Anorectal Abnormalities Research Articles

Development of Prediction Model for Hirschsprung-Associated Enterocolitis (HAEC) in Postoperative Hirschsprung Patients

BackgroundDespite identifying numerous risk factors for postoperative Hirschsprung-associated enterocolitis (HAEC), predicting individual risk remains challenging. This study aimed to develop a clinical prediction model for predicting the probability of postoperative HAEC within 5 years after surgery in Hirschsprung individuals. MethodsThe study included all children with Hirschsprung disease who underwent definitive surgery at Chiang Mai University Hospital from 2006 to 2021. Concomitant anorectal abnormalities and incomplete data were excluded. A multivariable logistic regression analysis, adjusted for correlated data, was utilized to develop the prediction model. ResultsOf the included 274 patients, 75 patients (27.4%) experienced postoperative HAEC within 5 years, totaling 121 episodes. Based on statistical and theoretical significance, eight parameters were utilized as predictors, which included male (OR1.23,95%CI:0.53–2.86), trisomy21(OR1.34,95%CI:0.21–8.45), weight at the time of surgery (OR0.86,95%CI:0.73–1.02), absence of exclusive breastfeeding (OR1.51,95%CI:0.65–3.51), length of the aganglionic segment (rectosigmoid (OR1.32,95%CI:0.48–3.62), long segment (OR41.39,95%CI:3.00–570.37), and total colonic aganglionosis (OR710.20,95%CI:23.55–21420.72)), preoperative stoma (OR1.72,95%CI:0.34–8.58), surgical approach (Duhamel (OR0.06,95%CI:0.01–0.81) and abdominal assisted trans anal endorectal pull-through (OR0.04,95%CI:0.002–0.65)), and early HAEC before two weeks following surgery (OR1.98,95%CI:0.67–5.82). The derived predictive model exhibited acceptable discriminative performance (AuROC:0.749,95%CI:0.679–0.816). Risk groups were categorized into low and high-risk, with positive likelihood ratios of 0.65 and 10.70, respectively. Recommendations for management and follow-up were generated based on these risk groups. An online application has been developed for calculating individual risk of postoperative HAEC and offering management suggestions with follow-up schedule: [https://w1.med.cmu.ac.th/surgery/personnel/pedsurgerycmu/#HAEC-Calculator]. ConclusionsThis risk predictive model accurately estimates the probability of postoperative HAEC within 5 years after surgery in Hirschsprung patients. It facilitates risk stratification and provides personalized recommendations to parents for the prevention and early detection of postoperative HAEC. Levels of EvidenceLevel II Retrospective cohort study (Prognosis study).

FECALOME GEANT A PROPOS D’UNE OBSERVATION ET REVUE DE LA LITTERATURE A L’HOPITAL DONKA

Fecal impaction is a mass of hardened fecal matter impacted primarily in the rectum and sigmoid. The most common sites of fecal impaction are the sigmoid colon and the rectum. We report a case of giant ileocecal fecal impaction causing OIA which was treated surgically. Case report: 25-year-old patient, student, admitted to the department for progressive abdominal pain accompanied by cessation of materials and gases, and abdominal bloating lasting for two (2) weeks. As a history, we noted stubborn constipation and episodes of subocclusion. The clinical examination noted a deterioration in general condition WHO stage I, conjunctival hypocoloration, polypnea at 35 cycles/mm and tachycardia at 100/min. The abdomen was very distended and tympanic, intestinal peristalsis was inaudible. Rectal examination revealed vacuity of the rectal bulb. The diagnosis of OIA/VCP was made; the unprepared abdominal X-ray showed aerocolia; biological examination, normochromic and normocytic anemia at 10g/l. Intraoperatively, we found a giant ileocecal fecal impaction extending from the rectosigmoid hinge to the last ileal loops (50 cm from the ileocecal angle) on dolichomegacolon. (Figure 2) We carried out a sigmoidectomy to extract the fecal impaction which weighed 15 KG (figure 3), using the colostomy according to Hartmann. The operating part addressed to the anapath did not show any particularity. Three (3) months later we restored continuity. The ileal fecal masses were extracted manually. The postoperative course was simple; 16 weeks after the first intervention we restored continuity. Conclusion: Fecal impaction occurs when a large amount of fecal matter is compacted and cannot be evacuated spontaneously. It is significantly common in severe chronic constipation and in other at-risk patients with anatomical or functional anorectal abnormalities. Key words: giant fecal impaction, intestinal obstruction, Donka Hospital.

