High selectivity in new chiral separations of dansyl amino acids by cyclodextrin derivatives in electrokinetic chromatography

Enantiomeric pairs of 11 dansyl derivatives of alpha-amino acids were used as analytes in electrokinetic chromatography to test the ability as chiral selectors of two pure derivatives of beta-cyclodextrin: the ethylendiamine derivative in primary position (CDen) and a member of a new class of receptors, the cysteamine-bridged hemispherodextrin THCMH. The selectivity obtained by the presence of the hemispherodextrin, appears particularly promising as shown by the large values of resolution obtained. The importance of a detailed analysis of these data is discussed in terms of suggestions for a rational approach to separation science.

[Extended high frequency audiometry in the prevention of noise-induced hearing loss]

An early detection of noise induced hearing loss (NIHL) may allow more effective protection measures. Our aim was to investigate the usefulness of high-frequency audiometry to evaluate the possibility of a future use of the high frequencies audiometry as an early indicator for noise induced hearing loss. A cross-sectional study was performed involving 204 industrial noise exposed and 100 non-industrial noise-exposed workers. Each subject was tested with both conventional-frequency (0.25-8 kHz) and high-frequency (9-18 kHz) audiometry during the annually health surveillance campaign conducted in two Italian cement factories. As expected, noise exposed workers were found to have significantly higher hearing thresholds (P < 0.05) at both conventional and extended high frequencies. Marked differences were found for EHFA. Moreover, significant differences at EHFA were detected also in the subgroup of noise-exposed workers with normal findings at conventional audiometry. Our finding indicate that the use of the extended high frequency test may represent a useful tool for detecting early changes of hearing impairment and that it could be used in addition to the conventional test to better prevent the progression of noise hearing loss.

Topical application of isosorbide dinitrate in patients with persistent constipation after pull-through surgery for Hirschsprung's disease

AIMS

The aim of this study was to evaluate the anal manometric changes and the clinical effects after topical application of isosorbide dinitrate (ISDN) in patients with persistent constipation after pull-through surgery for Hirschsprung's disease (HD).

METHODS

We studied 3 children (2 males and 1 female), aged 2, 3 and 5 years respectively, who had undergone the Soave-Boley surgical procedure for HD and who suffered from persistent constipation after operation. We performed a pre- and postoperative anorectal manometry study and we applied ISDN paste (1 mg/kg two times daily) in the anal region for three weeks. All patients were followed-up and re-evaluated at 1, 3, and 6 months.

RESULTS

All patients showed an improvement of symptoms, with an average of 4 spontaneous evacuations per week. Prior to the topical treatment, the medium pressure was 115.6 mmHg (range 102 - 130 mmHg), the maximum pressure was 160 mmHg (range 145 - 175 mmHg), and the medium length of the high pressure zone was 1.8 cm (range 1.5 - 2.0 cm). At the 6 month follow-up, the medium pressure was 57.3 mmHg (range 52 - 61 mmHg, a decrease of 54.4 %), the maximum pressure was 98 mmHg (range 88 - 107 mmHg; a decrease of 38.7 %), and the medium length of the high pressure zone was 1.6 cm (range 1.4 - 1.8 cm; a decrease of 11.1 %).

CONCLUSIONS

Topical treatment with ISDN is a valid therapeutic alternative to an anal myotomy in patients with persistent constipation after pull-through surgery for HD. However, a greater number of cases and a longer follow-up are necessary to confirm the validity of our experience.

Ruptured abdominal aortic aneurysm in the elderly patient

The authors discuss several aspects of the management of ruptured abdominal aortic aneurysm in elderly patients. The cost-effectiveness and indications of repair of rAAA in elderly patients are analysed. A literature survey of risk-factors and results of open treatment of rAAA in elderly patients is made. The challenge of endovascular repair of rAAA in the elderly patient is discussed. Finally, the authors report their personnal experience with AAA repair in 163 patients aged 75 years and older, operated on between January 2003 and September 2005(89 endoaneurysmal stentgrafts and 74 open repairs, 42 rAAA,23 symptomatic AAA and 98 selective asymptomatic AAA).

