[АNORECTAL DYSFUNCTION, OCCURRING AFTER SURGICAL TREATMENT OF HIRSCHPRUNG'S DISEASE AND ITS CORRECTION].

Results of examination and treatment of 12 children, operated on in various clinics for Hirschprung's disease, in whom chronic constipation and other signs of anorectal dysfunction have occurred, were analyzed. In 8 patients Duhamel-Bairov operation was conducted, in 2 ­ Soave-Lenyushkin operation, and in 2 ­ Soave-Boley operation. The main cause of postoperative chronic constipation occurrence after Duhamel operation is the colorectal septum preservation. The only one radical method of treatment of this complication is a transanal removal of colorectal septum. The cause of anastomotic narrowing after Soave-Boley operation was absence of myotomy intraoperatively and of bougienage ­ after it. Elimination of chronic constipation in such patients, using long-standing bougienage and complex conservative treatment. The main cause of chronic constipation and nocturnal encopresis after Soave-Lenyushkin operation was preservation of the tissue excess while doing resection of a large bowel stump and creation of the narrowed ring, looking like a pendent plica. Complete reconvalescence of such patients is possible in transanal method of excision of stenosing ring and conduction of complex treatment.

Rectal mucosal prolapse in males: surgery is effective for fecal incontinence but not for obstructed defecation.

BACKGROUND: The aim of this prospective study was to evaluate the functional outcome of transanal surgery in male patients suffering from fecal incontinence, soiling, and obstructed defecation associated with rectal mucosal prolapse. METHODS: All male patients who underwent transanal surgery (either stapled or Delorme mucosectomy) for rectal mucosal prolapse associated with fecal incontinence and obstructed defecation were prospectively enrolled in the study. The recruitment phase was 17 months (April 2011 to August 2012). Symptom evaluation was based on the validated scores preoperatively and 12 months after surgery (Wexner incontinence score and Wexner constipation score). The primary end point was "success," which was defined as a 50 % reduction in symptoms. Using a decision-tree algorithm, patient groups with the highest and lowest chance of success were identified. RESULTS: Thirty-eight male patients (mean age 51 years) underwent transanal surgery for rectal mucosal prolapse. The predominant symptoms were fecal incontinence in 31 patients (82 %) and obstructed defecation in 7 (18 %). Stapled mucosectomy was performed in 34 patients and Delorme mucosectomy in 4 patients. No major morbidity occurred. Symptom resolution for soiling was 77 %, itching and mucus secretion were improved in 47 and 50 %, and bleeding resolved in 89 % of patients affected. Functional outcome was good in 90 % (28/31) of the patients with fecal incontinence but in only 28 % (2/7) for obstructed defecation. The Wexner incontinence score decreased significantly (11.1 vs. 3.9, p < 0.01), whereas the Wexner constipation score was not influenced (18.4 vs. 15.6, p > 0.05). Using a decision-tree algorithm, a success rate of 96 % was observed in patients with fecal incontinence associated with younger age (age <45 years) and no presence of fecal urgency prior to surgery. CONCLUSIONS: Transanal stapled mucosectomy for rectal mucosal prolapse in males is effective for fecal incontinence, but not for obstructed defecation.

Quality of life in pediatric patients with unremitting constipation pre and post Malone Antegrade Continence Enema (MACE) procedure.

