Rectal Washouts Research Articles

Botulinium toxin, as bridge to transanal pullthrough in neonate with Hirschsprungs disease

Aims and Objectives:The aim of this study is to find easier way of home care while obviating the colostomy before single stage pull through operation.Materials and Methods:From August 2005 to December 2006, eight cases of neonatal Hirschsprung disease were treated. Mean age 4.5 (2-6) day/old with absent anorectal inhibitory reflex, rectosigmiod disease in Barium enema, positive Acetylcholine esterase (Ache) staining, good response to rectal washout. They underwent botulinium toxin injection (5 unit /kg/quadrant) in four quadrant intrasphincteric. They were followed until pull through operation in 8-10 weeks post injection.Results:Four of 8 (50%) cases only needed rectal washout for three to five days post injection until pull through operation, two had decrease in number of rectal washouts /day and the remaining two underwent colostomy five days post injection because of no response.Conclusion:Botulinium toxin injection can help in palliative care in patients with Hirschsprung disease who are waiting for colostomy or definitive pullthrough. It gives an option of eaiser home care for these patients.

Influence of bowel preparation and antimicrobials on colonic microflora

The influence of three types of preoperative mechanical bowel preparation on colonic microflora has been studied in 88 patients undergoing elective bowel resection and compared with 21 controls. Neither conventional bowel preparation (CBP) using oral magnesium sulphate, enemas and rectal washouts nor whole bowel irrigation (WBI) via a nasogastric tube influenced the type or number of organisms in the colon at the time of operation. The administration of an elemental diet (ED) was associated with only a small reduction the numbers of Escherichia coli (P less than 0.02). The addition of oral neomycin and metronidazole for 48 h before operation to all three methods of bowel preparation was associated with a highly significant reduction in the counts per ml of E. coli (P less than 0.001) and Bacteroides fragilis (P less than 0.001) in the colon. There was no correlation between the diameter of the lesion being resected with the numbers of bacteria in the colon even when oral neomycin and metronidazole were added to the bowel preparation.

Anterior resection for megarectosigmoid in congenital anorectal malformations

Purpose: The aim of this study was to review the effectiveness of resecting dilated distal bowel in children suffering unmanageable constipation or soiling who have been operated on previously for anorectal malformations. Methods: A retrospective review was performed of 9 children. Each child underwent excision of dilated bowel to leave normal caliber bowel anastomosed by hand to a rectal reservoir at the peritoneal reflection. The documented follow-up was reviewed. Results: The 9 children had primary surgery for the following anomalies: high (n = 1), intermediate (n = 1), low (n = 3), rectal stenosis (n = 3), and anal stenosis (n = 3), Seven children had persistent fecalomas, and 7 had major problems with soiling. All were on large doses of laxatives, with 5 having regular rectal washouts and 4 having regular enemas. In all radiologic studies there was a prompt change from normal caliber bowel to dilated bowel at the upper limit of the dilatation. The mean age at operation for excision was 4 years, 11 months (range, 11 months to 9 years, 11 months). The mean period of follow-up was 4 years, 7 months (range, 2 years, 3 months to 10 years). Follow-up showed that all children improved. None had major complications. All were having between one and 3 bowel actions per day. Three continued to soil but improved. Of the remaining 6, only 2 required occasional laxatives and had regular spontaneous bowel actions without soiling. No child was having enemas or washouts. Conclusion: Anterior resection for the treatment of megarectosigmoid is a safe and effective procedure. J Pediatr Surg 37:1464-1466. Copyright 2002, Elsevier Science (USA). All rights reserved.

Tube sigmoidostomy: a modification of the antegrade colonic evacuation.

The Malone appendicostomy enema has established its place in the treatment of paediatric faecal incontinence. More recently, the laparoscopic appendicostomy enema has gained favour. In the situation where the appendix has already been removed, caecal stomal tubes can be constructed to facilitate antegrade colonic wash-outs. These techniques may not provide an accept-able result if there is a significant time delay from the introduction of the enema to the result. Wash-outs through the more distal colon -- either by retrograde techniques with a rectal tube or, more recently, through a plastic stomal device inserted percutaneously into the sigmoid colon (the Chait tube) -- can result in rapid evacuation. Rectal wash-outs may not provide an adequate lavage and can be technically difficult for some children to perform, while many other children find external devices cosmetically unacceptable. We present a modification of this distal colonic technique that can allow greater control, can be used in the absence of an appendix and avoids the need for an external device. Two paediatric patients with spina bifida and faecal incontinence underwent tube sigmoidostomy formation. In both patients, the appendix was not available to be used for colonic wash-outs. Both patients reported excellent success with this procedure. They are continent, able to cannulate the stoma and irrigate independently. The technique can provide excellent continence control in patients who are not successful with a right-sided Malone appendicostomy. It also overcomes the need for a catheterizable appendix, and an external device.