Testicular hypotrophy in varicocele: pre and postoperative echographic follow-up in the pediatric age

AIM

Varicocele is characterised by an anomalous tortuosity and dilation of the veins of the pampiniform plexus. The etiopathogenetic mechanisms are still unclear, but a correlation seems to exist between varicocele and testicular development, with possible repercussions on the testicle's functionality. The aim of this study is to evaluate gonadic trophism through echographic monitoring in the pre and postoperative phases in patients affected by idiopathic varicocele with testicular hypotrophy in order to evaluate the treatment's benefits.

METHODS

Sixty-six patients (mean age 12,5; range 10-17) consecutively operated for left idiopathic varicocele were considered. Of these, 27 had ipsilateral testicular hypotrophy and thus they were included in the study. Fifteen were operated upon in videolaparoscopy (VLS), and 12 by the classic open inguinal access. The mean follow-up was 18 months (6-24 months). The data were analyzed by nonparametric Mann-Whitney U test.

RESULTS

An increase in the testicular volume was observed clinically and by ultrasound in 13 of the 15 patients treated by VLS and in 9 of the 12 patients operated by traditional means. The nonparametric Mann-Whitney U test showed a significativity between pre and post-operative values.

CONCLUSION

The testicular trophic healing observed in 81.5% of the operated patients leads to the belief that an early correction can allow a rapid volumetric increase and an improved function of the gonad.

Imaging data suggesting acute pyelonephritis in the kidney graft: report of five cases with atypical clinical presentation

Acute pyelonephritis is a common complication of kidney transplantation, occurring in up to 1% of grafts. Diagnosis is mainly clinical and atypical presentations have seldom been reported. The diagnostic role of imaging techniques has not been defined. Five cases of acute graft pyelonephritis are reported (three kidney, two pancreas-kidney grafts). The patients (median age 48 years) comprised three females and two males. Median post-transplant follow-up was 3 months, with three patients having predisposing factors for diabetes and one for an enteric bladder. None of the patients presented the 'classic' diagnostic tetrad (i.e. fever, positive urine cultures, low urinary tract symptoms and serum creatinine increase); although, at diagnosis, two of five patients presented with fever, one had increased creatinine levels and one had positive urine cultures. Of note, three patients had leucocyte casts at urinary sediment analysis, thus raising clinical suspicion. Renal ultrasounds were negative in all patients. Renal (99m)Tc-MAG3 (mercaptoacetyltriglycine) scintigraphy, which was used for the definition of kidney function impairment (one patient) or because of the presence of urinary casts (three patients), or after the biopsy diagnosis to locate the parenchymal lesions (one patient), was positive in all patients. The presence and pyelonephritic origin of the parenchymal lesions was confirmed by nuclear magnetic resonance or computed tomography scans. Acute graft pyelonephritis may develop in the absence of a full-blown clinical picture. Smouldering symptoms may occur in the presence of large perfusion deficits. (99m)Tc-MAG3 scintigraphy could be an important diagnostic tool in such cases.

Impaired decision-making in opiate-dependent subjects: effect of pharmacological therapies

Cognitive dysfunction is a major feature of drug addiction. In the present paper, we compared the decision-making ability using the Iowa gambling task of methadone- and buprenorphine-maintained individuals to non opiate-dependent drug-free controls. Buprenorphine-maintained individuals performed better than methadone-maintained individuals, and not differently than non opiate-dependent controls. In addition, methadone-maintained individuals had more perseverative errors on the Wisconsin card sorting task (WCST) as compared with non opiate-dependent drug-free controls whereas buprenorphine-maintained individuals had intermediate scores. Scores on Weschler adult intelligence scale (WAIS-R) were similar for methadone- and buprenorphine-maintained individuals whereas drug-free controls had significantly higher scores. In addition, both opiate-dependent groups performed more poorly than drug-free controls on the Benton visual retention test (BVRT). The results suggest that buprenorphine in contrast to methadone improves decision-making, and thus may be more effective in rehabilitation programs of opiate-dependent subjects and this improvement may be related to its distinct pharmacological action as a k antagonist.

Continuous quality improvement in intensive care medicine. The GiViTI Margherita Project - Report 2005

AIM

The assessment of the quality of intensive care medicine is mandatory in the modern healthcare system. In Italy, the GiViTI (Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva) network is working in this field since 1991 and it now involves 295 out of the about 450 Italian intensive care units (ICU). In 2002 GiViTI launched a project for the continuous quality assessment and improvement that is now joined by 180 ICUs. Data collected in 2005 are analyzed and presented.

