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megacolon in adulthood after surgical treatment of Hirschsprung's disease in early childhood

World Journal of Gastroenterology 2005年第36期11卷 5742-5745页

作者： Christoph R.Werner Gisela Stoltenburg-Didinger Henning Weidemann Christoph Benckert Marco Schmidtmann Ivo R.van der Voort Viola Andresen Burghard F.Klapp Peter Neuhaus Bertram Wiedenmann Hubert Mnnikes Department of Medicine Division of Hepatology and Gastroenterology Charite Campus Virchow-Klinikum Universitatsmedizin Berlin Augustenburger Platz 1 13353 Berlin Germany Department of Neuropathology Charité Campus Virchow-Klinikum Universittsmedizin Berlin Augustenburger Platz 1 13353 Berlin Germany Department of General Visceral and Transplantation Surgery Charité Campus Virchow-Klinikum Universittsmedizin Berlin Augustenburger Platz 1 13353 Berlin Germany Department of Medicine Division of Psychosomatic Medicine and Psychotherapy Charité Campus Virchow-Klinikum Universittsmedizin Berlin Augustenburger Platz 1 13353 Berlin Germany Department of Medicine Division of Hepatology and Gastroenterology Charité Campus Virchow-Klinikum Universittsmedizin Berlin Augustenburger Platz 113353 Berlin Germany

Hirschsprung＇s disease （HD） is a disorder associated with congenital malformation of the enteric nervous system with segmental aganglionosis. Prevailing therapy includes a resection of the affected part of the bowel, However, patients often do not obtain complete functional improvement after surgical treatment. We present the case of a 25-year-old woman who had surgical treatment of lid in early childhood. After that procedure she had clinical features of constipation for years in the end, passing of stool once a week, requiring laxatives and enemas. We diagnosed an incomplete resection of the aganglionic bowel via rectal biopsy and resected the remaining aganglionic segment. Two months after surgery the patient＇s bowel function improved to a frequency of 1-4 stools per day. We conclude that regular follow-up is required to identify lid patients with persistent alterations of bowel function after surgery. In patients presenting with constipation, recognition of a remaining aganglionic segment or other alterations of the enteric nervous system should be aimed at in an early stage. 2005 The WJG Press and Elsevier Inc. All rights reserved

关键词： Hirschsprung's disease megacolon Surgicaltreatment Constipation

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Toxic megacolon associated Clostridium difficile colitis

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World Journal of Gastrointestinal Endoscopy 2010年第8期2卷 293-297页

作者： Leena Sayedy Darshan Kothari Robert J Richards Division of Gastroenterology Department of MedicineStony Brook University School of Medicine

Toxic megacolon is a severe complication of Clostridium difficile (***) *** the prevalence of C. difficile colitis increases and treatments become more refractory, clinicians will encounter more patients with C. difficile associated toxic megacolon in the future. Here, we review a case of toxic megacolon secondary to C. difficile colitis and review the current literature on diagnosis and management. We identify both clinical and radiologic criteria for diagnosis and discuss both medical and surgical options for management. Ultimately, we recommend using the Jalen criteria in conjunction with daily abdominal radiographs to help establish the diagnosis of toxic megacolon and to make appropriate treatment recommendations. Aggressive medical management using supportive measures and antibiotics should remain the mainstay of treatment. Surgical intervention should be considered if the patient does not clinically improve within 2-3 d of initial treatment.

关键词： Toxic megacolon Clostridium difficile Colitis Diarrhea Surgery Colon Antibiotics Metronidazole Vancomycin

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A new modification of transanal Swenson pull-through procedure for Hirschsprung＇s disease

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Chinese Medical Journal 2008年第23期121卷 2420-2423页

作者： XU Zhi-lin ZHAO Zheng WANG Long AN Qun TAO Wen-fang Department of Pediatric Surgery First Hospital Affiliated to Harbin Medical University Harbin Heilongjiang 150001 China

