Assessing facial recognition after orthognathic surgery at automated border controls in airports.

The aim of this paper was to find out whether orthognathic surgery affects facial recognition at automated border controls in airports, and whether we should recommend that patients update their photographic identification postoperatively. We collected data on all 82 patients who had orthognathic surgery between August 2013 and June 2017. They were contacted by telephone and asked about any difficulties they had encountered when passing through automated or human-operated border controls or when using other forms of photographic identification such as driving licences. All questions were asked with reference to experiences before the operation. A total of 50 patients responded, of which 35 had travelled by aeroplane since their operations. Six of them had had problems passing through passport control (two human-operated and four automated) but after additional security checks had successfully continued their journeys. Four had had bimaxillary surgery, one had had maxillary advancement, and one mandibular advancement. Orthognathic surgery does affect identification at border controls, and most of our patients had had difficulties at automated checks because of the differences between the biometric data within the e-passport chip and the live biometric that was scanned. These findings will enable us to improve the information we give to our patients before operation, but further studies are required to increase the sample size and improve reliability.

Anorectal manometry with and without ketamine for evaluation of defecation disorders in children.

INTRODUCTION: Anorectal manometry (ARCM) provides valuable information in children with chronic constipation and fecal incontinence but may not be tolerated in the awake child. This study aimed to evaluate the effect of ketamine anesthesia on the assessment of anorectal function by manometry and to evaluate defecation dynamics and anal sphincter resting pressure in the context of pathophysiology of chronic functional (idiopathic) constipation and soiling in children. METHODS: This was a prospective study of children who were investigated for symptoms of chronic constipation and soiling between April 2001 and April 2004. We studied 52 consecutive children who had awake ARCM, biofeedback training and endosonography (awake group) and 64 children who had ketamine anesthesia for ARCM and endosonography (ketamine group). We age matched 31 children who had awake anorectal studies with 27 who had ketamine anesthesia. RESULTS: The children in awake and ketamine groups were comparable for age, duration of bowel symptoms and duration of laxative treatments. ARCM profile was comparable between the awake and the ketamine groups with regard to anal sphincter resting pressure, rectal capacity, amplitude of rectal contractions, frequency of rectal and IAS contractions and functional length of anal canal. Of 52 children who had awake ARCM, dyssynergia of the EAS muscles was observed in 22 (42%) and median squeeze pressure was 87mm Hg (range 25-134). The anal sphincter resting pressure was non-obstructive and comparable to healthy normal children. Rectoanal inhibitory reflex was seen in all children excluding diagnosis of Hirschsprung disease. CONCLUSIONS: Ketamine anesthesia does not affect quantitative or qualitative measurements of autonomic anorectal function and can be used reliably in children who will not tolerate the manometry while awake. Paradoxical contraction of the EAS can only be evaluated in the awake children and should be investigated further as the underlying cause of obstructive defecation in patients with chronic functional constipation and soiling.

Out with the old and in with the new: a comparison of rectal suction biopsies with traditional and modern biopsy forceps.

AIMS: Rectal suction biopsy, the gold standard for the diagnosis of Hirschsprung disease, has been associated with a varying incidence of complications and inadequate biopsy. The rbi2 is a modern alternative to the 'Noblett' biopsy forceps and has recently become available. The aim of this study was to compare the performance of this novel tool with the Noblett forceps. METHODS: Single-center retrospective study of all infants (<1 year) undergoing rectal suction biopsy from January 2004 to December 2007. During the study period, 2 different biopsy forceps were used--the Noblett forceps (first 2.5 years) and the rbi2 (last 1.5 years). A specimen was defined as inadequate if it was too small or contained inadequate submucosa for histological diagnosis. Fisher's Exact test and Mann-Whitney U test were used as appropriate. RESULTS: During the study period, 238 specimens were obtained from 88 infants in 102 biopsy episodes. Overall, 13 episodes were inadequate. There were no demographic differences between the 2 groups, and no serious complications (hemorrhage requiring transfusion, rectal perforation, pelvic sepsis) occurred in any infant. A significantly higher proportion of specimens taken with the Noblett forceps were inadequate compared with the rbi2 (Noblett 30/153 [20%] vs rbi2 6/85 [7%]; Relative risk (RR) = 2.8; 95% confidence interval, 1.2-6.3; P = .01). There was a nonsignificantly higher incidence of inadequate biopsy episode with the Noblett forceps compared with the rbi2 (Noblett 10/63 [16%] vs rbi2 3/40 [7%]; RR = 2.2; 95% confidence interval, 0.6-7.3; P = .24). The rbi2 carries a small cost premium for each biopsy episode compared with the Noblett forceps, but this is low when compared with the cost of repeat biopsy. CONCLUSIONS: Rectal suction biopsy is a safe procedure with a low incidence of complications. The rbi2 offers superior efficacy over the Noblett forceps, and its use is likely to be more cost-effective.

