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PubMed2002

Imaging and intervention in the gastrointestinal tract in children.

Vascular and interventional techniques have become an integral component of modern pediatric healthcare. Minimally invasive procedures of the gastrointestinal tract now comprise a large part of any active pediatric interventional practice. Magnetic resonance cholangiopancreatography offers a reliable, non-invasive means to evaluate patients with possible pancreatic or biliary pathology. This article reviews treatment of esophageal strictures and placement of gastronomy and gastrojejunostomy tubes and discusses new developments. Placement of percutaneous cecostomy tubes is a relatively new procedure that creatively uses the techniques developed for placement of percutaneous gastronomy tubes. This procedure offers significant benefits and lasting positive lifestyle changes for patients suffering from fecal incontinence. Liver biopsy in high-risk patients can be performed safely using measures designed to significantly decrease the risk of post-biopsy hemorrhage, such as track embolization or the transjugular approach.

Angioplasty, Balloon↗
PubMed1994

Endoscopic study of the ileal papilla in a normal case and in patients under several pathological conditions.

The ileal protrusion into the lumen of the large intestine was studied in 9 patients (8 adults and 1 girl), 6 females and 3 males, all Brazilians and Caucasians. One of the patients resulted to have no disease, whereas in the others was confirmed the suspected diverticulosis, non specific ulcerative colitis, polyposis, regional ileitis or tuberculosis. In all cases the papillary and bilabial types of the termination of the ileum was documented by endoscopic photography, justifying the change of the expression "Bauhin's ileocecal valve" to that of "eminentia ilealis". Even in cases (one with regional ileitis and the other with tuberculosis) in which the disease altered the eminentia ilealis, it was possible to recognize the ileal papilla. Endoscopy confirmed direct, in vivo observations of ileal papilla, excluding the influence of the surgical procedure (incision and exteriorization in cases of cecostomy) in the morphological aspect of the normal eminentia ilealis.

Adult↗
PubMed1997

Effects of intestinal stasis on intercellular adhesion molecule 1 expression in the rat: role of enteric bacteria.

BACKGROUND & AIMS: The mechanisms underlying the inflammatory changes associated with intestinal stasis are poorly understood. The objective of this study was to assess whether endothelial expression of intercellular adhesion molecule 1 (ICAM-1) and leukocyte recruitment are altered after intestinal stasis. METHODS: ICAM-1 expression and granulocyte recruitment were quantified in different tissues of Sprague-Dawley rats using the double-radiolabeled monoclonal antibody technique and peroxidase activity, respectively. RESULTS: Both constitutive and endotoxin-induced ICAM-1 expression were significantly higher in the cecum than in distal colon, a finding that cannot be explained by a difference in endothelial surface area between the two organs. Surgical procedures to improve cecal stool flow (cecostomy, ileocecostomy) elicited a significant decrease in constitutive ICAM-1 expression in both cecum and distal colon. Tissue peroxidase activity was normally higher in cecum than in distal colon, and this difference was significantly reduced by ileocecostomy. Oral administration of antibiotics (kanamycin and/or metronidazole for 2 days) significantly reduced constitutive ICAM-1 expression in the cecum, but not in the distal colon. CONCLUSIONS: This study indicates that intestinal stasis is associated with an increased expression of ICAM-1 and granulocyte infiltration, which may be mediated by enteric bacteria.

Animals↗
PubMed2001

Percutaneous endoscopic gastrostomy-20 years later: a historical perspective.

BACKGROUND/PURPOSE: Percutaneous endoscopic gastrostomy (PEG), initially developed for children with inability to swallow, had its first presentation at the annual meeting of the American Pediatric Surgical Association in Florida in 1980. Based on the novel concept of the sutureless approximation of a hollow viscus to the abdominal wall, this minimally invasive procedure has become the standard for direct gastric access worldwide. This report is a brief retrospective about the evolution of PEG and the expanded applications of the surgical concept on which it is based. METHODS: Information related to PEG was obtained from personal records, a focused literature search, and data from various registries and the industry. RESULTS: The search identified 836 peer-reviewed publications directly related to PEG. The original Journal of Pediatric Surgery article has received 483 bibliographic citations. The procedure has had a profound impact on nutritional management, particularly among adult patients. Over 216,000 PEGs are performed annually in the United States. Twelve major manufacturers produce PEG or PEG-related enteral access devices. Select expanded applications of PEG and its principle include indications beyond feeding, use in high-risk patients, percutaneous jejunostomy, percutaneous cecostomy, correction of gastrostomy leakage and gastric volvulus, multiple PEG portals for intragastric interventions, and laparoscopically assisted gastrostomies. CONCLUSIONS: Over 20 years, percutaneous endoscopic gastrostomy has experienced exponential growth. Improved guidelines and technical refinements have added to its safety. The concept on which it is based has created a ripple effect and led to numerous applications beyond gastric access for feeding. In an era when so many of our procedures are adopted from "adult" general surgery, it is worthwhile to have an historical perspective on PEG, a technique that originated in pediatric surgery.