METHODS

All admitted patients were entered in a validated software, which performs a multitude of validity checks during the data entry. Data were further reviewed by the co-ordinating center; patients admitted in months with more than 10% of incomplete or inconsistent records in each ICU were excluded from the analysis. Each year, a multivariate logistic regression model is fitted to identify predictors of hospital mortality. Starting from the SAPS 2 and the 2004 GiViTI model predictions of hospital mortality, two calibration tables and curves are presented.

RESULTS

In 2005, 180 Italian ICUs collected data on 55 246 patients. After excluding those admitted in months with an unjustified lower recruitment rate or with less than 90% of complete and consistent data, we had 52 816 (95.6%) valid cases. Although the rough hospital mortality in 2005 was 1% higher than in 2004 (22.6% vs 21.5%), the adjusted mortality shows a statistically significant 4% reduction (obser-ved-to-expected ratio: 0.96; 95% CI: 0.94-0.97).

CONCLUSIONS

Italian ICUs in 2005 performed better than in 2004, at a parity of patient severity.

[Treatment of varicocele in pediatric age with retroperitoneoscopic ''one trochar'' technique. Long term follow-up]

AIM

The incidence of varicocele varies from 6% to 16.2% in male children and adolescents. Various techniques were proposed to treat it. In the last years there was an increasing interest in the use of laparoscopy in pediatric urology. The authors reports their experience in the treatment of varicocele by retroperitoneoscopy with one trocar technique and the long-term follow-up in pediatric patients.

METHODS

Fourty patients were treated for idiopathic Horner's degree III or less, but symptomatic, and type 1 according to Coolsaet varicocele. All patients underwent a clinical examination and echo-color Doppler before treatment and during the follow-up.

RESULTS

The following parameters were evaluated: duration of the operation, intra and postoperative complications, duration of hospitalization and of antalgic therapy. Follow-up was at 6, 12, 24 and 36 months (mean 23.4 months). Testicles diameters, persistence/recurrence of varicocele and hydroceles were estimated.

CONCLUSIONS

The retroperitoneoscopic approach in the treatment of varicocele is an effective technique because it implies a minor surgical trauma, a rapid postoperative recovery and a good cosmetic result.

Myositis ossificans in children: description of a clinical case with a rare localization

Myositis ossificans (MO) also defined as myosteosis or hematoma ossificans, is a benign condition presenting as an heterotopic, well- defined neoformation in muscles and soft tissues. It was first described by Guy Patyn in 1692 and defined in its histopathological aspects by Von Dusch in 1868. It most frequently has a post-traumatic onset (60-75% of cases), usually following small repeated traumas or a single bruising episode. MO is rare in subjects under 10 years of age, whereas it is more frequent in teen-age athletes, and over 50% of cases are diagnosed in the third decade of life. Its etiopathogenesis in unknown, although it is associated with a traumatic event in 75% of cases. MO most common localizations are arms, legs, shoulders and hands, rarely chest. The lesion presents with different degrees of maturation and diagnostic tools are echotomography (ECT) as a primary investigation, and NMR for a better diagnostic assessment. Because of the self-limiting nature of the lesion and its spontaneous resolution, a conservative treatment is advised along with radiological follow-up which is most indicated in the presence of either typical MO features or highly suggestive ECT o NMR findings. In case of uncertain diagnosis, relevant muscular function impairment, considerable lesion dimension or severe pain, exeresis and histological examinations are suggested. The present paper describes and discusses a clinical case of MO in a child, with a rare localization.

Renal transplantation in patients over 65 years of age: no more a contraindication but a growing indication

INTRODUCTION

Worldwide organ shortage and the increasing age of end-stage renal disease patients demanding a graft have prompted extensive use of marginal donors. The "old-for-old" allocation has been proposed for the elderly. The aim of this study was to evaluate the results of a policy of free acceptance into the waiting list of recipients older than 65 years.

METHODS

From 1987 to 2004 70 patients whose mean age was 67.4 +/- 2.8 years, underwent an extensive pretransplant evaluation including cardiac studies. Immunosuppression was based upon low-dose steroids, and cyclosporine (50%) or tacrolimus (44%).

