Bilateral thoracoscopic splanchnicectomy in chronic intestinal pseudo-obstruction: report of two paediatric cases

A review of the thoracic splanchnic nerves and celiac ganglia

Anatomical variation of the thoracic splanchnic nerves is as diverse as any structure in the body. Thoracic splanchnic nerves are derived from medial branches of the lower seven thoracic sympathetic ganglia, with the greater splanchnic nerve comprising the more cranial contributions, the lesser the middle branches, and the least splanchnic nerve usually T11 and/or T12. Much of the early anatomical research of the thoracic splanchnic nerves revolved around elucidating the nerve root level contributing to each of these nerves. The celiac plexus is a major interchange for autonomic fibers, receiving many of the thoracic splanchnic nerve fibers as they course toward the organs of the abdomen. The location of the celiac ganglia are usually described in relation to surrounding structures, and also show variation in size and general morphology. Clinically, the thoracic splanchnic nerves and celiac ganglia play a major role in pain management for upper abdominal disorders, particularly chronic pancreatitis and pancreatic cancer. Splanchnicectomy has been a treatment option since Mallet-Guy became a major proponent of the procedure in the 1940s. Splanchnic nerve dissection and thermocoagulation are two common derivatives of splanchnicectomy that are commonly used today. Celiac plexus block is also a treatment option to compliment splanchnicectomy in pain management. Endoscopic ultrasonography (EUS)-guided celiac injection and percutaneous methods of celiac plexus block have been heavily studied and are two important methods used today. For both splanchnicectomies and celiac plexus block, the innovation of ultrasonographic imaging technology has improved efficacy and accuracy of these procedures and continues to make pain management for these diseases more successful.

Diagnosis and management of intestinal motility disorders

Gastrointestinal motility disorders in their most severe forms may directly lead to intestinal failure. Abnormal motor function may also contribute to the overall gut dysfunction of children who have other underlying gastrointestinal diseases, such as Hirschsprung disease or gastroschisis. Understanding the extent and the severity of the dysmotile segments has direct therapeutic and prognostic implications. Our ability to study gastrointestinal motility has greatly improved in the past few years, with the development of less-invasive diagnostic tests. Optimal treatment of children with intestinal motility disorders relies on a multidisciplinary approach, which focuses on optimizing nutrition, improving gastrointestinal motility, and reducing psychosocial disability. Patient education is important to avoid aggravations of symptoms caused by dietary indiscretions.

New tools in the treatment of motility disorders in children

Gastrointestinal motility disorders can develop in neurologically impaired children and those with congenital malformations of the gut. It is characterized by moderate to severe abdominal pain, vomiting, and failure to thrive. Antral dysmotility after fundoplication and increased sympathetic over activity are 2 factors associated with this condition that make it difficult to treat. This paper proposes a management strategy using metoclopramide, celiac plexus blockade, and thoracic splanchnectomy. It reviews our experience with 11 patients.

Thoracoscopic Splanchnectomy: A new treatment for Disorders of Motility: A Case Report

The case of a 15 year old female born with multiple anomalies, who subsequently developed severe gastro-intestinal dysmotility is discussed. Motility disorders are often seen in neurologically impaired children, those with a history of gastro-oesophageal reflux disease (GORD), and congenital malformations of the gut. It is characterized by abdominal pain, vomiting and failure to thrive. Once this condition develops, it is difficult to treat. This girl failed to improve with conventional treatment including repeated fundoplication. We hypothesised that her symptoms maybe due to antral dysmotility and sympathetic over-activity. She underwent celiac plexus blockade which was immediately curative but temporary and therefore underwent minimally invasive thoracic splanchnectomy. She continues to be asymptomatic. We discuss the relevant anatomy and management protocol which should be considered in such difficult cases.

Pediatric gastrointestinal motility disorders: challenges and a clinical update

Pediatric gastrointestinal motility disorders are common and can range from relatively benign conditions such as functional constipation to more serious disorders such as achalasia, Hirschsprung disease, and intestinal pseudoobstruction. Performing and interpreting motility evaluations in children presents unique challenges and is complicated by a dearth of control information, underlying gastrointestinal developmental maturation, technical challenges (eg, catheter size limitations), and patient cooperation. Primary diseases such as congenital pseudoobstruction or Hirschsprung disease occur more often in children, but as with adults, abnormal motility may be secondary to other processes. Diagnostic studies include radiographic studies, manometry, breath testing, myoelectrical testing, and histologic evaluation. Although recent advances in technology, genetics, and biology are making an important impact and have allowed for a better understanding of the pathophysiology and therapy of gastrointestinal motility disorders in children, further research and new therapeutic agents are needed.