Relationship of Age and Gender to Motility Test Results and Symptoms in Patients with Chronic Constipation.

Patients with chronic constipation (CC) exhibit symptoms and functional abnormalities upon testing, but their relationship to age and gender is unclear. We assessed age- and gender-related differences in symptoms, colon transit time, and anorectal motility, sensation, and expulsion. Retrospective, post hoc data analysis of patients with CC, who underwent Wireless Motility Capsule (WMC), High-Resolution Anorectal Manometry (HR-ARM), Balloon Expulsion Test (BET) and Rectal Sensory Testing (RST). Clinical assessment was made by questionnaires. Standard WMC criteria for colonic transit time (CTT) and the London classification was used for HR-ARM analyses, and regression plots between age, gender, CTT, HR-HRM, RST and BET were calculated. We studied 75 women and 91 men. Abdominal pain, infrequent defecation, incomplete evacuation, defecatory straining, and multiple motility and anorectal function abnormalities were common. Abdominal pain was least frequently, and straining was most frequently associated with a motility abnormality. For each symptom, the highest prevalence was associated with failed BET. There was a significant increase in CTT with age only in men (p = 0.0006). In men, for each year of age there was a CTT increase of 1.02 h. The prevalence of abdominal pain and incomplete evacuation for females was significantly higher than that for males (both P < 0.05). The prevalence of low anal squeeze pressure for females was significantly higher than that for males, and the prevalence of poor rectal sensation for males was significantly higher than that for females (both P < 0.05). A significant decrease in basal anal and squeeze pressures with age occurred in women (p < 0.0001); an increase in age of one year was associated with a decrease in anal base pressure of 1.2 mmHg. Abnormal CTT and HR-ARM tests were associated with increased symptom frequency, but not severity. There are significant age- and gender-related differences in symptoms, CTT, and HR-HRM parameters, rectal sensation, and expulsion, that may influence the multifaceted management of constipation.

Postoperative complications in males with anorectal malformations depending on the surgical approach

BACKGROUND: Anorectal abnormalities occur in 1:1,500 to 1:5,000 live births. There is still no agreement on the best surgical procedure for treating some types of anorectal abnormalities in males. Anorectoplasty could be performed using the posterior sagittal approach and using laparoscopic techniques.&#x0D; AIM: To assess the risk of postoperative complications and determine their specificity in males with anorectal malformations, depending on the surgery approach.&#x0D; MATERIALS AND METHODS: A single-center retrospective cohort study was performed. Male patients with anorectal malformations who had surgical correction of anorectal malformation by posterior sagittal (group I) or laparoscopic-assisted anorectoplasty (group II) at the age of up to 1 yr at the N.F. Filatov Childrens City Clinical Hospital from 2008 to 2022. Postoperative and intraoperative problems and the number of surgical interventions that had to be redone to correct issues were noted.&#x0D; RESULTS: Of the 33 patients in group I, 18 (55%) had anorectal malformations with bulbar fistula, 12 (36%) had anorectal malformations without fistula, and three (9%) had a prostatic fistula. Group II included 99 patients, with 53 (54%) having anorectal malformations with prostatic fistula, 30 (30%) having anorectal malformations with bulbar fistula, nine (9%) having anorectal malformations with bladder neck fistula, and seven (7%) having anorectal malformations without a fistula. The incidence of intraoperative and postoperative complications was statistically significantly higher in children after posterior sagittal anorectoplasty than laparoscopic-assisted anorectoplasty: I, 19 (58%) versus II, 33 (33%); p = 0.014. The number of redo surgical interventions to correct complications did not differ significantly between the studied groups: I, 8 (24%) versus II, 26 (26%); p = 0.819. The incidence of urethral damage was identified with posterior sagittal anorectoplasty compared with laparoscopic-assisted anorectoplasty: I, 4 (12%) versus II, 0 (0%); p 0.001. We found no differences in postoperative complications between laparoscopic-assisted and posterior sagittal anorectoplasty.&#x0D; CONCLUSIONS: The results define laparoscopic-assisted anorectoplasty as a viable and promising method that does not have specific postoperative complications if it is technically correctly performed. It is necessary to develop clear criteria for rectum mobilization and the volume of rectourethral fistula dissection during laparoscopic-assisted surgery to reduce the risks of postoperative problems and repeat surgery.

