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Evans-Barns HME, Tien MY, Trajanovska M, Safe M, Hutson JM, Dinning PG, King SK. Post-Operative Anorectal Manometry in Children following Anorectal Malformation Repair: A Systematic Review. J Clin Med 2023; 12:jcm12072543. [PMID: 37048627 PMCID: PMC10094903 DOI: 10.3390/jcm12072543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/02/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Despite surgical correction, children with anorectal malformations may experience long-term bowel dysfunction, including fecal incontinence and/or disorders of evacuation. Anorectal manometry is the most widely used test of anorectal function. Although considerable attention has been devoted to its application in the anorectal malformation cohort, there have been few attempts to consolidate the findings obtained. This systematic review aimed to (1) synthesize and evaluate the existing data regarding anorectal manometry results in children following anorectal malformation repair, and (2) evaluate the manometry protocols utilized, including equipment, assessment approach, and interpretation. We reviewed four databases (Embase, MEDLINE, the Cochrane Library, and PubMed) for relevant articles published between 1 January 1985 and 10 March 2022. Studies reporting post-operative anorectal manometry in children (<18 years) following anorectal malformation repair were evaluated for eligibility. Sixty-three studies were eligible for inclusion. Of the combined total cohort of 2155 patients, anorectal manometry results were reported for 1755 children following repair of anorectal malformations. Reduced resting pressure was consistently identified in children with anorectal malformations, particularly in those with more complex malformation types and/or fecal incontinence. Significant variability was identified in relation to manometry equipment, protocols, and interpretation. Few studies provided adequate cohort medical characteristics to facilitate interpretation of anorectal manometry findings within the context of the broader continence mechanism. This review highlights a widespread lack of standardization in the anorectal manometry procedure used to assess anorectal function in children following anorectal malformation repair. Consequently, interpretation and comparison of findings, both within and between institutions, is exceedingly challenging, if not impossible. Standardized manometry protocols, accompanied by a consistent approach to analysis, including definitions of normality and abnormality, are essential to enhance the comparability and clinical relevance of results.
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Evans-Barns HME, Tien MY, Trajanovska M, Safe M, Hutson JM, Dinning PG, King SK. Post-operative colonic manometry in children with anorectal malformations: A systematic review. Neurogastroenterol Motil 2022; 34:e14415. [PMID: 35699343 PMCID: PMC10078517 DOI: 10.1111/nmo.14415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 03/07/2022] [Accepted: 04/20/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Children with anorectal malformations may experience constipation and fecal incontinence following repair. The contribution of altered anorectal function to these persistent symptoms is relatively intuitive; however, colonic motility in this cohort is less well understood. Manometry may be used to directly assess colonic motility. PURPOSE The purpose of this systematic review was to synthesize the available evidence regarding post-operative colonic motility in children with anorectal malformations and evaluate the reported equipment and protocols used to perform colonic manometry in this cohort. This systematic review was conducted in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We conducted a systematic review of four databases: Embase, MEDLINE, PubMed, and the Cochrane Library (1st January 1985-22nd July 2021). Studies reporting colonic manometry performed in children following anorectal malformation repair were assessed for eligibility. Data were extracted independently by two authors. Four studies were eligible for inclusion. Of the combined total cohort of 151 children, post-operative colonic manometry was conducted in 35. Insufficient reporting of medical characteristics, bowel function, and manometric outcomes restricted comparison between studies, and limited clinical applicability. No results from high-resolution colonic manometry were identified. Despite the prevalence of post-operative bowel dysfunction in children with repaired anorectal malformations, this systematic review highlighted the markedly limited evidence regarding post-operative colonic motility. This cohort may benefit from assessment with high-resolution techniques; however, future work must emphasize adherence to standardized manometry protocols, and include robust reporting of surgical characteristics, bowel function, and manometric outcomes.
