[Evaluation of the anal position in newborns and children with chronic constipation. Incidence of anterior ectopic anus]. / Valoración de la posición del ano en recién nacidos y en niños con estreñimiento crónico. Incidencia del ano anterior ectópico.

INTRODUCTION: Anterior ectopic anus (AEA), continues to be a controversial issue. The objective is to determine the normal position of the anus or anal ano-genital index (AGI) in newborns (NB) and in a group of infants with chronic constipation, know the incidence of AEA in both groups, and its relationship with constipation. METHODS: A prospective aleatory study is performed in where the AGI is determined in 529 NB and 64 older patients with chronic constipation. The AGI is obtained by dividing the distances (cm): vulvar fornix-anus/fornix-coccyx in females and scrotum-anus/scrotum-coccyx in males. The NB group is further studied for gestational age, weight, number of meconium discharges and anal calibration. The newborns with AEA are then controlled to exclude constipation. In patients with chronic constipation, their age, sex and AGI are evaluated. The statistical comparisons are made by a Student's t test and Welch's t test for independent samples. RESULTS: 49.5% of NB are male. The average gestational age is 38.95 +/- 2.08/w in NB females and 38.54 +/- 2.26/w in NB males. The average weight is 3101.91 +/- 511.41/g in newborn females and 3145.14 +/- 573.36/g in newborn males. The average AGI of NB females is 0.40 +/- 0.05 and NB males 0.53 +/- 0.06. AEA is considered with AGI < 0.30 in females and < 0.41 in males. 2.2% of NB females (6/267) and 1.1% of NB males (3/262) have AEA. There is a significant difference between the AGI of NB females and NB males (p < 0.0001). 98% of NB discharge meconium in the first 24 hours. 2 NB females with AGI 0,21 and 0,26 had severe constipation in the first months of life. In group with chronic constipation (64 pacients), 59.4% are female. The AGI is 0.36 +/- 0.1 in females and 0.47 +/- 0.1 in males (p < 0.0001). Concerning of AEA in the NB group (AGI < 0.30 in females and 0.41 in males) incidence of AEA in group with chronic constipation is 35% in males and 47% in females. CONCLUSIONS: The position of the anus in the perineal floor is anterior in females, with significant differences (p < 0.0001) to the AGI in males. AEA has more incidence in females (2.2%). In the constipated group 47% of females had AEA and it is considered the probable reason for this disorder in these patients. To conclude, each NB evaluation protocol should include determination of the AGI in the neonatal period to exclude AEA and to prevent clinical consequences.

[Gastroesophageal reflux disease. Evaluation and indication for surgical treatment by esophageal phmetry]. / Enfermedad por reflujo gastroesofágico, Valoración e indicación de tratamiento quirúrgico mediante pHmetría esofágica.

INTRODUCTION: Oesophageal pH monitoring is considered the best procedure to assess the severity of gastroesophageal reflux disease (GERD), conditioning its treatment. The indication for surgery is becoming less common. We intend to meet this test to what extent it has influenced. MATERIAL AND METHODS: We recruit patients treated in our Centre since the introduction of pH monitoring. We compare the number of times before and after its use. We value clinical manifestations, usual pH metric values versus non-operated patients with pathological test, associated pathology. SAMPLE: 91 patients, 151 pH metric studies (98 preoperative). Number of interventions prior to introduction of pH monitoring: 20/year, post: 3.79/year. SYMPTOMS: gastrointestinal 60.2%, respiratory 10.2%, mixed 24.5%. 495 non-operated patients, 692 pathological studies. PH metric values operated/not operated: No. reflux 116.91 +/- 125.46/101.69 +/- 83.39 (p < 0.001), No. reflux >5 minutes 8.49 +/- 8.28/4.43 +/- 4.85 (p = 0.001), longest reflux 60.21 +/- 95.93/31.16 +/- 80.09 (p < 0.001), clearance 1.27 +/- 1.44/0.86 +/- 1.05 (p = 0.04), DeMeester 52.74 +/- 56.21/29.49 +/- 23.57 (p < 0.001). 14 of 98 preoperative pH monitoring were normal. Associated pathology operated/not operated: 13.26%/ 7.47%. CONCLUSIONS: The pH metric control of patients with GERD and the progress of medical treatment have led to a decrease in surgical procedures. In our experience, the intensity of GERD is a valuable parameter in deciding on the surgery. We attach particular value parameters measuring oesophageal clearance and indices that integrate several of them. However, in some patients without pathological pH monitoring, we have indicated the operation. The prevalence of associated pathology in the operated makes us value them more demanding.