Evaluation of outcome of anorectal anomaly in childhood: the role of anorectal manometry and endosonography.

The aim of this study was to evaluate role of anorectal manometry (ARM) and anal endosonography (ES) in assessment of the internal anal sphincter (IAS) quality on continence outcome following repair of anorectal anomalies (ARA). We devised a scoring system to evaluate the quality of the IAS based on ARM and ES and correlated the scores with clinical outcome, using a modified Wingfield score (MWS) for faecal continence. We also assessed the implication of megarectum and neuropathy on faecal continence. Of 54 children studied, 34 had high ARA and 20 had low ARA. Children with high ARA had poor sphincters on ES and ARM, and also poor faecal continence compared to those with low ARA. The presence of megarectum and neuropathy was associated with uniformly poor outcome irrespective of the IAS quality. The correlations between MWS on one hand, and ES and ARM scores for IAS on the other hand were weak in the whole study group, ES r = 0.27, P < 0.04, and ARM r = 0.39, P < 0.004. However, the correlations were strong in those who had isolated ARA without megarectum or neuropathy, ES r = 0.51, P < 0.02 and ARM r = 0.55, P < 0.01, respectively. In conclusion, the ARM and ES are valuable in evaluation of continence outcome in children after surgery for ARA and those with good quality IAS had better faecal continence. The IAS is a vital component in functional outcome in absence of neuropathy and megarectum.

Management of childhood constipation.

The effective management of constipation in childhood requires an understanding of the ways that the physical and psychological factors interact. The early difficulty with defecation that leads to pain, fear, and refusal to use the pot or lavatory often progresses to the formation of vicious cycles of increasing faecal retention as the rectum increases in capacity and the experience of passing large, hard stools is repeated. There is increasing distress as overflow faecal incontinence compounds the problem for the older child. The medical, psychological, and surgical management strategies are reviewed together with the rationale for their use.

Investigations for incontinence and constipation after surgery for Hirschsprung's disease in children.

Surgery for Hirschsprung's disease is associated with high rate of morbidity, in the form of either constipation or incontinence or a combination of the two. This study investigates the mechanisms responsible for incontinence and/or constipation following the pull-through operation for Hirschsprung's disease. There were 19 children (15 boys and 4 girls), who at the time of study; 16 had undergone Duhamel, 1 Rehbein, and 2 Soave operation. We classified patients according to their symptoms into 3 groups: Group A was incontinent of faeces; Group B was constipated and incontinent of faeces, and Group C was constipated only. The median age at referral was 6 years, and the median period after operation was 5 years. All patients were investigated by intestinal transit study, endoanal sonography and anorectal manometry. Group A had normal or rapid transit study, as opposed to Groups B and C, who had delayed-transit study. On endoanal sonography, all children had an intact internal and an external anal sphincter, below the level of pull-through operation. The anorectal manometry showed a significantly lower resting anal pressure in the incontinent Group A as compared to the constipated children with or without incontinence in Group B or C (38 mmHg versus 57 or 66 mmHg respectively). The rectal pressure was also significantly higher in children in Group A as compared to those in Group B or C (71 mmHg versus 42 or 36 mmHg). The ratio of rectal/anal pressure was higher in incontinent children in Group A, as compared to constipated children in Group B or C. Therefore, constipation can be caused by high anal resting pressure and a weak rectal peristalsis, while faecal incontinence can be secondary to poor compliance and elevated rectal pressure in the presence of normal or low anal sphincter resting pressure. Aperients are the mainstay of treatment of constipation, however, children with incontinence are more difficult to treat. We did not attempt to define the pattern of nerve plexus because of poor results of revision operation for residual hypoganglionic segment and intestinal neuronal dysplasia. Treatment of these children can become more rational, if furnished with detailed functional studies. We advocate investigation of the anorectal function at an early stage in symptomatic children after surgery for Hirschsprung's disease, and less invasive treatment should be considered before embarking on major surgery.