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Affiliation(s)
- Hannah M E Evans-Barns
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Melissa Y Tien
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Misel Trajanovska
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Mark Safe
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - John M Hutson
- Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Urology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Phil G Dinning
- Department of Surgery, College of Medicine and Public Health, The Flinders University and Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Sebastian K King
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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Corsetti M, Costa M, Bassotti G, Bharucha AE, Borrelli O, Dinning P, Di Lorenzo C, Huizinga JD, Jimenez M, Rao S, Spiller R, Spencer NJ, Lentle R, Pannemans J, Thys A, Benninga M, Tack J. First translational consensus on terminology and definitions of colonic motility in animals and humans studied by manometric and other techniques. Nat Rev Gastroenterol Hepatol 2019; 16:559-579. [PMID: 31296967 PMCID: PMC7136172 DOI: 10.1038/s41575-019-0167-1] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2019] [Indexed: 12/19/2022]
Abstract
Alterations in colonic motility are implicated in the pathophysiology of bowel disorders, but high-resolution manometry of human colonic motor function has revealed that our knowledge of normal motor patterns is limited. Furthermore, various terminologies and definitions have been used to describe colonic motor patterns in children, adults and animals. An example is the distinction between the high-amplitude propagating contractions in humans and giant contractions in animals. Harmonized terminology and definitions are required that are applicable to the study of colonic motility performed by basic scientists and clinicians, as well as adult and paediatric gastroenterologists. As clinical studies increasingly require adequate animal models to develop and test new therapies, there is a need for rational use of terminology to describe those motor patterns that are equivalent between animals and humans. This Consensus Statement provides the first harmonized interpretation of commonly used terminology to describe colonic motor function and delineates possible similarities between motor patterns observed in animal models and humans in vitro (ex vivo) and in vivo. The consolidated terminology can be an impetus for new research that will considerably improve our understanding of colonic motor function and will facilitate the development and testing of new therapies for colonic motility disorders.
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Affiliation(s)
- Maura Corsetti
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Marcello Costa
- Human Physiology and Centre of Neuroscience, College of Medicine, Flinders University, Bedford Park, South Australia, Australia
| | - Gabrio Bassotti
- Department of Medicine, University of Perugia Medical School, Perugia, Italy
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Osvaldo Borrelli
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Sick Children, London, UK
| | - Phil Dinning
- Human Physiology and Centre of Neuroscience, College of Medicine, Flinders University, Bedford Park, South Australia, Australia
- Department of Gastroenterology and Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Carlo Di Lorenzo
- Department of Pediatric Gastroenterology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Jan D Huizinga
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Marcel Jimenez
- Department of Cell Physiology, Physiology and Immunology and Neuroscience Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Satish Rao
- Division of Gastroenterology/Hepatology, Augusta University, Augusta, GA, USA
| | - Robin Spiller
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nick J Spencer
- Discipline of Human Physiology, School of Medicine, Flinders University, Bedford Park, South Australia, Australia
| | - Roger Lentle
- Digestive Biomechanics Group, College of Health, Massey University, Palmerston North, New Zealand
| | - Jasper Pannemans
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - Alexander Thys
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - Marc Benninga
- Translational Research Center for Gastrointestinal disorders (TARGID), Department of Clinical and Experimental Medicine, University of Leuven, Leuven, Belgium
| | - Jan Tack
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands.
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Rodriguez L, Sood M, Di Lorenzo C, Saps M. An ANMS-NASPGHAN consensus document on anorectal and colonic manometry in children. Neurogastroenterol Motil 2017; 29. [PMID: 27723185 DOI: 10.1111/nmo.12944] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 08/18/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Over the last few years, the study of the colon and anorectal function has experienced great technical advances that have facilitated the performance of the tests and have allowed a more detailed characterization of reflexes and motor patterns. As a result, we have achieved a much better understanding of the pathophysiology of children with defecation problems. Anorectal and colonic manometry are now commonly used in all major pediatric referral centers as diagnostic tools and to guide the management of children with intractable constipation and fecal incontinence, particularly when a surgical intervention is being considered. PURPOSE This review highlights some of the recent advances in pediatric colon and anorectal motility testing including indications and preparation for the studies, and how to perform and interpret the tests. This update has been endorsed by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN).
