to underlying disease. CONCLUSION: We concluded that gastrostomy and Nissen fundoplication are safe procedures and help parents give a better care to these children.

The female condom as a temporary silo: a simple and inexpensive tool in the initial management of the newborn with gastroschisis.

OBJECTIVE: The aim of this study is to report the use of a female condom as a non-surgical silon pouch in the early management of newborns with gastroschisis with large visceroabdominal disproportion. METHODS: Pre-washed, sterile female condoms without spermicide were used as an early approach to treat gastroschisis in 20 newborns with large defects and in whom staged correction was anticipated. The condom was placed in the neonatal intensive care unit using sterile technique, with no anesthesia, and it was removed only at the time of the surgical procedure for gastroschisis correction. RESULTS: There were no complications associated with the use of a female condom as a temporary silo for gastroschisis. It protected the exposed organs and also allowed a careful evaluation of the bowel and a better pre-operative planning without the need for emergency procedures. CONCLUSION: The use of a female condom as a silon pouch is a low-cost and simple alternative in the initial management of newborns with gastroschisis in whom primary correction is considered non-feasible.

Babies with brain damage who can not swallow: surgical management / Recém-nascidos com lesão cerebral que não deglutem: manejo cirúrgico

BACKGROUND: Neonates with severe neurological impairment are often unable to swallow, necessitating gastrostomy for feeding. Because of the risk of developing severe reflux, this procedure is often associated with fundoplication. OBJECTIVE: To assess the safety and efficacy of gastrostomy and Nissen fundoplication in 22 neonates with swallowing difficulties due to serious neurological impairment. METHOD: All children underwent an initial period of nasogastric feeding and after informed consent underwent gastrostomy and Nissen fundoplication. RESULTS: There were no significant intraoperative complications. There were two cases of postoperative periostomy leakage. Of the 22 neonates 16 were alive four months after surgery. Six neonates died of complications due to underlying disease. CONCLUSION: We concluded that gastrostomy and Nissen fundoplication are safe procedures and help parents give a better care to these children.

INTRODUÇÃO: Neonatos com dano neurológico são freqüentemente incapazes de deglutir necessitando de gastrostomia para alimentação. Devido ao risco de refluxo grave, esse procedimento é associado à fundoplicatura. OBJETIVO: Avaliar a segurança e eficácia da gastrostomia com fundoplicatura Nissen em 22 neonatos com dificuldades de deglutição devido à lesão neurológica grave. MÉTODO: Todos os neonatos foram submetidos a um período inicial de alimentação por sonda nasogástrica e, após consentimento informado, foram submetidos a gastrostomia com fundoplicatura Nissen. RESULTADOS: Não houve complicações intra-operatórias significativas. Houve dois casos de vazamento pós-operatório da ostomia. Dos 22 neonatos, 16 estavam vivos 4 meses após a cirurgia. Seis neonatos morreram por complicações devido à doença de base. CONCLUSÃO: A gastrostomia com fundoplicatura Nissen é procedimento seguro e ajuda os pais a darem melhor cuidado a crianças com lesão neurológica.

Changes in intestinal motility and in the myenteric plexus in a rat model of intestinal ischemia-reperfusion.

BACKGROUND/PURPOSE: Early histologic changes induced by intestinal ischemia-reperfusion injury (IIRI) have been extensively studied using animal models. However, information regarding late effects on intestinal motility is lacking. The aim of this study was to investigate the late effects of IIRI on myenteric plexus histology and intestinal motility. MATERIALS AND METHODS: Thirty-two postweaning male rats weighing between 58 and 103 g were divided randomly into 4 groups: Control (unoperated), Sham (celiotomy), 30-minute ischemia (celiotomy and superior mesenteric artery ischemia for 30 minutes), and 45-minute ischemia (celiotomy and superior mesenteric artery ischemia for 45 minutes). Postoperative intestinal motility was assessed by weighing total fecal output for 24 hours on the 3rd, 7th, 14th, and 21st day after surgery. Segments of duodenum, jejunum, and ileum were examined at light microscopy for changes in the myenteric plexus. RESULTS: Three weeks after IIRI, the ganglion cells from the myenteric plexus appeared in light microscopy, spongy or foamy, containing many vacuoles in their cytoplasm. The neuronal nucleus became irregular, with degenerative signs. These alterations did not occur among animals from the control or sham groups. Although the animals of the 45-minute ischemia group showed a significant drop in fecal output in the 21st postoperative day, this appeared to have no effect on weight gain. CONCLUSIONS: The results suggest that intestinal ischemia-reperfusion causes late neuronal damage. These changes resulted in alterations of intestinal motility, which, within the conditions of the present study, had no repercussion on general weight gain.