Bibliometrics↗
PubMed2002

Sigmoid irrigation tube for the management of chronic evacuation disorders.

BACKGROUND/PURPOSE: Antegrade colonic irrigation, in which the right colon is accessed via appendicostomy or cecostomy, now is an important adjunct in the management of children with chronic evacuation disorders. However, in most children, the major area of dysfunction is the left rather than the right colon. The authors developed a simple, percutaneous endoscopic, laparoscopically controlled sigmoid irrigation tube placement and evaluated the results in 4 children. METHODS: A rigid sigmoidoscope is advanced into the upper sigmoid and the loop brought in contact with the abdominal wall under laparoscopic control. A small skin incision is made and a needle pushed across the abdominal and sigmoid walls into the lumen of the sigmoidoscope. A guide wire is advanced through the needle into the scope and retrieved. After the scope is removed, a PEG-type catheter is attached to the guide wire and pulled back, securing the sigmoid loop to the abdominal wall. The tube is subsequently converted to a skin-level device by simply adding an external port valve. RESULTS: All 4 patients achieved prompt evacuation in the sitting position. CONCLUSIONS: Sigmoid tube for antegrade irrigation is an appealing alternative to conventional cecal access. The procedure is simple and may offer physiologic advantages.

Adolescent↗
PubMed1982

Cecal volvulus: A diagnostic and therapeutic challenge.

Cecal volvulus is a malrotational abnormality of the intestine that causes obstruction. Diagnosis is difficult and, if delayed, the results may be intestinal ischemia, perforation, sepsis, and even death. Cecal ischemia or gangrene cannot always be determined from physical and laboratory findings. Although not always conclusive, contrast radiography may be helpful; however, laparotomy is often required for definitive diagnosis and therapy. If vascular compromise of the cecum is found, right hemicolectomy is the treatment of choice. In the absence of ischemia, decompressive tube cecostomy, simple detorsion, and cecopexy have all been recommended, but the optimal treatment is a matter of controversy.

Barium Sulfate↗
PubMed2005

Totally laparoscopic combined freehand ileocystoplasty and Malone procedures.

BACKGROUND AND PURPOSE: Cecostomy performed together with open enterocystoplasty can allow continent bowel evacuation in children with neurogenic dysfunction. We present the first report on a combined approach to fecal and urinary incontinence in children with myelomeningocele that was performed exclusively by freehand laparoscopy. PATIENTS AND METHOD: We treated six dysrhaphic patients for total urinary and fecal incontinence by laparoscopy. Through five ports, a selected segment of ileum was isolated with cautery. A single-layer intestinal anastomosis, fashioning of the U-shaped patch, and anastomosis to the opened bladder dome were all done by endocorporeal freehand suturing. The tip of the appendix was simply brought to the skin via a trocar site. RESULTS: The procedures took 5 to 8.5 hours. Patients remained hospitalized for 5 to 16 days (median 5 days). At 13 to 16 months' follow-up, all patients remain continent of urine, and nearly perfect fecal continence has resulted on antegrade enema. Leak from the ileal anastomosis in one patient resolved rapidly with conservative management. One short retrocecal appendix later developed stenosis and was replaced by a tubed cecal flap. CONCLUSION: Apart from its cosmetic advantage, this procedure is notable for addressing all evacuation problems at one session. Our suturing time seems reasonable compared with open sutured precedents. Use of a gastrointestinal stapling device for anastomosis would have significantly increased the cost while not necessarily guaranteeing against complications. We present this laparoscopic combination as an effective alternative to its open counterpart.

Adolescent↗
PubMed1979

Cecal volvulus: analysis of 50 patients with long-term follow-up.