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Affiliation(s)
- L Rodriguez
- Department of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - M Sood
- Department of Pediatric Gastroenterology, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - C Di Lorenzo
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - M Saps
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
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Rodriguez L, Nurko S, Flores A. Factors associated with successful decrease and discontinuation of antegrade continence enemas (ACE) in children with defecation disorders: a study evaluating the effect of ACE on colon motility. Neurogastroenterol Motil 2013; 25:140-e81. [PMID: 23035840 PMCID: PMC3546133 DOI: 10.1111/nmo.12018] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND Antegrade continence enemas (ACE) have been used in the treatment of defecation disorders in children; little is known on their effect on colon motility and the utility of the colon manometry (CM) predicting long-term ACE outcomes. METHODS Retrospective review of children with constipation undergoing CM before and after ACE to evaluate CM changes and their utility on predicting ACE outcome. KEY RESULTS A total of 40 patients (mean age 8.8 SD 3 years and 53% female patients) were included; 39 of 40 responded to the ACE. Of these 39, 14 (36%) were dependent and 25 (64%) had decreased it (11 of those or 28% discontinued it). On repeat CM we found a significant increase in the fasting (P < 0.01) and postprandial (P = 0.03) motility index, number of bisacodyl-induced high amplitude propagating contractions (HAPCs) (P = 0.03), and total HAPCs (P = 0.02). Gastrocolonic response to a meal, propagation and normalization of HAPCs improved in 28%, 58%, and 33%, respectively, with CM normalizing in 33% of patients. The baseline CM did not predict ACE outcome. The presence of normal HAPCs on the repeat CM was associated with ACE decrease. Progression and normalization of HAPCs (P = 0.01 and 0.02, respectively) and CM normalization (P = 0.01) on repeat CM were individually associated with ACE decrease. No CM change was associated with ACE discontinuation. Multivariate analysis showed that older age and HAPC normalization on CM predict ACE decrease and older age is the only predictor for ACE discontinuation. CONCLUSIONS & INFERENCES Colon motility improves after ACE and the changes on the repeat CM may assist in predicting ACE outcome.
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Affiliation(s)
- Leonel Rodriguez
- Center for Motility and Functional Gastrointestinal Disorders Division of Gastroenterology, Department of Medicine, Children’s Hospital Boston, Harvard Medical School, Boston MA
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders Division of Gastroenterology, Department of Medicine, Children’s Hospital Boston, Harvard Medical School, Boston MA
| | - Alejandro Flores
- Division of Gastroenterology, Department of Pediatrics, Floating Hospital for Children, Tufts University School of Medicine, Boston MA
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Dinning PG, Di Lorenzo C. Colonic dysmotility in constipation. Best Pract Res Clin Gastroenterol 2011; 25:89-101. [PMID: 21382581 DOI: 10.1016/j.bpg.2010.12.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 11/23/2010] [Accepted: 12/13/2010] [Indexed: 01/31/2023]
Abstract
Constipation is a common and distressing condition with major morbidity, health care burden, and impact on quality of life. Colonic motor dysfunction remains the leading hypothesis to explain symptom generation in the most severe cases of chronic constipation and physiological testing plays a role in identifying the colonic dysmotility and the subsequent patient management. Measurement of colonic motor patterns and transit has enhanced our knowledge of normal and abnormal colonic motor physiology. The scope of this review encompasses the latest findings that improve our understanding of the motility disorders associated with colonic dysfunction in both the paediatric and adult population suffering from constipation.
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Affiliation(s)
- Philip G Dinning
- Department of Gastroenterology, University of New South Wales, St George Hospital, Gray St, Kogarah, NSW 2217, Sydney, Australia.