Evaluating the utility of cystoscopy, distal colostography, and sonography for locating the fistula in patients with anorectal malformation: a case series.

This study was performed on patients with anorectal abnormalities who had undergone decompressive colostomy and were planned for anorectoplasty in the period from September 2017 to March 2019 in a pediatric surgical center. To answer our question, all three mentioned methods were conducted before the surgery and were compared with the intraoperative findings. Sonography, distal colostography, and the second cystoscopy findings were similar to intraoperative conclusions concerning the presence of a fistula in patients, whereas blind cystoscopy had 30% accuracy and similarity. Regarding the type of fistula sonography, distal colostography, and second cystoscopy each had 50, 37.5, and 10 inconsistency with the intraoperative findings. In all cases where a fistula was detected in blind cystoscopy, the location of the fistula was correctly determined by this modality. Data analysis on the pouch to perineum distance measurements obtained from sonography and colostography were significantly different from that of surgery. The results of this study emphasize the need to perform several diagnostic modalities to determine the location and type of fistula to improve diagnostic accuracy.

Anesthesia-dependent stress responses in pediatric anorectal abnormalities

Anesthesia-dependent stress responses in pediatric anorectal abnormalities

Vertebral anomalies associated with anorectal malformations incidentally found on contrast studies: a case series

Background: Spinal congenital malformations are closely associated with other congenital anomalies, are usually asymptomatic and be found incidentally. Moreover, spine abnormalities such as hemivertebra may cause further complications if left untreated. Among patients with VACTERL anomalies, spine anomalies account for 60-95% of them. This report aimed to describe rare and interesting cases of spinal malformation in children to provide further information on the importance of a proper approach in such cases. Case Presentation: We present three pediatric cases of vertebral anomalies associated with anorectal malformations incidentally found in contrast studies. All patients have a history of anorectal abnormalities at birth and are referred to the hospital for contrast studies. The first case found semi-segmented hemivertebra at T8-9 levels, cleft at T10 level and high-type anorectal malformations (ARMs). The second case showed unsegmented hemivertebra at the level of L1 and butterfly vertebra at T10, approximately at the same level as the skin lesion, with the possibility of occult spina bifida and high-type ARMs. The third case revealed bilateral vesicoureteral reflux (VUR), grade 1 right hydroureteronephrosis and left hydroureter, with semi-segmented hemivertebra at the level of L3, unsegmented hemivertebra at L4-5 and an extra lumbar vertebra, possibly a lumbosacral transitional vertebra (LSTV). Conclusion: Thorough screening and other examinations such as contrast studies could reduce their morbidity as more sophisticated imaging may be done to better visualize the anatomical malformation.

Townes-Brocks syndrome with craniosynostosis in two siblings

This report describes a novel truncating c.709C > T p.(Gln237*) SALL1 variant in two siblings exhibiting sagittal craniosynostosis as a unique feature of Townes-Brocks syndrome (TBS, OMIM #107480). TBS is a rare autosomal dominant syndrome with variable phenotypes, including anorectal, renal, limb, and ear abnormalities, which results from heterozygous variants in the SALL1 gene, predominantly located in the 802 bp “hot spot region” within exon 2. Recent studies have suggested that aberrations in primary cilia and sonic hedgehog signalling contribute to the TBS phenotypes. The presence of the novel c.709C > T p.(Gln237*) SALL1 variant was confirmed in both the siblings and their father, whereas no mutations currently associated with craniosynostosis were detected. We hypothesise that the truncating c.709C > T p.(Gln237*) SALL1 variant, which occurs outside the “hot spot region” and inside the glutamine-rich domain coding region, could interfere with ciliary signalling and mechanotransduction, contributing to premature fusion of calvarial sutures. This report broadens the genetic and phenotypic spectrum of TBS and provides the first clinical evidence of craniosynostosis as a novel feature of the syndrome.