OBJECTIVE: The primary aim of this study was to determine if there is a change in the quality of life in pediatric patients with unremitting functional constipation and/or encopresis after undergoing a MACE procedure. METHODS: Patients, ages 5 to 18 years with unremitting constipation and a normal evaluation, including anorectal manometry and colonic manometry, who opted to undergo a MACE procedure were contacted to participate in the study. Patients with congenital anorectal malformations as well as spinal cord disorders were excluded from the study. The patient's parent/guardian completed the PedsQL(TM) Generic Core Scales QOL survey prior to the operation, 6 months, and 12 months after the procedure. RESULTS: A total of 15 consecutive patients meeting protocol criteria were recruited within a period of 20 months. The mean age at the MACE procedure was 9.8 years (range 7.0-11.1). 5 patients were female. The mean QOL score pre-MACE was 64.1. At 6 months post-MACE the mean overall QOL score was 90.2, and it was 92.0 at 12 months. All 15 patients at the 6 month follow up had significant improvement in their QOL (p=1.9 × 10(-7)) and all subcategories of QOL were significantly improved as well. CONCLUSIONS: A MACE procedure is of benefit to otherwise normal pediatric patients who have unremitting functional constipation with failure of medical treatment. Our patients had a significant improvement in all QOL categories and overall QOL.

Advances in pediatric colorectal surgical techniques.

The operative management of pediatric colorectal diseases has improved significantly in recent years through the development of innovative approaches for operative exposure and a better understanding of colorectal anatomy. Advances in transanal and minimal access techniques have formed the cornerstone of this innovation, leading to improved functional outcomes, earlier recovery, and superior cosmetic results for a number of colorectal diseases. In this regard, we have witnessed a significant evolution in the way that many of these conditions are managed, particularly in the areas of anorectal malformations and Hirschsprung disease. Furthermore, a more thorough understanding of the pathophysiology underlying encopresis and true fecal continence has led to novel and less invasive approaches to the operative management of these conditions. The goal of this review is to describe the evolution of operative management pertaining to these diseases, with an emphasis on technical aspects and relevant clinical pitfalls.

Cecostomy button for antegrade enemas: survey of 29 patients.

OBJECTIVE: This study evaluated the Trap-door button use (Cook Medical, Bloomington, IL) for antegrade enemas in children. METHODS: Since 2002, patients with fecal incontinence or encopresis and constipation underwent percutaneous cecostomy under laparoscopy using a button. Technical details are described. Age at surgery, operative time, hospital stay, diagnosis, indications for cecostomy, and duration of follow-up were recorded. A survey was proposed via a questionnaire that was sent to the patients. Patients wearing the button for less than 1 month were excluded from this evaluation. The survey concerned volume and frequency of enemas, difficulties encountered, benefits and disadvantages of this method, and assessment of the antegrade enemas in continence. RESULTS: Twenty-nine patients, 18 males and 11 females, aged 3 to 21 years (mean, 8.5 years) underwent laparoscopic Trap-door button placement. The indications for all the patients were intractable fecal incontinence in 24 cases and constipation with encopresis in 5 cases. Incontinence was because of myelomeningocele (n = 10), anorectal malformations (n = 11), caudal regression syndrome (n = 1), 22q11 syndrome (n= 1), and Hirschsprung disease with encephalopathy with convulsions (n = 1). Constipation with encopresis was because of sacrococcygeal teratoma (n = 1), cerebral palsy (n = 1), and acquired megarectum with psychiatric and social disorders (n = 3). A total of 26 cecostomy button placements and 3 sigmoidostomy button placements were successful with no intraoperative complication. The mean operative time was 25 minutes (10-40 minutes), and the hospital stay was 2.5 days (1-4 days). Twenty-two parents or patients answered the questionnaire. At the time of this survey, 2 patients had improved their fecal continence and had had the button removed. A mean of 4 weekly enemas was enough to improve fecal continence troubles (range, 1 daily to 1 for 2 weeks). The volume for enemas was 250 to 1000 mL (mean, 700 mL). The time required for the irrigation of the bowel by gravity took from 5 to 60 minutes (mean, 25 minutes) for 20 patients. Before surgery, 14 patients needed a diaper, day and night, and 6 needed sanitary protection. Soiling was a very significant inconvenience for all the patients. After surgery, only 5 patients needed a diaper (cerebral palsy, 22q11, cloacal malformation, myelomeningocele, bladder exstrophy) because of moderate results or urinary incontinence and continued soiling. Patients were asked to give an assessment (null = 0, bad = 1, fair = 2, good = 3, very good = 4). None of the patients felt there had been no changes or a bad result. There were 5 patients who felt they had an average result, 5 a good result, and 12 a very good result. The mean grade was 3.44 (17.2/20). A total of 3 patients had hypertrophic granulation tissue formation around the cecostomy button, and 12 had tiny leakage. CONCLUSION: Percutaneous placement of a cecostomy button under laparoscopic control is an easy and major complication-free procedure. The use of the Trap-door device by the patients or with the help of the parents for antegrade enemas is effective and satisfactory. It improves the quality of life and is reversible.