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Demirogullari B, Sari S, Egritas O, Karakus C, Ozen I, Sonmez K, Dalgic B, Kale N, Basaklar AC. Colonic phasic motor activity is stronger in patients with repaired anorectal malformations than patients with severe colonic dismotility. Pediatr Rep 2010; 2:e18. [PMID: 21589831 PMCID: PMC3093997 DOI: 10.4081/pr.2010.e18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Accepted: 10/21/2010] [Indexed: 11/23/2022] Open
Abstract
In this study, colonic manometry studies of the patients with repaired anorectal malformations (ARM) were compared with those of patients with severe colonic dismotility due to chronic constipation (CC) and acute pseudo-obstruction (PSO). The patients with repaired ARM were accepted as group #1 (n=10). The patients with CC and acute PSO composed group #2 (n=10). Eight-channel water perfused catheter was inserted into the colon under sedation. Colonic activity was recorded in three phases including fasting, after meal and after bisacodyl installation. The results were assessed by Pearson χ(2) test, P<.05 was considered statistically significant. Mean age was 9.6 and 12.1 in groups #1 and #2, respectively. Ninety-five per cent of all patients had propagated contractions (PCs) and 20% and 40% of the patients in group #1 had PCs during fasting and after meal, respectively. These contractions were seen 30% and 70% of the patients in group #2, but no statistical difference was found between the groups. PCs after bisacodyl were observed 90% and 40% of the patients in groups #1 and #2, respectively, and this difference was statistically significant (P=.019). In this study, the prominent difference between the groups was found in response to intraluminal stimulation. This finding may indicate that the colon of the patients with ARM has more capacity to develop PCs by peripheral stimuli and more regular enteric nervous integrity.
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Affiliation(s)
- Billur Demirogullari
- Gazi University Medical Faculty Departments of Pediatric Surgery and Pediatric Gastroenterology, Ankara, Turkey
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Abstract
Fecal incontinence is a devastating underestimated problem, affecting a large number of individuals all over the world. Most of the available literature relates to the management of adults. The treatments proposed are not uniformly successful and have little application in the pediatric population. This paper presents the experience of 30 years, implementing a bowel management program, for the treatment of fecal incontinence in over 700 pediatric patients, with a success rate of 95%. The main characteristics of the program include the identification of the characteristics of the colon of each patient; finding the specific type of enema that will clean that colon and the radiological monitoring of the process.
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Affiliation(s)
- Andrea Bischoff
- Colorectal Center for Children, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, ML 2023, Cincinnati, OH 45229 USA
| | - Marc A. Levitt
- Colorectal Center for Children, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, ML 2023, Cincinnati, OH 45229 USA
| | - Alberto Peña
- Colorectal Center for Children, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, ML 2023, Cincinnati, OH 45229 USA
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Abstract
We review the current clinical evaluation and management of the most common esophageal and gastrointestinal motility disorders in children based on the literature and our experience in a pediatric motility center in the United States. The disorders discussed include esophageal achalasia, pre- and post-fundoplication motility disorders, gastroparesis, motility disorders occurring after repair of congenital atresias, motility disorders associated with gastroschisis, chronic intestinal pseudo-obstruction, motility after intestinal transplantation, motility disorders after colonic resection for Hirschsprung's disease, chronic functional constipation, and motility disorders associated with imperforate anus.
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Affiliation(s)
- Cheryl E Gariepy
- Center for Cell and Developmental Biology, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio 43205, USA.
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Constipation in 44 patients implanted with an artificial bowel sphincter. Int J Colorectal Dis 2009; 24:969-74. [PMID: 19283389 DOI: 10.1007/s00384-009-0693-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE Constipation with or without obstructed defecation (OD) is frequent in patients with artificial bowel sphincter (ABS). The aims of this study were (1) to evaluate the functional outcome of ABS based on postoperative constipation and (2) to assess pre-implantation data to predict post-implantation constipation. MATERIALS AND METHODS Thirteen men and 31 women were followed up. Both fecal incontinence and constipation with and without OD were assessed after implantation. Pre-implantation characteristics were compared in patients with and without postoperative constipation. RESULTS After implantation, nine patients (20.4%) had constipation without OD, 16 patients (36.4%) had OD, and 19 patients (43.2%) had neither of these. Incontinence was significantly more frequent in patients with postoperative constipation with or without OD. In these patients, an increase in preoperative constipation, anismus, and ultraslow waves was noted. CONCLUSION Constipation with and without OD is frequent after implantation and interfere with the functional outcome of ABS.