Outcome of Posterior Sagital Ano Recto Plasty (PSARP) In Anorectal Malformation: Our Experience at tertiary care hospital M.T.I/L.R.H Peshawar

Objective: This study aimed to evaluate the functional result of pediatric patients at MTI / LRH, Peshawar, who had Posterior Sagittal Anorectoplasty (PSARP) for anorectal abnormalities. Methods: Three hundred and fifty cases with anorectal anomalies were analyzed in this research from 2017 to 2021 at MTI/Lady Reading Hospital Peshawar. Except for female patients with rectogenital tract fistula, distal logograms were regularly done on all patients. Each patient diagnosed with an intermediate, high-type, or cloacal malformation underwent PSARP. Both intraoperative and postoperative mortality and morbidity rates were documented. Following the PSARP treatment, patients should continue to have their anesthetics dilated regularly for three to six months after discharge. Six months to a year of patient follow-up was conducted. Results: Three hundred and fifty patients (12–36 months of age) participated in the study (245 males and 110 girls). All patients had PSARP done. One hundred ninety-five males were diagnosed with a rectourethral fistula, 95 girls with a genitourinary tract fistula, and five girls with a cloacal malformation. There was a 2.5% death rate (9/35 operations) from the surgery and its aftermath. At the outset of treatment, 30% of patients had excellent outcomes, 45% experienced fair results, and 25% experienced poor outcomes. Ninety-nine individuals had chronic constipation, and 35 had anal stenosis. Sixty individuals had mucosal prolapse and perineal irritation. In 5 patients, recurrent UTIs occurred, and in 3 cases, orchitis. The urethral stricture was discovered in two patients, and a urethral diverticulum was identified, necessitating revision surgery. Practical implication: The recorded data outcomes will be useful for the surgeons in the same setting. Conclusion: Most severe and mild anorectal abnormalities were seen in male infants. Regarding bowel control, PSARP surgery is a safe option with positive functional outcomes. Keywords: Anorectal Malformation, Anomalies, Posterior Sagittal Anorectoplasty, Pull Through, Faecal Continence, Constipation.

Anaesthesia in Correction of Anorectal Defects in Children

Anorectal abnormalities are among the most common congenital malformations in children requiring emergency surgical interventions. The objective is to analyze existing domestic and foreign publications on the features of anesthesia in anorectal abnormalities in children. Subjects and Methods. The search for publications was carried out in the abstract bases of Russian Scientific Citation Index, PubMed and Scopus according to the key words: anorectal abnormalities, anesthesia, regional anesthesia, children. 105 publications were found, 49 studies were selected for analysis. Results. For the purpose of anesthesia, both general and regional anesthesia are used to correct anorectal anomalies. Among regional techniques, spinal and caudal anesthesia is most often used. The most effective anesthesia option for anorectal surgery is saddle anesthesia since it is accompanied by a significant decrease in the tone of the anal sphincter. Combined use of general anesthesia and caudal analgesia contributes to the reduction of intraoperative blood loss and early restoration of bowel functions. Conclusion. Further research is needed to establish rapid pos t-o perative recovery protocols for anorectal malformations in children.

Transverse vaginal septum evaluation

Female genital malformations mostly affect women`s reproductive health. Vaginal septa are rare conditions that occur secondary to defectuous fusion or canalization of the Mullerian ducts. There are longitudinal and transverse septa. Transverse septa can be found in the upper, middle or lower vagina and the main symptom is primary amenorrhea in the presence of cyclic pelvic pain. Imaging discoveries can reveal urological, anorectal and uterine abnormalities that accompany the vaginal abnormalities.

Effect of anesthesia on hemodynamics in correction of anorectal abnormalities in children: a randomized study

INTRODUCTION: Anorectal anomalies are one of the most common congenital malformations in children that require corrective surgical interventions. OBJECTIVE: To study the influence of anesthesia on the hemodynamic indices in the correction of anorectal anomalies in children. MATERIALS AND METHODS: A prospective single-center randomized study. Sixty children were examined, all underwent posterior sagittal anorectoplasty according to Penya. Children were divided into two groups: group 1 — combined anesthesia (n = 30), group 2 — general with regional anesthesia (n = 30). The study included five stages: Stage I — one day before surgery; Stage II — after induction of anesthesia; Stage III — bowel reduction; Stage IV — awakening; Stage V — one day after surgery. Heart rate (HR), systolic and diastolic blood pressure (BP), ejection fraction (EF) and stroke volume (SV) were assessed during the study. RESULTS: It was revealed that at the stage of bowel movement in children where concomitant anesthesia was used, there was a more pronounced decrease of HR (120 vs 106; p &lt; 0.001). Similar changes were characteristic of diastolic BP (48 vs 42; p &lt; 0.001). Mean BP was also significantly lower in the concomitant anesthesia group, and this was statistically significant in both stages III and IV (59.3 vs 54.7, p &lt; 0.001; 61.5 vs 57.0, p &lt; 0.001). In the group where combined anesthesia was used, a decrease in stroke volume was noted at the awakening stage, which was statistically significant compared to the I–III stages. The maximum ejection fraction indices were observed at the stage of bowel lowering against the background of combined anesthesia, which was statistically significant compared to other stages of the study CONCLUSIONS: At the stage of bowel reduction using concomitant anesthesia there was a significant statistically significant decrease of HR and systemic BP which was most probably due to the powerful sympatholytic effect of local anesthetics.