Valoración de la posición del ano en recién nacidos y en niños con estreñimiento crónico. Incidenciadel ano anterior ectópico / Evaluation of the anal position in newborns and children with chronic constipation. incidence of anterior ectopic anus

Introducción. El ano anterior ectópico (AAE) continúa siendo una entidad controvertida. El objeto es determinar la posición normal del ano o índice anogenital (IAG) en recién nacidos (RN) y en un grupo de niños con estreñimiento crónico, conocer la incidencia del AAE en ambos grupos, y la relación de éste con el estreñimiento. Material y métodos. Se realiza un estudio prospectivo y aleatorio en el que se determina el IAG en 529 RN y en 64 pacientes de más edad con estreñimiento crónico. El IAG se obtiene dividiendo las distancias(cm): horquilla vulvar-ano/horquilla-coxis en niñas y escrotoano/escroto-coxis en niños. En el grupo de RN se estudian, además, la edad gestacional, peso, evacuación meconial y calibre anal. Los RN con AAE son controlados para el despistaje de estreñimiento. En los paciente scon constipación crónica se valora la edad, sexo e IAG. Las comparaciones estadísticas se efectúan mediante los tests de t-Student y elde Welch para muestras independientes .Resultados. De los 529 RN, el 49,5% son hombres. La edad gestacional media en RN niñas es 38,95 ± 2,08/s y 38,54 ± 2,26/s en RN niños. El peso es 3.101,91 ± 511,41/g en RN niñas y 3.145,14 ± 573,36/gen RN niños. El IAG medio en RN niñas es 0,40 ± 0,05 y en niños 0,53± 0,06. Se considera AAE los IAG de menos 2 DS por debajo de la (..) (AU)

Introduction. Anterior ectopic anus (AEA), continues to be a controversial issue. The objective is to determine the normal position of theanus or anal ano-genital index (AGI) in newborns (NB) and in a group of infants with chronic constipation, know the incidence of AEA in both groups, and its relationship with constipation. Methods. A prospective aleatory study is performed in where the AGI is determined in 529 NB and 64 older patients with chronic constipation. The AGI is obtained by dividing the distances (cm): vulvarfornix-anus/fornix-coccyx in females and scrotum-anus/scrotum-coccyx in males. The NB group is further studied for gestational age, weight, number of meconium discharges and anal calibration. The newborns with AEA are then controlled to exclude constipation. In patients with chronic constipation, their age, sex and AGI are evaluated. The statistical comparisons are made by a Student’s t test and Welch’s t test for independent samples. Results. 49.5% of NB are male. The average gestational age is38.95 ± 2.08/w in NB females and 38.54 ± 2.26/w in NB males. The average weight is 3101.91 ± 511.41/g in newborn females and 3145.14± 573.36/g in newborn males. The average AGI of NB females is 0.40± 0.05 and NB males 0.53 ± 0.06. AEA is considered with AGI < 0.30in females and < 0.41 in males. 2.2% of NB females (6/267) and 1.1%of NB males (3/262) have AEA. There is a significant difference between (..) (AU)

Enfermedad por reflujo gastroesofágico. Valoración e indicación de tratamiento quirúrgicomediante pHmetría esofágica / Gastroesophageal reflux disease. Evaluation and indication for surgical treatment by esophageal phmetry