Laparoscopic upper-pole nephroureterectomy in infants.

OBJECTIVE: Report the results of laparoscopic upper-pole nephroureterectomy in infants. MATERIALS AND METHODS: Six consecutive infants underwent 7 laparoscopic upper-pole nephroureterectomy. Pre and postoperative evaluation included renal sonography, voiding cystourethrogram and renal scintigraphy. All infants showed upper-pole exclusion. Surgery was performed through a transperitoneal approach with full flank position in all infants. Three or 4 ports were used according to the necessity of retracting the liver. The distal ureter was ligated close to the bladder whenever reflux was present and the dysplastic upper-pole was divided with the help of an electrocautery. Data regarding operative time, postoperative use of analgesics, time to resume oral feeding, hospital stay and tubular function were collected and analyzed. RESULTS: All procedures were concluded as planned. Mean operative time was 135 min. One patient underwent staged bilateral upper-pole nephrectomy. There were no complications and the postoperative hospital stay was 48 hours in 5 procedures and 24 hours in 2 procedures. Pain medication was required only in the first day. Renal tubular function showed improvement in half of the cases. CONCLUSION: Laparoscopic partial nephrectomy is a safe and feasible procedure in infants. Due to the magnification provided by the lenses, a better vision of the structures is achieved, facilitating selective dissection of vascular upper-pole, renal parenchyma and distal ureter. This approach is less damaging to the lower pole, and is associated to low morbidity and a short hospital stay.

Laparoscopic upper-pole nephroureterectomy in infants

OBJECTIVE: Report the results of laparoscopic upper-pole nephroureterectomy in infants. MATERIALS AND METHODS: Six consecutive infants underwent 7 laparoscopic upper-pole nephroureterectomy. Pre and postoperative evaluation included renal sonography, voiding cystourethrogram and renal scintigraphy. All infants showed upper-pole exclusion. Surgery was performed through a transperitoneal approach with full flank position in all infants. Three or 4 ports were used according to the necessity of retracting the liver. The distal ureter was ligated close to the bladder whenever reflux was present and the dysplastic upper-pole was divided with the help of an electrocautery. Data regarding operative time, postoperative use of analgesics, time to resume oral feeding, hospital stay and tubular function were collected and analyzed. RESULTS: All procedures were concluded as planned. Mean operative time was 135 min. One patient underwent staged bilateral upper-pole nephrectomy. There were no complications and the postoperative hospital stay was 48 hours in 5 procedures and 24 hours in 2 procedures. Pain medication was required only in the first day. Renal tubular function showed improvement in half of the cases. CONCLUSION: Laparoscopic partial nephrectomy is a safe and feasible procedure in infants. Due to the magnification provided by the lenses, a better vision of the structures is achieved, facilitating selective dissection of vascular upper-pole, renal parenchyma and distal ureter. This approach is less damaging to the lower pole, and is associated to low morbidity and a short hospital stay.

Effect of different types of fundoplication on the gastric emptying of liquids and gastric compliance in rats.