Case report: a de-novo 7p12.3 microduplication detected in an infant with perineal hamartoma and imperforate anus

BackgroundAnorectal malformations (ARM) represent a wide spectrum of defects. Caudal and genitourinary malformations can associate with anorectal malformations. Genetic factors may play role in the development of anorectal malformations. Perineal masses like sacrococcygeal teratoma, rectal prolapse, or duplication cysts were reported before, but their association with perineal hamartoma and anal atresia is extremely rare.Case presentationHere, we report an 11-month-old female infant. She had 551 kb duplication at 7p12.3 with perineal hamartoma and anal atresia consisting a cystic lesion with a diameter of 4 mm at the filum terminale (L2 vertebra) on lumbar magnetic resonance imaging (MRI) in neonatal period. She presented with hypotonia. She had anorectal anomaly and external perineal mass bulging from left major labium extending across anal region with imperforate anus. There was 1 × 1 cm polyp-like protrusion on it. She was operated in neonatal period. Genetic laboratory investigations showed karyotype 46, XX. The microduplication of the chromosome 7p12.3 was detected by microarray analysis. There were not any significant homozygous or heterozygous variants determined by whole-exome sequencing.ConclusionsTo the best of our knowledge, this is the first report of a patient with a microduplication of the chromosome 7p12.3, and second case with perineal hamartoma and imperforate anus. Clinicians should pay attention to microdeletions and microduplications while giving genetic counseling to patients with urogenital and anorectal abnormalities.

Diagnosis of Functional Gastrointestinal Disorders and Choice of Treatment Regimen in Constipation Patients

Aim. A practical review of functional gastrointestinal disorder diagnosis in constipation patients and the rationale for opting treatment.Key points. Functional constipation commonly afflicts different ages and negatively impacts the quality of life. The current diagnostic algorithm in chronic constipation includes the disease identification according to Rome Criteria IV, red-flag symptom detection and instrumental laboratory examination. Functional constipation is notably often associated with anorectal abnormalities that bear a diagnostic value to elaborate an apt treatment strategy. Anorectal manometry, rectal sensation and balloon expulsion tests are the well-studied and significant probing techniques for objective anorectal zone sensorimotor function assessment in patients with functional constipation. The article reviews modern diagnostic methods in functional defecation disorders.Conclusion. The examination and treatment algorithms presented will help improve diagnosis and apply the most suitable management in a constipation-associated functional digestive pathology.

Rectal prolapse and abdominal compartment syndrome: Formerly unknown complications of hernia repair in a neonate

Rectal prolapse, a troublesome diagnosis in children, can be associated with anatomic anorectal abnormalities among other pathologies, including parasitic infestations, cystic fibrosis, and constipation, but the precise mechanism remains unknown [1]. Abdominal compartment syndrome (ACS), however, is a potentially lethal complication in the pediatric population, with estimated case fatality rate of approximately 50% [2]. While cases of both rectal prolapse and ACS have been described in the pediatric surgical literature, occurrences of such diagnoses following inguinal hernia repair in infants have not been documented previously. Here we describe the unique hospital course of an infant with trisomy 21 who underwent two sequential inguinal hernia repairs, the first complicated by rectal prolapse, the second by ACS. • Rectal prolapse is a previously unknown acute complication of inguinal hernia repair in infants. • Abdominal compartment syndrome (ACS) is also a previously unknown complication of inguinal hernia repair in infants. • Future patients with tissue laxity may be better served by general anesthesia than spinal anesthesia.