Fifty patients operated upon for cecal volvulus were analyzed. The ages ranged from 14 to 88 years and averaged 53 years. Eighteen were males and 32 were females. The presentation was acute, requiring urgent surgery in 41 patients; nine patients presented with chronic symptoms and were operated upon electively. In 14 patients (28%) the cecal volvulus was temporally related to another acute medical problem. The diagnosis was made radiographically in 22 patients (44%) and at operation in 28 patients (56%). Cecal volvulus was correctly diagnosed by barium enema in 20 of the 29 patients (69%) undergoing the study. Eighteen of the patients were treated by cecopexy, 14 by resection, 12 by detorsion alone, and six by tube cecostomy. Mortality was 12% (6/50) and was associated with gangrenous cecum (33%, 3/9), other systemic diseases (24%, 5/21), age over 50 years (19%, 6/31), and acute presentation (15%, 6/41). In the absence of gangrenous cecum, enterotomy was associated with subsequent wound infection in 23% (7/30), as compared to none (0/11) when enterotomy was not performed. There were no recurrences of cecal volvulus in the entire series during follow-up which extended to 17 years, averaged 5.7 years, and was complete in 96% (42/44) of survivors. When gangrenous cecum is present, resection is the treatment of choice. In the absence of gangrenous bowel, cecopexy is recommended because of a low mortality (0/18), low morbidity (3/18), low recurrence rate (0/18) and absence of need to open the unprepped bowel.

Adolescent↗
PubMed1982

Colonoscopic decompression of acute pseudo-obstruction of the colon.

The recent advances in technology have made it possible to decompress acute pseudo-obstruction of the colon with colonoscope instead of celiotomy and cecostomy. Twenty-two patients who developed acute pseudo-obstruction of the colon and underwent colonoscopy were analyzed. The authors were successful in completely or partially decompressing the dilated colon in 19 of 22 patients. There were no complications. Acute pseudo-obstruction of the colon is usually secondary to intra- or extra-abdominal insult resulting in direct or reflex derangement of the sacral parasympathetic outflow. This causes a functional obstruction of the left colon. The goal of management is to prevent colonic perforation while treating the primary problems. Once the diagnosis has been made, colonoscopy should be attempted. Celiotomy should be reserved to cases in which colonoscopy is unsuccessful or in cases with perforation or impending perforation.

Adult↗
PubMed1983

Therapeutic and diagnostic colonoscopy in nonobstructive colonic dilatation.

Cecal perforation has been well established as a consequence of mechanical obstruction of the distal colon and has been estimated to occur in 1.5% to 7% of patients with colon obstruction. Perforation of the cecum also occurs in cases of nonobstructive colonic dilatation (NCD). Although the incidence is unknown, the mortality rate is nearly 50%. Over an eight-year period, 44 patients (mean age 59 years) underwent 52 colonoscopic examinations for presumed NCD. Twelve patients (27%) developed NCD while convalescing from a recent operation and 29 patients (66%) had major systemic disorders that preceded the development of NCD. Medical treatment for an average of 2.6 days was uniformly unsuccessful. Mean cecal diameter prior to colonoscopy was 12.8 cm (range 9.5 to 17 cm). Based on radiographic or clinical criteria, 38 patients (86%) were successfully decompressed on the initial colonoscopic examination; mean cecal diameter decreased to 8.7 cm (p less than 0.01). Perforation of the cecum during colonsocopy occurred in one patient (2%) who survived. Fourteen patients died; six deaths were attributed solely to the patient's who underwent operation. In summary, colonoscopy is a safe and effective therapeutic and diagnostic tool in cases of massive cecal dilatation. It should be considered before cecostomy in patients without radiographic evidence of pneumoperitoneum or clinical signs of peritoneal irritation.

Adult↗
PubMed2004

Colonic tubes for the antegrade continence enema: comparison of surgical technique.

PURPOSE: The Malone antegrade continence enema has revolutionized the management of intractable fecal incontinence and constipation. When the appendix is absent, surgical options are limited. Small series with short-term followup have demonstrated the feasibility but not the reliability of the continent colonic tube. We present our experience with a lateral based colonic tube. We also compared lateral based colonic tubes to medial based tubes. MATERIALS AND METHODS: The medical records of patients treated with a continent colonic tube for intractable fecal incontinence were reviewed. We identified 8 patients who underwent the procedure between July 2000 and February 2003. The literature was reviewed to compare lateral vs medial based tubes. RESULTS: Average followup was 28 months (range 10 to 41). Stomal stenosis developed in 4 patients (50%) within 3 to 6 months of surgery. Passive dilation at the clinic corrected the problem in 3 patients and 1 required operative stomal revision. All 8 patients reported almost complete relief of rectal incontinence and constipation. A literature review demonstrated a significantly higher rate of stomal stenosis in lateral vs medial based colonic tubes (40% vs 12%). CONCLUSIONS: The continent colonic tube is a safe and effective alternative in patients with refractory fecal incontinence and constipation who do not have an available appendix. These results appear durable during the described period. We believe that this technique is an alternative to the cecostomy button and it should be offered to suitable patients. The lateral based colonic tube appears to have a higher rate of stomal stenosis than medial based colonic tubes, which may be attributed to the local blood supply of the colon.