Introducción. La pHmetría esofágica es considerada el mejor procedimiento para valorar la intensidad del reflujo gastroesofágico (RGE),condicionando su tratamiento. La indicación quirúrgica es cada vez menos frecuente. Nos proponemos conocer en qué medida esta prueba ha influido en ello. Material y métodos. Reclutamos los pacientes intervenidos en nuestro Centro desde la introducción de la pHmetría. Comparamos número de intervenciones antes y después de su utilización. Valoramos manifestaciones clínicas, valores pHmétricos habituales frente a no intervenidos patológicos, patología asociada. Resultados. Muestra: 91 pacientes, 151 estudios pHmétricos (98prequirúrgicos). Número de intervenciones previas a introducción de pHmetría: 20/año, posteriores: 3,79/año. Sintomatología: digestiva (..) (AU)

Introduction. Oesophageal pH monitoring is considered the best procedure to assess the severity of gastroesophageal reflux disease(GERD), conditioning its treatment. The indication for surgery is be comingless common. We intend to meet this test to what extent it has influenced. Material and methods. We recruit patients treated in our Centre since the introduction of pH monitoring. We compare the number oftimes before and after its use. We value clinical manifestations, usual (..) (AU)

[Anorectal manometry in the neonatal diagnosis of Hirschsprung's disease]. / La manometría anorrectal en el diagnóstico neonatal de la enfermedad de Hirschsprung.

OBJECTIVE: To determine the usefulness of anorectal manometry (AM) in neonatal screening for Hirschsprung's disease (HD). MATERIAL AND METHODS: We review the anomanometric studies of 98 newborn (63 males and 35 females) with clinical suspicion of HD, noting the indications of AM, gestational age, weight, age in days at the test, and whether or not other diagnostic methods were performed. Studied at rest were the pressures (mmHg) in the rectal ampulla (RA), proximal anal canal (PAC), and distal anal canal (DAC), and, in the stimulation phase, the presence or absence of a recto-anal inhibitory reflex (RAIR). In patients with no RAIR, the study was repeated weekly until the end of the first month, and if there was still no RAIR a suction rectal biopsy (SRB) was performed. In these patients and those with signs of intestinal obstruction, a contrast enema was carried out. RESULTS: The indications of AM are: delayed meconium passage, abdominal distension, and/or vomiting in 61.5% of the patients, intestinal obstruction in 16%, constipation in 15.1%, and other causes in 7.4%. The mean gestational age was 35.59 +/- 4.59 weeks, and the weight 2518 +/- 912.91 g. The mean age at the first test was 15.08 +/- 11.33 days. A RAIR was observed at the first study in 65 patients (healthy 54, meconium plug 2, meconium ileus 2, intestinal neuronal dysplasia 1, false negative 1, and other diagnoses 6), and was absent in 27 (HD 20, small left colon syndrome 4, hypoganglionism 1, and false positives 2). In 6 patients the first study was considered invalid. Histological studies confirmed HD in 21 newborn, in 11 of whom the contrast enema showed a transition zone. There were no differences between healthy and HD newborn in the RA, PAC, or DAC resting pressures. The sensitivity of AM for the diagnosis of HD was 95% and its specificity 90.24%. The sensitivity and specificity of rectal biopsy were 100%. The sensitivity of contrast enema was 52.3%, and its specificity 78.6%. CONCLUSIONS: AM is a simple and safe method with high sensitivity and specificity for the neonatal diagnosis of HD. We consider it indicated prior to SRB in every newborn with clinical suspicion of this disease.

La manometría anorrectal en el diagnóstico neonatal de la enfermedad de Hirschsprung / Anorectal manometry in the neonatal diagnosis of hirschsprung's disease

Objetivo. Es conocer la utilidad de la manometría anorrectal (MA)para el screening neonatal de la enfermedad de Hirschsprung (EH). Material y métodos. Se revisan los estudios anomanométricos de 98 neonatos (63 hombres y 35 mujeres) con sospecha clínica de EH. Se valoran las indicaciones de la MA, la edad gestacional, peso, días de vida al test y la realización o no de otros métodos diagnósticos. Se estudia, en reposo, las presiones (mmHg) en la ampolla rectal (AR), cana lanal proximal (CAP) y canal anal distal (CAD), y en la fase de estimulación se investiga la presencia o ausencia del reflejo inhibidor del (..) (AU)

