Bowel dysfunction in spina bifida--an American experience with the ACE procedure.

Fecal incontinence remains a detriment to improved quality of life in many patients with spina bifida. Previous methods of conservative management frequently prove to be inadequate, causing many patients to withdraw from the social mainstream. Recent descriptions of procedures to provide access to the proximal colon for antegrade colonic enemas (ACE procedure) have provided a new approach to managing fecal incontinence. We report here our experience with these procedures in 43 patients with spina bifida. The background, techniques and outcomes of these procedures are discussed and a plea is made to consider this approach in all patients who are hampered in their social or vocational progress because of neurogenic anorectal dysfunction.

Laparoscopic appendicostomy for management of fecal incontinence.

Fecal incontinence from any cause is a socially unacceptable condition and a major detriment to educational and psychosocial development in young people with certain disabilities. Recently several procedures have been described that allow antegrade colonic enemas in the treatment of this problem. We report here an additional method of establishing this proximal colon access, namely laparoscopic appendicostomy. Although not applicable to all patients, this procedure has been successful in a select group with excellent results, and we recommend its consideration when open surgery is not otherwise required.

The Malone antegrade colonic enema enhances the quality of life in children undergoing urological incontinence procedures.

PURPOSE: Functional alterations of the gastrointestinal and genitourinary tracts, and physical limitations in children with spina bifida, imperforate anus and spinal cord injury challenge the ability to have independent fecal and urinary continence. Urologists have successfully helped these patients achieve urinary continence. We report our experience with the antegrade colonic enema procedure, which allows select individuals to achieve continence of stool, enhancing quality of life. MATERIALS AND METHODS: Since December 1992, 18 antegrade colonic enema procedures were performed in 12 female and 6 male patients 5 to 31 years old of whom 14 had spina bifida, 2 had imperforate anus and 2 had spinal cord injury. Simultaneous urological continence procedures were performed in 8 patients, including appendicovesicostomy in 4, augmentation cystoplasty in 2 and augmentation cystoplasty plus an ileal Mitrofanoff procedure in 2. Four patients previously underwent urological reconstruction. RESULTS: In 24 months of followup (average 6.6) all patients with a functioning stoma remained continent of stool and 17 were continent of urine. Complications related to the antegrade colonic enema procedure occurred in 4 children (22%) of whom 3 required further surgery. Three patients (17%) had minor stomal stenosis. CONCLUSIONS: The antegrade colonic enema procedure is easily performed and it should be considered for any child with significant physical limitations and/or refractory fecal incontinence before urological continence promoting procedures are done.

Resection of the inferior vena cava for recurrent Wilms' tumor.

Wilms' tumor is one of the most common solid tumors of childhood. Approximately 500 cases occur annually in the United States, and the overall incidence is 0.8 per 100,000 children per year. Direct involvement of the inferior vena cava occurs in 5% to 10% of cases. The National Wilms' Tumor Study (NWTS), an intergroup cooperative clinical trial, indicates that aggressive primary surgical management combined with chemo-radiation therapy improves (with respect to both survival and recurrence) the long-term prognosis for children who have extrarenal involvement. In addition, aggressive surgical resection may further improve the survival rate for patients with recurrent Wilms' tumor after initial multimodal therapy.

The popliteal artery entrapment syndrome in children.

This article reviews 41 cases of the popliteal artery entrapment syndrome in individuals less than 20 years of age. In this syndrome, symptoms are caused by vascular insufficiency produced by either an anomalous course of the popliteal artery or anomalous muscles impinging upon it. Because vascular insufficiency is uncommon in orthopedic patients in this age group and this syndrome has received little attention in the orthopedic literature, orthopedists unfamiliar with this relatively easily diagnosed condition may miss it.

Gastric infarction secondary to small bowel obstruction: a preventable complication after Nissen fundoplication.

Two infants who required a Nissen fundoplication for severe gastroesophageal reflux developed small bowel obstruction 5 and 21 months postoperatively. Their inability to belch or vomit, coupled with inappropriate airway management during resuscitation led to massive gastric dilation, and eventual infarction of their stomach, duodenum, and small intestines. These complications are preventable with appropriate management.

Protection of the solitary testis.

In 15 negative explorations for unilateral cryptorchidism, inspection of the contralateral scrotum revealed a "bell-clapper" deformity in 13 patients. Since the descent of the testis is influenced by the gubernaculum and gubernacular abnormalities are usually bilateral, the data suggest that an inadequate gubernaculum is associated with most instances of antenatal and postnatal torsion. Unilateral absence of the testis is a form of this syndrome; congenital monorchidism is probably due to antenatal torsion rather than hypoplasia or agenesis. When monorchidism is confirmed at operation, exploration and suture fixation of the contralateral testis at the same procedure is recommended to protect the solitary testis from future torsion.

Mycobacterial lymphadenitis.

The plan for cervical lymph node biopsy should include special maneuvers for recognition of patients with lymphadenitis due to atypical mycobacteria, since these children need extensive operations. The diagnosis should be suspected in children less than 3 yr old with lymphadenopathy present for several months and no exposure to cats (or with negative cat scratch skin tests). Wide local excision of all visibly involved nodes is recommended; acid-fast touch preparations should be done and interpreted during operation in any suspicious case. Limited operations should be avoided in children with mycobacterial lymphadenitis. The illness may be more common than previously suspected.

Radioisotope diagnosis of splenic trauma.

Multiple injury or delay in seeking medical attention may prevent confident clinical diagnosis of splenic trauma. The spleen scan is a rapid, simple, noninvasive test useful in such circumstances. When peritoneal lavage is contraindicated, unrevealing, or inapproapriate, radioisotope imaging of the spleen can help confirm a suspicion of splenic injury.