BACKGROUND/PURPOSE: The aim of this study is to evaluate the early and late effects of partial fundoplication (PFp) and total fundoplication (TFp) on gastric emptying (GE) and on gastric compliance (GC) in rats. METHODS: One hundred fifty-nine male Wistar rats, 6 to 8 weeks of age and weighing 150 to 250 g underwent sham operation, PFp or TFp. They were randomly divided into early group (group E) and late group (group L), evaluated on the 7th and 28th postoperative days, respectively. Gastric emptying studies were performed with and without short-term induction of GE delay. RESULTS: Gastric emptying studies: In group E, TFp altered gastric retention when compared with sham subgroup in rats with GE delay. In group L, neither PFp nor TFp produced changes in GE. Gastric volume-gastric compliance studies: In group E, only TFp reduced significantly gastric volume, but both PFp and TFp caused a significant decrease in GC. A trend toward normalization of gastric volume and GC was perceived in group L. Partial fundoplication did not change the intragastric pressure response in either group E or group L. Total fundoplication increased the intragastric pressure significantly in group E, but this difference disappeared on the 28th postoperative day. CONCLUSIONS: Partial fundoplication induces less change in gastric motor physiology than TFp. These findings provide background to explain some differences in the postoperative course after PFp and TFp.

Genitoplastia feminizante e hiperplasia congênita das adrenais: análise dos resultados anatômicos / Feminizing genitoplasty and congenital adrenal hyperplasia: analysis of anatomical results

OBJETIVO: Avaliar os resultados anatômicos e cosméticos das genitoplastias feminizantes realizadas em meninas com genitália ambígua devido à Hiperplasia Congênita das Adrenais (HCA). CASUíSTICA E MÉTODOS: Vinte e sete meninas com HCA e ambigüidade genital (Prader III-V) foram submetidas a genitoplastia feminizante em um estágio e acompanhadas por período médio de quatro anos. Em doze meninas, dois retalhos labioescrotais em ilha foram associados à genitoplastia convencional para adequar os grandes lábios e ampliar o intróito vaginal. Episódios de infecção urinária foram observados em dezesseis meninas no pré-operatório e em apenas sete no pós-operatório. Os resultados cosméticos foram avaliados por meio de sistematização da avaliação anatômica das diferentes estruturas RESULTADOS: Os da clitoroplastia foram considerados bons em 62,9 por cento dos casos; houve atrofia clitoriana em quatro meninas. Excesso de grandes lábios ocorreu em 25 por cento, e persistência do seio-urogenital em 11 por cento (três meninas nas quais não havia sido associado retalho labioescrotal). O retalho labioescrotal em ilha foi considerado de simples confecção e reprodução. Cinco meninas precisaram ser re-operadas. De um modo geral, os resultados cosméticos foram considerados ótimos ou bons em 63 por cento dos casos, satisfatórios em 18,5 por cento e insatisfatórios ou ruins em 18,5 por cento. CONCLUSÕES: Os resultados anatômicos e cosméticos foram classificados como bons na maioria dos casos, porém alguns aspectos técnicos devem ser ajustados com a intenção de evitar complicações irreversíveis e re-operações.

[Feminizing genitoplasty and congenital adrenal hyperplasia: analysis of anatomical results]. / Genitoplastia feminizante e hiperplasia congênita das adrenais: análise dos resultados anatômicos.

OBJECTIVE: To evaluate the anatomical and cosmetic results of feminizing genitoplasty in girls with ambiguous genitalia due to Congenital Adrenal Hyperplasia (CAH). CASUISTIC AND METHOD: Twenty-seven females with genital ambiguity (Prader III-V) due to CAH underwent an one-stage feminizing genitoplasty and were followed for a mean time of 4 years. In twelve girls, two cutaneous labioscrotal island-flaps were associated with the conventional genitoplasty, to decrease the excess of labia majora and to enlarge the vaginal introitus. Urinary tract infections were observed in sixteen girls in the preoperative and in only seven in the postoperative period. The cosmetic results were obtained by the systematic anatomical evaluation of the different structures that compose the genitalia. RESULTS: The results of clitoroplasty were considered good in 63% of the cases; however, 4 girls developed clitoral atrophy. An excess of labia majora was present in 25% and persistence of the urogenital sinus occurred in 11% (three children without labioscrotal island flap). The labioscrotal island flap was considered technically feasible and reproducible. Five girls had to be re-operated. The cosmetic results were considered excellent or good in 63% of the cases, satisfactory in 18.5% and unsatisfactory or bad in 18.5%. CONCLUSIONS: The anatomical and cosmetic results were good in majority of the cases; however, some technical aspects should be adjusted, to avoid irreversible sequels and re-operations.