Adolescent↗
PubMed2005

Lower urinary tract reconstruction for spina bifida -- does it improve health related quality of life?

PURPOSE: Reconstruction for incontinent myelomeningocele is assumed to improve health related quality of life (HRQOL) yet there are no published data to support this assumption. MATERIALS AND METHODS: A retrospective cohort study was performed of 36 consecutive incontinent meningomyelocele cases undergoing surgery (augmentation, with or without Mitrofanoff, bladder neck reconstruction and cecostomy). Controls were matched 2:1 for age, lesion level, parental marital status, ambulatory status and shunt status. HRQOL was assessed with a previously validated disease specific discriminative instrument that stratifies for ages 12 years or less and 13 years or greater. An additional 5-point Likert questionnaire was used for self-scoring of bladder and bowel continence. RESULTS: Responses were 89% and 84% for cases and controls, respectively. The 2-sample t testing for subjects 12 years old or younger revealed no significant difference in mean HRQOL score between those who underwent reconstruction (12, mean 165 +/- 23) and those who did not (9, mean 162 +/- 27, p=0.73). Results in older subjects were similar for cases (20, mean 190 +/- 23) and controls (3, mean 192 +/- 26, p=0.80). This finding occurred despite the fact that 78% of reconstructed cases achieved urinary continence for 3 hours or more with equal or superior self-reported bladder and bowel continence compared to controls. CONCLUSIONS: We were unable to demonstrate superior HRQOL in patients over controls. Several possible interpretations exist, such as surgery may have no impact on HRQOL, patients might have scored much lower without surgery, or perhaps only caregiver quality of life improves. The impact of urinary tract reconstruction upon quality of life in the myelomeningocele population warrants further study.

Adolescent↗
PubMed1999

Cecal volvulus in pregnancy.

Colonic volvulus is an important entity to consider in any pregnant patient with abdominal pain. X-ray and colonoscopy can be useful to obtain the earliest diagnosis, leading to surgical intervention if necessary. Limited use of x-rays with shielding of the fetus is of minimal risk and useful for early diagnosis of volvulus. Colonoscopy may confirm or exclude the diagnosis of colonic volvulus, detect mucosal ischemia, and avoid the requirement for emergency surgery by reducing the volvulus in cases in which ischemia is not present. If surgery is necessary for a cecal volvulus, cecostomy is a viable option because of a low rate of morbidity and subsequent volvulus recurrence.

Adult↗
PubMed1988

Quantitative measurement of feline colonic transit.

Colonic transit scintigraphy, a method for quantitatively evaluating the movement of the fecal stream in vivo, was employed to evaluate colonic transit in the cat. Scintigraphy was performed in duplicate in five cats and repeated four times in one cat. After instillation of an 111In marker into the cecum through a surgically implanted silicone cecostomy tube, colonic movement of the instillate was quantitated for 24 h using gamma scintigraphy. Antegrade and retrograde motion of radionuclide was observed. The cecum and ascending colon emptied rapidly, with a half-emptying time of 1.68 +/- 0.56 h (mean +/- SE). After 24 h, 25.1 +/- 5.2% of the activity remained in the transverse colon. The progression of the geometric center was initially rapid, followed later by a delayed phase. Geometric center reproducibility was found to be high when analyzed using simple linear regression (slope = 0.92; r = 0.73; P less than 0.01). Atropine (0.1 mg/kg im) was found to delay cecum and ascending colon emptying and delay progression of the geometric center. These results demonstrate both 1) the ability of colonic transit scintigraphy to detect changes in transit induced by pharmacological manipulation and 2) the fact that muscarinic blockade inhibits antegrade transit of the fecal stream. We conclude that feline colonic transit may be studied in a quantitative and reproducible manner with colonic transit scintigraphy.

Animals↗
PubMed2000

Cecal diverticulitis: a diagnostic challenge.