RESULTS

Patient and graft survival at 1, 3, 5, and 10 years were 85%, 78.5%, 75%, 50%, and 80%, 74%, 70%, 36%, respectively. Death occurred in 17/70 (24%), 14 of whom had a functioning graft. The causes of death were 30% cancer, 23% cardiovascular, 23% sepsis, 12% cerebrovascular hemorrhage, 12% meningitis. The acute rejection (AR) rate was 18.6%. The causes of graft loss were: 71% patient death, 4% irreversible AR, 4% vascular thrombosis, and 21% chronic allograft dysfunction. The main complications were: 52% prostatic hypertrophy, 40% urinary tract infections, 8.6% diabetes, 11% pneumonia, 10% cardiovascular diseases, 7% urological complications, 8% abdominal pathology, 6% acute pyelonephritis, 8% non-skin cancer.

CONCLUSIONS

Despite the increased vulnerability of the elderly, they should not be excluded a priori from renal transplantation. Extensive pretransplant screening, mainly cardiovascular, and a tailored immunosuppression are two crucial issues. The moderate rate of AR suggests that these patients do not have an impaired immunocompetence as far as acute rejection is concerned.

Diffuse vascular damage in a transplanted kidney: an indication for nuclear magnetic resonance?

Vascular lesions are an increasing challenge after renal transplantation due to the wider indications for recipients and acceptance criteria for donors. Diagnostic approach and prognostic interpretation are still matter of controversy. The case reported herein may summarize some of the issues in this regard. A 54-year-old woman, on renal replacement therapy since 1974, and a kidney graft recipient from 1975 to 1999, received a second graft in 2001. The donor age was 65 years (cold ischemia 22 hours; two mismatches). The early posttransplant follow-up was characterized by delayed graft function, hypertension, and diabetes. During the initial hypertension workup, renal graft ultrasound (US) Doppler demonstrated increased vascular resistances, stable over time (resistance index 0.74 to 0.77); renal scintiscan displayed homogeneously parenchymoa and angio-magnetic resonance imaging (MRI), an homogeneous parenchymal vascularization. Initial immunosuppression with tacrolimus and steroids was modulated by adding mycophenolate mofetil to taper tacrolimus (to reduce nephrotoxicity and hypertension). Despite this, kidney function slowly deteriorated; serum creatinine reached 3 to 3.5 mg/dL by the second year. After a severe hypertensive crisis with unchanged scintiscan and US doppler examinations, angio-MRI revealed the almost complete disappearance of parenchymal enhancement beyond the lobar arteries. A renal biopsy confirmed the severe vascular damage. The patient was switched to rapamycine and a low-dose of an angiotension converting enzyme (ACE) inhibitor. She did relatively well (serum creatinine 2.2 to 3 mg/dL) for 6 months, when rapid functional impairment forced her to restart hemodialysis. This case, almost paradigmatic of the problems occurring when the rigid vasculature of long-term dialysis patients is matched with "marginal kidneys," suggests that MRI may be a sensible good to define vascular damage in the grafted kidney.

Airway hyperresponsiveness in the elderly: prevalence and clinical implications

Airway hyperresponsiveness is associated with an increased risk of developing respiratory symptoms. The assessment of airway hyperresponsiveness can provide valuable information regarding the natural course of respiratory diseases. However, little information is available for populations of more advanced age, and data are conflicting. It was assessed whether age influences the occurrence of airway hyperresponsiveness by reviewing those studies that specifically addressed this issue, and attempting to identify the factors responsible for discrepancies between studies. Eighteen studies, published between 1983 and 2002, are included in this review. Overall, the results of the analysis are in favour of a positive association between age and airway hyperresponsiveness, the prevalence of which appears to increase in the elderly. The most important determinants were reduced lung function, probably due to geometric factors, and a history of smoking, primarily because of the length of exposure, although acute effects were also demonstrated. Atopy should also be considered as an independent determinant of airway hyperresponsiveness in the elderly population. In addition, inflammatory and neuronal mechanisms could be involved. Finally, the role of sex requires further investigation. Assessing the impact of age on the occurrence of airway hyperresponsiveness has important implications: the age-associated alterations to the lung provide a model for evaluating the contribution of structural changes to the pathogenesis of airway hyperresponsiveness. From a clinical standpoint, evaluation of the magnitude of airway hyperresponsiveness could permit the early identification of individuals who are at risk, even at more advanced age. Assessment of airway hyperresponsiveness in the aged should be considered as an additional tool in the diagnostic work-up in the subset of elderly subjects with long-term smoking exposure and/or documented atopy.