Papel da manometria anorretal no diagnóstico diferencial da conspitação em crianças / Role of anorectal manomeetry in the differentiall diagnosis of chronic constipation in children

Objetivos: 1.Avaliar a acurácia da manometria anorretal na identicação da constipação secundária à disfunção dos plexos mioentéricos e 2.correlacinar características clínicas com o diagnóstico etiológico da constipação. Métoodos: O diagnóstico etiológico da constipação foi identificado retrospectivamente dos prontuários de 57 pacientes que realizaram manometria anorretal no Laboratório de Gastroenterologia Pediátrica do Hospital de Clínicas/UNICAMP. O procedimento foi realiazado utilizando-se balão único e sistema de perfusão capilar pneumo-hidráulico, em que a pressão transmitida a um polígrafo era apresentada, por meio de software específico, em mmHg. O exame foi indicado para pacientes que, após 6 a 23 meses de tratamento com laxativo osmóticos e fíbras alimentares (20 g/dia), mantiveram a necessidade de clisteres evaculatórios e/ou apresentaram recidiva de impactação fecal. Regularização do hábito intestinal por pelo menos 24 meses de seguimento ou visualização de anormalidades morfológicas dos plexos mioentéricos em biópsia retal foram considerados como pontos de referência para dianóstico definitivo. Resultados: O reflexo inibitório retoesfincteriano foi identificado nos traçados manométricos de 44 dos 57 pacientes (77 por cento). Os 13 pacientes nos quais o reflexo não foi desencadeado realizaram biópsia retal. O estudo histológico dessas amostras, coradas pela hematoxilina-eosina, identificou anormalidades dos plexos mioentéricos em 10 pacientes. Um segundo estudo manométrico nos outros três pacientes identificou reflexo retoesfincteriano. Sensibilidade, especificidade, valores preditivos positivo e negativo do estudo manométrico foram, repectivamente, 1,000; 0,94; 0,77 e 1,00.Conclusão: Manometria anorreetal é uma técnica de investigação com pequena possibilidade de erro no diagnóstico diferencial entre a constipação funcional e secundária a distúrbios dos plexos mioentéricos

Cisto de colédoco: experiência de 10 anos / Choledochal cyst: a 10-year experience

Introdução: O prognóstico do tratamento do cisto colédoco depende do diagnóstico precoce, da exérese completa e da derivação bileo-digestiva adequada. Objetivo: Avaliar os resultados do tratamento cirúrgico do cisto de colédoco. Métodos: Análise retrospectiva dos prontuários de 18 pacientes operados por cisto de colédoco. Resultados e discussão: Idade variando de 20 dias a 13 anos. 15 (83 por cento) eram do sexo feminino e 03 (17 por cento) do sexo masculino. A apresentação inicial dos pacientes foi seguinte: 15 (83 por centro) pacientes com icterícia, colúria em 11 (61 por cento), acolia fecal em 10 (55 por cento), dor abdominal em 09(50 por cento) e massa papável em 02 (11 por cento). O ultra-som de abdome foi diagnóstico em 14 (77 por cento) pacientes. A colangiopancreatografia endoscóspica retrógada foi realizada em 04 pacientes, demonstrando um ducto comum longo em três. Nove pacientes apresentavam cisto tipo I, 01 tipo II, 07 tipo IV e 01 tipo V. Com exceção do paciente com cisto de colédoco tipo V, todos foram submetidos a exérese do cisto mais hepaticojejunostomia em Y de Roux. Este paciente submeteu-se apenas à derivação bileo-digestiva. Houve dois (11 por cento) óbitos pós-operatórios por complicações ligadas à deterioração da função hepática. Dos 15 pacientes que puderam ser seguidos a longo prazo, dois (14 por cento) apresentam pancreatite crônica e 13 (86 por cento) estão bem, sem evidências de complicações tardias com o tratamento efetuado