Orpha disease – FRASER syndrome (ORPHA:2052) in children: phenotype and genotype characteristics

Fraser syndrome (OMIM # 219000; ORPHA: 2052; ICD-10: Q87.0) is a rare, disease with an autosomal recessive type of inheritance is characterized by abnormalities in the development of the eyes, kidneys, larynx, ears, and bone systems (cryptophthalmos, syndactyly, abnormalities of the kidneys, urogenital tract, and respiratory system). The article presents current literature data on the phenotypic and genotypic features of Fraser syndrome, the management of patients with new opportunities for genetic diagnosis and treatment. The syndrome, described by D. Fraser in 1962, is caused by mutations in the FRAS1, FREM2, GRIP genes. The diagnosis of the Fraser syndrome phenotype is established in the presence of the main criteria (cryptophthalmos, syndactyly, abnormalities of the urinary and respiratory system, genitals, family history indicating a closely related marriage) and secondary (congenital malformations of the nose and ears, skull ossification defects, anorectal abnormalities, umbilical hernia, etc.). Molecular genetic testing proves a rare disease, requires genetic counseling. The management of patients is carried out jointly by an ophthalmologist, an otolaryngologist, an audiologist, a nephrologist, a urologist, a maxillofacial surgeon and other specialists.

Diagnosing Constipation Spectrum Disorders in a Primary Care Setting.

Understanding pathophysiological causes of constipation is worthwhile in directing therapy and improving symptoms. This review aims to identify and fill gaps in the understanding of the pathophysiology of constipation, understand its prevalence, review diagnostic tools available to primary care physicians (PCPs), and highlight patients’ expectations for the management of this common spectrum of disorders. Literature searches conducted via PubMed included terms related to constipation, diagnosis, and patient perceptions. Case studies were developed to highlight the differences between patients who may be appropriately managed in the primary care setting and those requiring specialty consultation. Myriad pathophysiological factors may contribute to constipation, including stool consistency, altered intestinal motility, gut microbiome, anorectal abnormalities, as well as behavioral and psychological factors. Common diagnoses of “primary constipation” include slow-transit constipation, defecation disorders, irritable bowel syndrome with constipation, and chronic idiopathic constipation. A detailed medical history should be conducted to exclude alarm features and PCPs should be familiar with pathophysiological factors that cause constipation, available diagnostic tools, alarm signs, and the various classification criteria for constipation subtypes in order to diagnose and treat patients accordingly. PCPs should understand when a referral to a gastroenterologist, anorectal specialist, pelvic floor physical therapist, and/or mental health specialist is appropriate.

RETRACTED ARTICLE: Evaluation of obstructed defecation syndrome (ODS) using magnetic resonance defecography (MRD)

BackgroundObstructed defecation syndrome is associated with varying combinations of a host of ano-rectal abnormalities, and no physical examination can demonstrate these abnormalities. The present study was aimed to evaluate the spectrum of various pelvic floor abnormalities in obstructed defecation syndrome (ODS).ResultsOf the total 302 patients imaged with age range of 18–72 years (mean age 54 years), 218 were females, and 84 were males. Ano-rectal junction descent was the commonest abnormality observed in 273 (90.3%) patients followed by rectocele (232) (76.8%), rectal intussusception (93) (30.7%), and cystocele (92) (30.4%). Cervical descent was observed in 78 (35.7%) of female patients. Spastic perineum was seen in 27 (8.9%) patients.ConclusionMRD serves as single stop shop for demonstrating and grading a gamut of pelvic organ abnormalities underpinning ODS which in turn helps in choosing the best treatment plan for the patient.

Constipation in Children: A guide to Prompt Diagnosis and Effective Treatment

Constipation Is a common pediatric symptom that can affect children of all ages. It impacts children both physically and psychosocially while also causing significant emotional and financial stress to their families. Constipation presenting early in life can be secondary to conditions such as anorectal malformations, anal stenosis, Hirschsprung disease, spine abnormalities, cystic fibrosis, or metabolic dysfunction. Yet, the majority of children and adolescents who struggle with constipation do so as a result of a functional disorder. Diagnosis Is primarily based on fulfilling defined clinical criteria. Despite being so prevalent, functional constipation is often misdiagnosed and inappropriately treated. Laxative use Is often avoided due to misconceptions related to their efficacy and safety. This review addresses how to effectively diagnose and treat functional constipation in children of different ages and with variable severity at the time of presentation. Guidelines from several medical societies for the evaluation and treatment of a child presenting with constipation have been published. It has become increasingly clear that early treatment of functional constipation is associated with improved long-term outcomes. The diagnostic role of anorectal and colonic manometry has been clarified and these tests have been standardized in the pediatric population. New medical and surgical treatments have been developed and Are leading to improved outcomes in children who fail conventional medical and behavioral interventions. Childhood constipation Requires a comprehensive therapeutic plan, comprised of education, behavioral intervention, and medication that jointly produce effective defecation. Children with chronic constipation who Are unresponsive to maximal medical treatment benefit from further evaluation with colonic transit studies, anorectal and colonic manometry, imaging studies of the spine, and defecography—especially if more invasive interventions such as anal sphincter botulinum toxin injection, appendicostomy, cecostomy, colonic resection, ileostomy, and sacral nerve stimulation are being considered. These children Are best evaluated in specialized centers that offer a multi-disciplinary approach to both the physical and psychosocial components of chronic constipation treatment.