Objective. To determine the usefulness of anorectal manometry(AM) in neonatal screening for Hirschsprung’s disease (HD). Material and methods. We review the anomanometric studies of 98 newborn (63 males and 35 females) with clinical suspicion of HD, noting the indications of AM, gestational age, weight, age in days at the test, and whether or not other diagnostic methods were performed. Studied at rest were the pressures (mmHg) in the rectal ampulla (RA), proximal anal canal (PAC), and distal anal canal (DAC), and, in the stimulation phase, the presence or absence of a recto-anal inhibitory reflex(RAIR). In patients with no RAIR, the study was repeated weekly until (..) (AU)

[Re-education of the anal sphincter in patients with myelomeningocele]. / Reeducación del esfínter anal en el mielomeningocele.

OBJECTIVE: The aim of this study was to analyze the usefulness of biofeedback techniques based on manometrical procedures in the treatment of defecation disorders in patients with myelomeningocele. PATIENTS AND METHODS: We studied 24 patients with myelomeningocele, aged 13 days to 15 years, who were referred to our Instrumental Diagnosis Unit for evaluation of anorectal function, or constipation and/or fecal incontinence study. Biofeedback was given to 12 patients who fulfilled the following criteria: age more than 5 years, existence of anorectal sensitivity with a perceptual threshold of less than 60 ml of rectal expansion, ability to contract and relax the gluteus muscles and thus be able to exercise pressure on the anal margin, and collaboration on the part of child and the family. As a complement defecatory maneuvers were performed. RESULTS: Between 4 and 65 sessions took place (35.14 19.97) after which rectal perceptual volume decreased from 24.66 14.13 to 3.33 2.95 ml and pressure on the anal margin increased from 45.62 17.82 to 114.37 13.99 mmHg. These differences were statistically significant (p < 0.001). Clear clinical improvement was produced in 10 of 12 patients who achieved good fecal continence with spontaneous depositions. Partial improvement was produced in 2 patients. CONCLUSIONS: We consider that biofeedback based on manometrical procedures is more useful than other conservative therapies in the treatment of defecatory problems in patients with myelomeningocele. In most patients this technique produces clinical improvement with satisfactory continence and without the drawbacks of other procedures.

Reeducación del esfínter anal en el mielomeningocele / Reeducation of the anal sphincter in patients with myelomeningocele

Objetivo: Analizar la utilidad de las técnicas de biorretroalimentación basadas en procedimientos anomanométricos en el tratamiento de los trastornos de la defecación de los pacientes con mielomeningocele. Pacientes y método: Estudio de 24 pacientes afectados de mielomeningocele, con edades comprendidas entre 13 días y 15 años, remitidos a la Unidad de Diagnóstico Instrumental para valoración funcional anorrectal o estudio de estreñimiento y/o incontinencia. Se realizó biorretroalimentación a 12 pacientes que reunieron los criterios preestablecidos: edad superior a 5 años, existencia de sensibilidad anorrectal con un umbral de percepción menor de 60 ml de distensión rectal, habilidad del niño para contraer y relajar los músculos glúteos y de esta forma poder ejercer presión sobre el margen anal, colaboración por parte del niño y su familia. Como complemento se realizan maniobras defecatorias. Resultados: Se realizaron entre 4 y 65 sesiones (35,14 ± 19,97) tras las cuales se consiguió una disminución del volumen de percepción rectal de 24,66 ± 14,13 a 3,33 ± 2,95 ml y un aumento de la presión sobre el margen anal que pasó de 45,62 ± 17,82 a 114,37 ± 13,99 mmHg. Estas diferencias fueron estadísticamente significativas (p < 0,001). Así mismo, se consiguió una mejoría clínica clara en 10 de los 12 pacientes, que pasaron a tener una continencia fecal adecuada con deposiciones espontáneas y una mejoría parcial en dos pacientes. Conclusiones: Consideramos que la biorretroalimentación basada en procedimientos anomanométricos es un medio más útil que otras terapias conservadoras, para los problemas defecatorios de los pacientes afectados de mielomeningocele, puesto que consigue una mejoría clínica en la mayoría de los pacientes, con una continencia adecuada y sin los inconvenientes de otros procedimientos (AU)