Total intravenous anesthesia, spinal anesthesia or combined sciatic-femoral nerve block for outpatient knee arthroscopy

AIM

The aim of this study was to compare efficacy, efficiency and surgeon's satisfaction of total intravenous anesthesia with propofol and remifentanil with those of spinal or peripheral nerve blocks for outpatient knee arthroscopy.

METHODS

One hundred and twenty patients undergoing elective outpatient knee arthroscopy were randomly allocated to receive total intravenous anesthesia with propofol and remifentanil (40), combined sciatic-femoral nerve block (40), or spinal anesthesia (40). Preparation times, surgeon's satisfaction, and discharge times with the 3 anesthesia techniques were measured. Anesthesia-related costs were also compared based on costs of drugs, disposable materials, and anesthesia and nurse staff.

RESULTS

Preparation time was 13 min (8-22 min) with general anesthesia, 15 min (5-30 min) with spinal anesthesia and 15 min (5-25 min) with sciatic-femoral blocks (p=0.006). Surgeon's satisfaction was similar in the 3 groups, but 17 patients receiving peripheral nerve block (42%) and 12 receiving spinal anesthesia (30%) by-passed the postanesthesia care unit after surgery as compared with only 2 general anesthesia patients (5%) (p=0.01). Discharge from the postanesthesia care unit required 5 min (5-20 min) after peripheral block as compared with 15 min (5-25 min) with spinal and 15 min (5-80 min) with general anesthesia (p=0.005); however, stay in the Day-Surgery Unit was shorter after general anesthesia [170 (100-400) min] than peripheral [265 (110-485) min] or spinal blocks [230 (95-800) min] (p=0.026). Urinary retention was reported in 3 spinal patients only (8%) (p=0.03).

CONCLUSION

Regional anesthesia techniques reduce the rate of admission and the duration of stay in the postanesthesia care unit as compared with general anesthesia. Peripheral rather than spinal nerve blocks should be preferred to minimise the risk for urinary retention.

Living donor kidney transplant in Italy: is the underutilization justified?

Living donor transplants (LDtx) represent an underutilized resource in Italy. It is, however, a therapeutic option that deserves greater consideration not only due to the increasing gap between the number of uremic patients on waiting lists (6956) and the number (1464) of cadaveric transplants (CADtx), as evidenced in 2002, but also due to the advantages of LDtx over CADtx. The superiority of LDtx include better graft survival, independent of the donor/recipient relationship, less need for dialytic treatment with preemptive transplants and reduced immunogenicity of the graft due to the brain death-related "cytokine storm." Moreover, some emerging procedures namely laparoscopic nephrectomy instead of open surgery and spiral CT instead of renal angiography namely, reduce the physical and socioeconomic burden of the donor. In the light of these considerations, LDtx should be reconsidered in the Italian scenario of kidney transplantation.

Preparation of candidates for renal transplantation: cost analysis

While the costs of renal transplantation are lower than those of dialysis, little is known about the costs of managing the waiting list. We performed a cost analysis of admission and clinical management of a waiting list for renal and pancreas-kidney transplantation. Admission to the waiting list included (1) renal graft from cadaver: minimum cost Euros () 1784.56 for men < 55 years, maximum 2127.85 for women >/= 55 years; (2) pancreas-kidney transplantation: minimum 2475.50 for men, maximum 2540.10 for women >/= 35 years. Check of suitability state on waiting list after 2 and 5 years: minimum 1400.15 for men >/= 55 years (check every 2 years), maximum 1467.07 for women >/=40, <55 years (every 5 years). The differences are related to the imaging techniques: from 43.90 (Doppler ultrasonography) to 283.28 (coronary angiography). Maintenance of the waiting list: minimum cost 1885.21 in the first year and 3187.02 in the (fifth year) for men < 55 years; maximum 2228.50 (first year) and 5116.70 (fifth year) for women >/= 55 years. These results show different costs for recipients on the basis of sex and age ranges, due to the different requirements for imaging tests such as cardiac scintiscan at age >/= 55 years) and economic charges that increase with age. Reduced waiting times allow lowered total costs. This evaluation allowed us to calculate for our region (Piemonte, Northern Italy), the management costs of the patients presently on our waiting list (369 patients at December 31, 2002) from preparation to transplantation as 959,179.18.