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Athanasakos EP, Ward HC, Williams NS, Scott SM. Importance of extrasphincteric mechanisms in the pathophysiology of faecal incontinence in adults with a history of anorectal anomaly. Br J Surg 2008; 95:1394-400. [PMID: 18844264 DOI: 10.1002/bjs.6327] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Although surgery for congenital anorectal anomalies (ARAs) aims to preserve anorectal function, faecal incontinence and constipation often result. Apart from the anal sphincters, continence is dependent on multiple anatomical and physiological factors. The aim of this study was to evaluate adults with a history of ARA to determine the role of such factors in functional outcome. METHODS The study included 20 consecutive adult patients with faecal incontinence who had undergone anorectal surgery as infants. Comprehensive testing included anal manometry, endoanal ultrasonography, tests of pudendal nerve function and rectal sensory function, evacuation proctography and colonic transit studies. RESULTS Anal resting tone and squeeze increments were both attenuated in 15 of 19 patients. Integrity of the internal and external anal sphincters was compromised in 16 and 15 of 18 patients respectively. Eleven of 13 had evidence of pudendal neuropathy. Rectal sensation was abnormal in 14 of 18 patients, of whom ten were hypersensitive and four hyposensitive. Rectal evacuation was abnormal in nine of 14. Colonic transit was delayed in five of eight patients with constipation. CONCLUSION Faecal incontinence in adult patients with ARA is related to various pathophysiologies. Structural integrity of the anal sphincters is a major factor, but extrasphincteric mechanisms, notably rectal sensory function, may be as important.
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Affiliation(s)
- E P Athanasakos
- Centre for Academic Surgery, Barts and The London School of Medicine and Dentistry, The Royal London Hospital, Whitechapel, London, UK
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Vital PF, Martins JL, Peterlini FL. Posterior sagittal anorectoplasty in anorectal anomalies: clinical, manometric and profilometric evaluation. SAO PAULO MED J 2007; 125:163-9. [PMID: 17923941 PMCID: PMC11020576 DOI: 10.1590/s1516-31802007000300007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2006] [Revised: 05/05/2006] [Accepted: 05/22/2007] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE Anorectal malformations comprise a spectrum of anomalies that continue to be difficult to treat, even today. The aim was to evaluate the fecal continence of children who underwent posterior sagittal anorectoplasty due to anorectal malformations, via computerized anorectal manometry and profilometry. DESIGN AND SETTING Prospective study at Universidade Federal de São Paulo. METHOD 82 patients (56.1% boys; 43.9% girls) of mean age 85.5 months were evaluated. They were divided into continent, partially continent and incontinent groups. Age, sex, manometric variables and profilometric parameters were studied. The results were statistically analyzed. RESULTS Among the 82 patients, 37.8% were continent, 25.6% were partially continent and 36.6% were incontinent. The overall mean resting pressure was 22 mmHg, and the means for the continent, partially continent and incontinent groups were, respectively, 30.7 mmHg, 23 mmHg and 14.7 mmHg. The overall mean pressure response to voluntary contraction was 56 mmHg, and the means for the groups were 65.4 mmHg, 55.8 mmHg and 46.6 mmHg, respectively. The rectosphincteric reflex was absent in 82.9% of the cases. In the profilometry analysis for all patients together, blue (20 to 50 mmHg) and yellow (50 to 80 mmHg) were predominant, and there was a similar distribution for the continent and partially continent patients. However, among the incontinent patients, green (< 20 mmHg) and blue prevailed. CONCLUSIONS Manometric and computerized profilometric analyses were an excellent method for postoperative evaluations on patients with intermediate and high anorectal anomalies, and for therapeutic planning.