BACKGROUND: Cecal diverticulitis is frequently indistinguishable from acute appendicitis preoperatively and is sometimes mistaken for carcinoma at laparotomy. The surgeon must be aware of the possibility of diverticulitis of the cecum in the operating room and choose the appropriate treatment. PURPOSE: Because there is no universal therapeutic approach to these patients, we decided to assess the presenting symptoms, clinical findings, preoperative diagnosis, operative findings determining the proper management of these patients. METHODS: A retrospective chart review of 13 patients with pathologically confirmed cecal diverticulitis, who underwent surgery in our department from 1984 to 1998, was undertaken. RESULTS: The mean age of patients was 43.5 years. Right lower quadrant pain and local tenderness were the only clinical findings in 92.3%, with preoperative diagnosis of acute appendicitis in 84.6% of patients. The operative finding in most cases was inflammatory mass of the cecum; in 6 cases it was indistinguishable from perforated cecal carcinoma. Six patients underwent right hemicolectomy, 5 had ileocecectomy, 1 patient was treated by tube cecostomy, and 1 had diverticulectomy. There were three minor postoperative complications: pneumonia, wound infection and lower limb superficial thrombophlebitis. CONCLUSIONS: Cecal diverticulitis needs a high index of suspicion for achieving a preoperative diagnosis. We suggest that the operative therapy should be ileocecectomy. The surgical specimen should be examined during surgery and only if carcinoma is found should the patient have a formal colectomy.

Adult↗
PubMed2005

Colonic rupture in a patient on combination chemotherapy for metastasized carcinoma of the esophagogastric junction. Case report and review of the literature.

BACKGROUND: Cecal perforation due to neutropenic colitis is a known and described side effect of many chemotherapy regimens. We present a case of a patient with gastric adenocarcinoma who developed spontaneous cecal perforation during chemotherapy without the classic pattern of typhlitis. CASE REPORT: A 58-year-old woman was on chemotherapy for an adenocarcinoma of the gastric junction, when she developed a cecal perforation. There was neither evidence for leucopenia nor for typhlitis. Laparotomy was performed and cecostomy was established using the perforated bowel. Postoperative course was uneventful. The patient died from tumor progression 8 months after the diagnosis was made. CONCLUSION: There is no evidence for a connection between this event and chemotherapy treatment but neither can it be excluded. Even if unusual, colon toxicity could be a potential life-threatening complication associated with more drugs than usually thought.

Adenocarcinoma↗
PubMed2005

Early surgery for the treatment of toxic megacolon.

BACKGROUND: Toxic megacolon (TM) is a potentially lethal complication of idiopathic inflammatory bowel disease or infectious colitis, characterized by total or segmental non-obstructive colonic dilatation of at least 6 cm associated with systemic toxicity. METHODS: Overall, 15 patients had surgery for TM at our institutions over a 10-year period (1993-2003). In contrast to other studies that used medical therapy as the first-line treatment for TM, in our experience all patients underwent surgery as soon as possible after diagnosis of TM (early surgery). RESULTS: 14 patients underwent subtotal colectomy with terminal ileostomy, while for 1 patient the surgical procedure consisted only in a decompressive cecostomy. Two major complications occurred consisting of 2 cases of multiple organ failure leading to death. No other major complications or deaths were reported. The overall mortality rate was therefore 13% (0% in patients <65 years). CONCLUSION: This study shows that early surgery has the potential to represent a valid therapeutic strategy for patients with TM resulting in a small number of TM-related complications and deaths. Elderly patients seem to have a high risk of multiple organ dysfunction syndrome and post-surgical death.

Adult↗
PubMed1989

Colonic volvulus. Etiology and management.

Colonic volvulus accounts for 1-7% of cases of large bowel obstruction in the United States and Western Europe. It is, however, a much commoner condition in parts of Africa, South Asia and South America. Volvulus is thought to be an idiopathic condition, probably with an anatomical basis, particularly in cecal volvulus. Some cases are, however, secondary to a known condition such as Chagas' disease. The sigmoid colon is involved in 65-80% of cases and the right colon in 15-30%. Transverse colon and splenic flexure volvulus are rare. Emergency surgery has in the past been associated with a high mortality. Nonoperative, tube decompression of sigmoid volvulus has been the single most important advance in the management of the condition--this has allowed surgery to be deferred to an elective schedule and performed on a fitter patient with a prepared bowel. Emergency surgery is still required for a minority of patients--those in whom tube decompression is unsuccessful; in those with signs of gangrenous bowel and patients with volvulus proximal to the sigmoid. When the bowel is not viable, resection is mandatory. In patients with a viable colon, there are several options. Sigmoid resection and colostomy for sigmoid volvulus and detorsion, cecopexy and tube cecostomy as a combined procedure for cecal volvulus are the usually recommended procedures.

Colonic Diseases↗