[Double renal transplant. Retrospective analysis of data on the patient population with double kidney transplantation in the setting of the AIRT]

BACKGROUND

The number of patients on the waiting list for renal transplantation has progressively increased in the last decade, while the number of potential donors have remained the same. The expansion of the donor pool using marginal donors may represent a possible, although partial solution to this problem. Thus, the aim of the present analysis was to evaluate the graft survival of double renal transplant from marginal donors performed within the Associazione InterRegionale Trapianti (AIRT) and to assess whether this procedure is characterized by an increase in surgical complications.

PATIENTS

79 double renal transplants were performed from January 1st 1999 to December 31st 2002 in three AIRT transplant centers (Bari, Bologna, Torino). Immunosuppressive therapy for all patients included anti-IL-2 receptor antibodies, corticosteroids, tacrolimus and mofetil micophenolate.

RESULTS

Graft survival was 90% at 36 months. Acute rejection incidence was 6.4%, while the incidence of surgical complications was 16.6%.

CONCLUSIONS

The present study opens new perspectives to overcome the actual shortage of donor kidneys. Indeed, the use of marginal organs for double renal transplantation not suitable for single transplantation may create an additional pool of potential donors and significantly increase the number of kidney transplants.

Prospective, randomized, controlled evaluation of the preventive effects of positive end-expiratory pressure on patient oxygenation during one-lung ventilation

BACKGROUND AND OBJECTIVE

This prospective, randomized, controlled study evaluated the effects on oxygenation by applying a selective and patient-specific value of positive end-expiratory pressure (PEEP) to the dependent lung during one-lung ventilation.

METHODS

Fifty patients undergoing thoracic surgery under combined epidural/general anaesthesia were randomly allocated to receive zero PEEP (Group ZEEP, n = 22), or the preventive application of PEEP, optimized on the best thoracopulmonary compliance (Group PEEP, n = 28). Patients' lungs were mechanically ventilated with the same setting during two- and one-lung ventilation (FiO2 = 0.5; VT = 9mL kg(-1), inspiratory :expiratory time = 1 : 1, inspiratory pause = 10%).

RESULTS

Lung-chest wall compliance decreased in both groups during one-lung ventilation, but patients of Group PEEP had 10% higher values than patients with no end-expiratory pressure (ZEEP) applied--Group ZEEP (P < 0.05). During closed chest one-lung ventilation, the PaO2 : FiO2 ratio was lower in Group PEEP (232 +/- 88) than in Group ZEEP (339 +/- 97) (P < 0.05); but no further differences were reported throughout the study. No differences were reported between the two groups in the need for 100% oxygen ventilation (10 patients of Group ZEEP (45%) and 14 patients of Group PEEP (50%) (P = 0.78)) or re-inflation of the operated lung during surgery (two patients of Group ZEEP (9%) and three patients of Group PEEP (10%) (P = 0.78)). Postanaesthesia care unit discharge required 48 min (25th-75th percentiles: 32-58 min) in Group PEEP and 45 min (30-57 min) in Group ZEEP (P = 0.60).

CONCLUSIONS

The selective application of PEEP to the dependent, non-operated lung increases the lung-chest wall compliance during one-lung ventilation, but does not improve patient oxygenation.

[Traumatic gut perforation (seat-belt syndrome): a case report]

Seat belts have dramatically reduced the severity of traumas in car accidents. On the other hand, specific lesions have appeared, related to seat belt use. These lesions are defined as "seat belt syndrome". The Authors describe an intestinal medio-ileal perforation due to seat belts in a child.

[Enema-induced intestinal perforation. A case report]

Constipation is a frequent clinical condition in pediatric age, with a low frequency of evacuation and emission of voluminous and hardened stools. In the most serious cases enemas became necessary, and are usually carried out without trouble. Nevertheless, traumatic events of great importance can take place, leading the patient to urgent surgical observation. The clinical case of a girl suffering from birth from chronic constipation is reported. The girl underwent a colostomy according to Mikulitz's technique on the descending colon, due to a rectal perforation induced during an enema. After the re-canalisation and the contemporaneous resection of 18 cm of the dolicho-sigmoid colon (which was most likely the cause of chronic constipation) the girl presented a normal defecatory rhythm.