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Affiliation(s)
| | - José Luiz Martins
- José Luiz Martins Rua dos Otonis, 131 — Vila Clementino São Paulo (SP) — Brasil — CEP 04025-000 Tel. (+55 11) 7100-0907 — Fax. (+55 11) 5575-4761 E-mail:
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Zuccarello B, Romeo C, Scalfari G, Impellizzeri P, Montalto AS, D'Oppido D, Campennì A, Formica I, Baldari S. Scintigraphic evaluation of colonic motility in patients with anorectal malformations and constipation. J Pediatr Surg 2006; 41:310-3. [PMID: 16481241 DOI: 10.1016/j.jpedsurg.2005.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE Constipation is one of the major sequelae in patients after correction of anorectal anomalies (ARAs). The aim of the present work has been to assess the colonic transit time, using radioisotope scintigraphy, in patients operated for ARA and experiencing constipation in the follow-up. The results were compared with transit time from children with true functional constipation. METHODS Twelve or 32 patients operated for ARA during the period 1994-2003 experienced mild or severe constipation (6 with high or intermediate form of ARA and 6 with low type) at follow-up. The mean age of this group was 5.8 years. Eighteen patients, mean age 6.7 years, with true functional constipation were studied as well. Colonic transit times were investigated using radioisotope scintigraphy. Normal values for colonic transit time were derived from historical controls. Radioisotope diethylenetriamine pentaacetic acid labelled with indium 111 was administered orally to determine a segmental colonic transit. Images of the abdomen have been taken at 6, 24, 48, and again at 72 hours, if radioactivity was not cleared from the colon. To quantify colonic transit, we calculated the geometric centre (GC) dividing the colon into anatomic regions. RESULTS According to normal controls, 2 different type of delayed transit can be observed: (a) slow-transit constipation if GC at 48 hours is less than 4.1; (b) functional rectosigmoid obstruction (FRSO) if GC at 48 hours is 4.1 or more but less than 6.1 at 72 hours. Patients with functional constipation were divided into 2 groups: (a) slow-transit constipation in 12 patients with a GC at 48 hours of 3.7 +/- 0.5; (b) FRSO in 6 patients with a GC of 4.7 +/- 0.04 and 5.02 at 48 and 72 hours, respectively. Patients operated for high ARA had values characteristic of FRSO with GC at 48 hours of 5.1 +/- 0.8 and 4.75 +/- 0.5 at 72 hours. In low ARA, the transit times were similar to the ones observed in patients with high ARA at 48 hours with a GC of 4.9 +/- 0.5. CONCLUSIONS Patients with ARA frequently have functional sequelae in the postoperative period such as constipation. According to our results, constipation seems to be secondary to segmental motility disorders limited to the rectosigmoid area, similar to constipated children with FRSO. No evidence of more generalised motility disturbance, as previously postulated, could be recorded.
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Affiliation(s)
- Biagio Zuccarello
- Department of Medical and Surgical Pediatric Sciences, University of Messina, 98125 Messina, Italy.
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Stanton MP, Hutson JM, Simpson D, Oliver MR, Southwell BR, Dinning P, Cook I, Catto-Smith AG. Colonic manometry via appendicostomy shows reduced frequency, amplitude, and length of propagating sequences in children with slow-transit constipation. J Pediatr Surg 2005; 40:1138-45. [PMID: 16034759 DOI: 10.1016/j.jpedsurg.2005.03.047] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND/PURPOSE We wish to define colonic motor function in children with slow-transit constipation (STC) using manometry catheters introduced through appendiceal stomas, previously sited for controlling fecal retention by colonic irrigation. METHODS We undertook 24-hour pancolonic manometry of 6 children (5 boys; mean, 11.5 years; SD, 3.0) using a multilumen silastic catheter. RESULTS were compared to nasocolonic motility studies obtained in healthy young adults. RESULTS Antegrade propagating sequences (APSs) originated less frequently in the cecum compared to controls. There were fewer APS (mean +/- SEM: STC, 13 +/- 6 per 24 hours; controls, 52 +/- 6 per 24 hours; P < .01) and high-amplitude propagating contractions (HAPCs: STC, 5 +/- 2 per 24 hours; controls, 9.9 +/- 1.4 per 24 hours; P < .05). The amplitude of APS and HAPC was less in STC (APS, 39 +/- 9 mm Hg; controls, 54 +/- 3 per 24 hours; P < .05) (HAPC: STC, 94 +/- 10 mm Hg; control, 117 +/- 3 mm Hg; P < .01), whereas the amplitude of retrograde propagating sequences was greater in STC (43 +/- 6 mm Hg; control, 27 +/- 1 mm Hg; P < .01). The distances propagated by HAPC were significantly less in STC (36 +/- 4.5 vs 47 +/- 2.3 cm, controls; P < .05), and there was no evidence of a region-specific difference in propagation velocity of APS. Neither meal ingestion nor waking significantly increased colonic motor activity in patients with STC. CONCLUSIONS Despite the small numbers available to be studied, we found that children with STC in whom an appendicostomy had been placed show significant abnormalities in pancolonic motor function.