Revision anorectoplasty in the management of anorectal anomalies.

Twelve patients who had a revision posterior sagittal anorectoplasty (PSARP) were evaluated by questionnaire. They were 11 months to 15 years old (median 5 years) at the time of revision surgery. All were born with an intermediate to high anorectal anomaly (ARM) and had ongoing problems of rectal prolapse (3), stenosis (1), faecal incontinence (9), or severe constipation (4). All but 1 had a huge megarectum with a poor anorectal angle and stool impaction, causing overflow incontinence. After revision surgery, marked improvement occurred in 7 and at least some improvement was achieved in the remaining 5. Previous severe constipation resolved in 2 and improved in another 2 children. The number of soiling episodes significantly decreased in 8 patients: while before surgery 8 had been wearing nappies all the time, only 2 use them postoperatively. The anorectal prolapse has resolved in 3 and sensation improved in 5, and as a group, there has been a reduced need for laxatives and rectal washouts. The favourable outcome of our patients confirms that PSARP is an excellent technique for revision surgery, and tapering of a secondary megarectum plus the formation of an anorectal angle can produce clinical improvement, even in more severe forms of ARM.

Transanal mucosectomy in the treatment of hirschsprung's disease

Background/Purpose:Transanal mucosectomy of theagangli-onic segment of colon is a critical step in minimally invasive surgery for Hirschsprung's disease. The purpose of this study was to examine the outcome of patients undergoing transanal mucosectomy.Methods: From January 1979 to November 1998, 26 patients (ages 25 days to 17 years) underwent transanal mucosectomy for Hirschsprung's disease. Seventeen (65%) had partial transanal mucosectomy (PTM; 1979 to 1998) and 9 (35%) complete transanal mucosectomy (CTM; 1995 to 1998). In PTM, a 2- to 3-cm mucosal dissection was begun 1 cm above the dentate line in conjunction with transabdominal endorectal dissection (modified Soave). In CTM, the entire mucosal dissection was performed transanally as part of a laparoscopically assisted Soave procedure. Results were obtained by chart review and personal communication. Patients were assessed clinically for continence where age appropriate (>3 years) and for development of constipation, postoperative enterocolitis, and anal stricture.Results: One of 16 (6.2%) of the PTM group was incontinent versus none (4 patients) in the CTM group. Five of 17 (29.4%) of the PTM group were constipated versus 4 of 9 (44.4%) in the CTM group (t test, P = not significant). Postoperative enterocolitis developed in 4 of 17 (23.5%) of the PTM group versus 6 of 9 (66.6%) in the CTM group (ttest, P < .05). Three of 6 (50%) of the CTM group versus none in the PTM group required hospitalization for bowel rest, rectal washouts, and antibiotics. All patients were well at the time of the report. Anal stricture was not seen in either group.Conclusions: Constipation and postoperative enterocolitis are a significant feature of transanal mucosectomy for Hirschsprung's disease deserving close surveillance, especially in patients in whom the entire mucosal dissection was performed transanally. Continence appears to be satisfactorily preserved from these preliminary results.

Fetal echogenic gut: a marker of intrauterine gut ischaemia?

The pathophysiological significance of fetal echogenic gut (FEG) is unknown. Our aim was prospectively to evaluate FEG in infants with intrauterine growth retardation (IUGR) and absent umbilical artery end diastolic flow velocities. Over a 15 month period, nine infants with FEG met these criteria. Nine infants who, on antenatal assessment, had demonstrated IURG and absent umbilical artery end diastolic flow velocities, but no evidence of FEG, were selected as case-controls. Gastrointestinal function was then prospectively evaluated in both groups after delivery. All liveborn infants received nasogastric feeds of breast milk by 8 days of age. All in the FEG group developed marked abdominal distension, large, bile stained, nasogastric aspirates, and constipation requiring rectal washouts. This led to a discontinuation of enteral feeds on one or more occasions. Two patients in the FEG group required water soluble contrast enemas in order to relieve intestinal obstruction. In the control group, 3/9 patients had abdominal distension, but no rectal washouts were given and enteral feeds were not interrupted. The median (range) time to tolerate full enteral feeds was 15 (7-32) days in the FEG group, compared with 4 (1-8) days in the control group. In the FEG group 5/6 patients required parenteral nutrition for 5-27 days. In the control group one patient required parenteral nutrition over a period of four days only. No child had necrotising enterocolitis or cystic fibrosis. When FEG is observed in the fetus with IUGR, problems with enteral feeding should be anticipated.