Incarceration of umbilical hernia in children: is the trend increasing?

Umbilical hernias are common in infants and young children. The natural history of umbilical hernia is spontaneous closure, usually in the first 3 years of life. Complications of incarceration or strangulation of an umbilical hernia are believed to be rare. Therefore, an expectant policy of non-operative management until at least 5 years of age has been considered acceptable. We have managed seven children with complications of umbilical hernia in the past three years. We have reviewed the epidemiological changes in the incidence of abdominal wall defects in children and postulated a possible relationship to the increasing trend of incarceration of umbilical hernias.

Urological consequences of incomplete cord lesions in patients with myelomeningocele.

OBJECTIVES: To determine the urological consequences of incomplete cord lesions in patients with myelomeningocele and a neuropathic bladder. PATIENTS AND METHODS: From a total of 407 patients with myelomeningocele and a neuropathic bladder, 31 (8%) were identified as having a combination of sacral sensory or motor sparing and positive conus reflexes. Their case-notes were reviewed with reference to spinal neurology, patterns of micturition, including the degree of spontaneous continence, findings on imaging and urodynamic studies, and forms and outcomes of any treatment given. RESULTS: The anatomical distribution of the lesions was thoracic (two), thoracolumbar (three), lumbar (six), lumbosacral (four) and sacral (11). The mean age at presentation was 9.5 years (range 3.5-19.5) and the mean follow-up 4.5 years (range 0.5-10.5). At presentation, 14 patients had urinary incontinent episodes both day and night, 10 by day only, seven by night only, and the upper urinary tracts were dilated in eight (26%). Nineteen were ambulant unaided and 10 with aid of crutches or calipers, whilst two were wheelchair-bound. Only one patient had faecal incontinence. A urodynamic examination in 18 patients showed competent sphincteric mechanism and detrusor hyper-reflexia in all, and detrusor sphincter dyssynergia in 11. The methods of treatment included oxybutynin and/or clean intermittent catheterization alone or in combination. Thirty patients are currently reliably dry by day and 26 also by night. Five patients have undergone surgical treatment for vesico-ureteric reflux, three a Mitrofanoff procedure and two augmentation cystoplasty. CONCLUSION: Although patients with congenital incomplete cord lesions and positive conus reflexes may gain some measure or urinary continence spontaneously, they are at serious risk of developing upper urinary tract complications. The treatment of urinary continence is simple and effective because there is a competent sphincter mechanism. These patients require life-long supervision even if they require no treatment for urinary incontinence.

Wandering calcified ovary in children.

A case of a mobile, calcified, intrapelvic mass representing an autoamputated ovary in an asymptomatic girl is presented. There was no previous history of acute abdominal pain indicating possible torsion of the adnexa. The diagnosis should be suspected when radiological investigations show a freely mobile, calcified intraperitoneal mass incidentally in young females with absent adnexa. The diagnostic and therapeutic role of laparoscopy in this case is emphasised.

Recent developments in the management of Peutz-Jeghers syndrome in childhood.

A combined surgical and endoscopic approach for managing extensive polyposis in a child with Peutz-Jeghers syndrome (PJS) is presented. Application of this technique offers the following advantages over conventional surgical practice -- 1) an accurate assessment can be made of the extent of intestinal polyposis; 2) small polyps can be easily removed endoscopically; 3) endoscopy can direct the operating surgeon to selected enterotomy sites for open excision of larger polyps and 4) multiple laparotomy, extensive intestinal resection(s) and the potential threat of short-gut syndrome in PJS patients may be avoided.