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Affiliation(s)
- Michael P Stanton
- Department of Surgical Research, Royal Children's Hospital, Parkville, Victoria 3052, Australia
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Doughty D. Structure and function of the gastrointestinal tract in infants and children. J Wound Ostomy Continence Nurs 2005; 31:207-12; quiz 213-4. [PMID: 15851864 DOI: 10.1097/00152192-200407000-00010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
An understanding of gastrointestinal tract development is essential in understanding the pathology and management of common structural anomalies and functional disorders in the pediatric population. This article reviews key steps in the embryologic development of the gastrointestinal tract and the acquisition of fecal continence, with brief explanations of common functional and structural disorders.
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Affiliation(s)
- Dorothy Doughty
- Emory University WOC Nursing Education Center, Atlanta, GA 30322, USA.
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16
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Mandhan P, Qi BQ, Beasley SW. Aberrations of the intrinsic innervation of the anorectum in fetal rats with anorectal malformations. J Pediatr Surg 2005; 40:397-402. [PMID: 15750936 DOI: 10.1016/j.jpedsurg.2004.10.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Fecal accumulation, constipation, soiling, and incontinence are common sequelae after repair of anorectal malformations (ARMs) in children. It is believed that besides the abnormalities of sacral roots, certain inherent abnormalities of the myenteric plexuses may play an important role in the final outcome after definitive repair. METHODS This study was conducted to investigate the distribution of neuron-specific enolase (NSE), vasoactive intestinal peptide (VIP), and substance P (SP)-100 neurotransmitters in the rectosigmoid and fistulous tract of the ethylenethiourea-treated rat with ARMs. RESULTS ARMs were induced by administering 1% ethylenethiourea (125 mg/kg) on gestational day 10, and the litter was harvested on gestational day 21 by cesarean section. Forty-eight controls and 63 with ARMs (46 high-type and 17 low-type) were recovered. Whole-mount preparations of each rectosigmoid and fistulous communication between the rectum and genitourinary tract were stained with fluorescent antibodies against NSE, VIP, and SP-100. The tissues were counterstained with Eriochrome black-T and methyl green dyes to improve the visualization of the myenteric plexuses. CONCLUSIONS The immunoreactivity of NSE, VIP, and SP-100 was markedly reduced in the rectum and fistulous tract of high-type ARMs and slightly reduced in low-type ARMs compared with controls. Intramural nerves stained by VIP and SP-100 antisera were decreased in both types of ARM, indicating that both inhibitory and excitatory motor neural elements were affected, and this may explain the distal colonic dysmotility seen postoperatively in both high and low ARMs.