Posterior myotomy/myectomy for persistent stooling problems in Hirschsprung's disease.

BACKGROUND: Hirschsprung's disease (HD) patients after pull-through (PT) may have recalcitrant constipation or recurrent enterocolitis (EC). Posterior myotomy/myectomy (POMM) are possible options for these problems. This study analyzed the outcome of POMM in HD patients post-PT. METHODS: Records of 348 HD patients were reviewed, and 32 were found to have undergone a POMM post-PT (1981 to 2002). Outcomes after this procedure were assessed. Statistics used linear and logistic regression. RESULTS: Of the 32 patients, 29 had complete records for analysis. Of those with pure constipation (12), 6 had aganglionosis post-PT. Of those with recurrent EC (17) only 1 had aganglionosis post-PT. POMM was performed at a mean of 3.1 years post-PT (11 myotomy, 18 myectomy). Average follow-up was 8.6 years (range, 0.7 to 21). Type of POMM had no correlation with overall functional outcome (P =.44). Of those with chronic constipation, 60% had good results after POMM; the remainder required a redo-PT or colostomy. Interestingly, most patients with retained aganglionosis and chronic constipation did not respond after POMM (83%). Of those with recurrent EC, 75% became free of symptoms; none of the patients not responding have required redo-PT. CONCLUSIONS: POMM to treat chronic constipation or recurrent EC in patients with HD post-PT is moderately successful. Because of the unsuccessful outcome with POMM in patients with a combination of constipation and aganglionosis, one should defer to a redo-PT in this group.

Laparoscopic antegrade continence enema (Malone) procedure: description and illustration of technique.

The antegrade continence enema (ACE Malone) procedure has improved the lives of many patients who struggle with intractable forms of constipation. We describe a laparoscopic approach to this technique and review the literature.

Three-dimensional endosonography of the pelvic floor: an additional diagnostic tool in surgery for continence problems in children.

Three-dimensional endorectal sonography with a specially developed system is able to produce an image of the entire pelvic floor including the sphincter muscles and the rectal wall even in small children. This special system is based on conventional endorectal ultrasound and allows recording of a controlled withdrawal of the axially rotating transducer, creating an image sequence resembling that of a spiral CT-scan; this sequence is digitized off-line and evaluated in a three-dimensional form by a workstation computer. This evaluation has several advantages compared with conventional examination, for example, the complete recording of organs with the possibility of volumetry, construction of arbitrary sections, volume-rendering procedures and the interactive segmentation of organ borders and their three-dimensional visualization. Based on images from this 3D endorectal sonography, the normal anatomy of the pelvic floor that is visible using ultrasound is described, followed by some pathological findings concerning continence surgery. Finally we discuss the advantages and restrictions compared to other examination procedures and the possibilities of technical development.

[Biofeedback as a complementary treatment in surgery for anal incontinence]. / Biofeedback como tratamiento complementario de la cirugía de la incontinencia anal.

Anal incontinence is a severe condition which may be treated by surgery, with unpredictable results. Biofeedback technique is designed to re-educate the function of the anal sphincter; it employs a probe for anorectal manometry, connected to the screen of an oscilloscope. The use of this technique in 43 patients with incontinence, treated with surgery resulted in 48.1% of total continence, 39.53% of partial continence and 11.62% of null response.