Application of magnetic compression anastomosis technique in pediatric surgery

Malformation of digestive tract is common in neonates. Esophageal atresia (EA) comprises a group of congenital abnormalities defined by discontinuity of the esophagus. EA with communication with the trachea is known as tracheoesophageal fistula (TEF). For the repair of EA, it is needed to establish an anastomosis between two structures that may be significantly spaced apart, such as in long-gap EA (with a gap >3 cm). The repair across a long-gap can induce tension on the anastomosis, leading to dehiscence, anastomotic leak, or procedure failure. In neonatal patients with long-gap EA with TEF, the complications of significant gastroesophageal reflux, or anastomotic leaks and severe refractory esophageal stricture after surgery are common, which remains challenging for pediatric surgery. There are multiple options for lengthening and approximating the ends in long-gap EA such as myotomies, Gough flap, or the Foker technique. The treatment of long gap EA usually requires thoracotomy or thoracoscopy to place traction sutures on each esophageal in multiple stage operations, the treatment period of which is long. Esophageal stricture is the most common complication following EA repair. Refractory esophageal anastomotic stricture after repair of EA in infants is a challenging surgical problem. In general, these strictures can be successfully managed using endoscopic techniques including bougie and balloon dilation, stenting, and chemotherapeutic agents. If these techniques are unsuccessful, treatment options are limited to surgical resection of the strictured segment and reanastomosis, or esophageal replacement. Magnetic compression anastomosis (MCA) has been introduced for several decades. Recently, rare-earth magnets have been employed to create solid anastomosis for long-gap EA and refractory esophageal stricture in children. In MCA, a sutureless anastomosis of the gastrointestinal tract can be formed using two magnetic Harrison rings. Magnetic compress has been shown to be effective for the treatment of long-gap EA in children. MCA can be conducted during the same stage surgery of ligating the TEF with customized magnetic rings. Under the magnetic force, the two magnetic rings pull along the gastric tube to achieve anastomosis. Once the postoperative permanent suction of these two pouches is instituted, spontaneous growth can be awaited. MCA has been shown to be effective in anastomosis of stomach, small bowel and colon in both experimental and clinical cases. The magnets are most commonly made of neodymium-boron or samarium-cobalt, which can display strengths significantly greater than those of ferrite. Magnetic compression has been used to treat biliary strictures in adult patients who have undergone liver transplantation, as magnetic connectors for coronary surgery, and for the functional undiversion of ileostomy in pediatric patients. Reports also describe the use of magnetic compression in restoring patency of anastomotic strictures of the alimentary tract in patients who have undergone surgery for esophageal, gastric, and rectal cancer. Yamanouchi and colleagues have published many papers on their experience with Samarium cobalt magnets. They even used them to treat recurrent anastomotic strictures after initial MCA. It has been reported that in conditions such as congenital oesophageal atresia or rectal atresia in children, and also is a safe, minimally invasive way to gradually refunctionalize the excluded distal bowel after previous diverting ostomy. MCA using mated magnets with their interposed compressed tissue may result in serosa-to-serosa apposition. At present, MCA for the treatment of EA patients is restricted to gross type A (without TEF) and anastomotic stenosis without thoracotomy. Magnamosis offers a minimally invasive technique for repair of this congenital anomaly. This is particularly helpful in those patients who cannot undergo initial or repeat thoracotomy or thoracoscopy due to anatomic considerations or overall severity of illness. Translumenal digestive tract anastomosis using the constant magnetic field is reliable and feasible as a minimally invasive technique to treat congenital esophageal and anorectal abnormalities. Magnamosis is technically feasible for esophago-esophageal anastomoses. In anorectal malformations with favorable anatomy, this procedure may avoid an operative repair such as posterior sagittal reconstruction. We propose that magnamosis can be considered as an alternative for the treatment of rectal atresia in certain children.