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Affiliation(s)
- Parkash Mandhan
- Department of Paediatric Surgery, Christchurch Hospital, Christchurch 8000, New Zealand
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Martin MJ, Steele SR, Mullenix PS, Noel JM, Weichmann D, Azarow KS. A pilot study using total colonic manometry in the surgical evaluation of pediatric functional colonic obstruction. J Pediatr Surg 2004; 39:352-9; discussion 352-9. [PMID: 15017551 DOI: 10.1016/j.jpedsurg.2003.11.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE Total colonic manometry (TCM) can directly measure intraluminal pressures and contractile function of the entire colon. The utility of TCM to guide the surgical management of functional colonic obstruction has not been reported. METHODS Total colonic manometry was performed on all patients referred for surgical evaluation of refractory functional colonic obstruction. Manometric tracings were obtained while fasting, after feeding, and after pharmacologic stimulation. RESULTS Nine patients were referred for refractory colonic obstruction. The mean age was 4.8 years, and the mean duration of follow-up was 29 months. Two patients had functional obstruction after repair of Hirschsprung's disease, and 7 patients had idiopathic functional obstruction. In the idiopathic group, 4 distinct motility patterns were identified: (1) normal colonic motility, (2) dysmotility with massive distension, (3) persistent segmental dysmotility, and (4) global neuropathy/myopathy. Both Hirschsprung's patients showed globally abnormal motility. Surgical management was guided by TCM results. There was significant improvement in bowel function and weight gain after manometry-guided intervention. An unnecessary laparotomy was avoided in 2 patients. CONCLUSIONS TCM can be valuable in deciding the need for and timing of diversion, the extent of resection required, and the suitability of the patient for restoring bowel continuity in refractory functional obstruction.
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Affiliation(s)
- Matthew J Martin
- Department of Surgery, Madigan Army Medical Center, Fort Lewis, WA, USA
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Abstract
This article addresses the diagnosis and treatment of pediatric fecal incontinence in 4 main categories: (1) Functional fecal retention, the withholding of feces because of fear of painful defecation, results in constipation and overflow soiling. Treatment includes dietary changes, use of laxatives, and cognitive and behavioral interventions such as toilet training, which diminishes phobia and provides positive reinforcement through a rewards system. (2) For functional nonretentive fecal soiling (encopresis), antidiarrheal agents can increase the consistency of stools and facilitate continence. Anorectal biofeedback for children has been proposed, but its efficacy remains unproven. Parents should be educated to conduct nonaccusatory toilet training and help children alleviate guilt and enhance self-esteem. Appropriately constructed trials are necessary to gauge the effect of adding prolonged use of enemas to an intensive toilet training program. (3) Surgery can correct minor congenital anorectal anomalies by identifying the external sphincter, separating the rectum from the genitourinary tract, and reconstructing the anus. However, there is great variation in postsurgical functional outcomes for anorectal malformations. Double-blinded, randomized controlled trials could help define the role of appendicostomy, cecostomy, sphincter reconstruction, colostomy, and artificial sphincters. (4) Children with spina bifida and fecal incontinence may benefit from techniques that teach them how to defecate. A continent appendicostomy (Malone procedure) is a promising treatment that completely cleanses the colon, increases the child's autonomy, and decreases the chance of soiling. A cecostomy can be performed surgically, endoscopically, or radiologically to provide some of the same benefits.
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Affiliation(s)
- Carlo Di Lorenzo
- Division of Pediatric Gastroenterology, Children's Hospital of Pittsburgh, Pennsylvania 15213-7355, USA.
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Abstract
Anorectal disorders are common in children. It has been estimated that 10% of children are brought to medical attention because of a defecation disorder, and constipation is the chief complaint in 3% to 5% of all visits to pediatricians. Most of these children suffer from functional constipation. There are substantial differences in the approach to children and adults with anorectal disorders. This article discusses the commonest pediatric anorectal disorders, emphasizing the differences between children and adults in terms of clinical presentations, pathophysiology, diagnosis, and treatment.
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Affiliation(s)
- C Di Lorenzo
- Division of Gastroenterology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA
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Brisseau GF, Langer JC. Surgical approaches to pediatric defecatory disorders. Curr Gastroenterol Rep 2000; 2:241-7. [PMID: 10957936 DOI: 10.1007/s11894-000-0067-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Defecation is one of the most basic of human activities. Problems with evacuation of feces have plagued people since the beginning of time. In modern society, defecatory disorders are the source of embarrassment, discomfort, and stress. Society's lack of openness on this subject forces many people to endure their affliction silently. Nevertheless, although these conditions consume significant medical resources, little research has been done on their causes and treatment. This review summarizes recent developments in surgical treatment of children with these disorders, either in the ability to pass stool or the ability to control defecation.
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