Background The one-stage pull-through procedures for Hirschsprung＇s disease （HD） have become popular because it is well accepted by surgeons and mothers with no visible scar and a short hospital stay. It represents the latest development in the concept of a minimally invasive surgery for HD. We introduce a new method of transanal one-stage pull-through for Hirschsprung＇s disease, different from the transanal Scare procedure. Methods One hundred and thirty-four patients aged 9 days to 5 years underwent a transanal one-stage pull-through procedure. The diagnosis was definite by barium enema or rectal biopsies preoperatively. The patients were anesthetized and placed in the lithotomy position. A urinary catheter was optional. Giving anorectal dilatations for half a minute, a pull-through of the rectum above the peritoneal reflection and into the intussusception was performed. Fine silk suturing was performed circumferentially at the level of that point which was used for traction for the distal end. Another circumferential suture was performed parallel 0.5 cm distance above the original one and used for traction for the proximal intestines. The full-thickness rectal wall was truncated between the above two circumferential sutures with cautery. The proximal intestines were pulled down and the mesenteric vessels were dissected with ligation until normal intestines were accessed; the presence of ganglion cells was determined by intraoperative rapid frozen section. The distal end was dissected anteriorly 2.5-3.5 cm above the dentate line. The posterior rectal wall was split longitudinally and dissected to a point 0.5-1.0 cm above the dentate line. The segment of the lesion was resected. The length of bowel resected ranged from 12 to 50 cm （median 16.5 cm）. An oblique anastomosis was made. Results The mean operating time was 70 minutes. Postoperative rectal dilation was not required. The patient tolerated feeding on the first postoperative day. Eighty-eight patients wer

关键词： anal canal megacolon pull-through operation new method

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Fulminant ulcerative colitis in a healthy pregnant woman

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世界胃肠病学杂志：英文版 2015年第19期21卷 6060-6064页

作者： Rossana Orabona Adriana Valcamonico Marianna Salemme Stefania Manenti Guido AM Tiberio Tiziana Frusca Maternal Fetal Medicine Unit Department of Obstetrics and Gynecology University of Brescia Pathology Department University of Brescia Surgical Clinic Department of Clinical and Experimental Sciences University of Brescia

This case report concerns a 25-year-old patient with6-7 bloody stools/d, abdominal pain, tachycardia,and weight loss occurring during the third trimester of pregnancy. Severe ulcerative colitis complicated by toxic megacolon and gravidic sepsis was diagnosed by clinical evaluation, colonoscopy, and rectal biopsy that were performed safely without risk for the mother or baby. The patient underwent a cesarean section at28+6 wk gestation. The baby was transferred to the neonatal intensive care unit of our hospital and survived without complications. Fulminant colitis was managed conservatively by combined colonoscopic decompression and medical treatment. Although current European guidelines describe toxic megacolon as an indication for emergency surgery for both pregnant and non-pregnant women, thanks to careful monitoring, endoscopic decompression, and intensive medical therapy with nutritional support, we prevented the woman from having to undergo emergency pancolectomy. Our report seems to suggest that conservative management may be a helpful tool in preventing pancolectomy if the patient's condition improves quickly. Otherwise, surgery is mandatory.

关键词： Ulcerative colitis Toxic megacolon Pregnancy Cesarean section Colonoscopy

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Observations on a Giant Sigmoid Volvulus with Unusual Clinical Presentation and Challenging Postoperative Course: Case Report

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Surgical Science 2015年第11期6卷 499-505页

作者： Giuseppe Pisano Pietro Giorgio Calò Stefano Piras Enrico Erdas Department of Surgical Sciences University of Cagliari Cagliari Italy

Introduction: The present report describes a case of a giant sigmoid volvulus (SV) where acute respiratory distress was associated with toxic megacolon. Clinical features, surgical treatment and postoperative course deserved our attention and discussion. Presentation of Case: A 67-year-old man with psychiatric disturbances was admitted to our Department with severe respiratory distress due to an enormous abdominal distension caused by a sigmoid volvulus. Endoscopic derotation was unsuccessful and surgery immediately performed. After a wide colonic resection the patient underwent a prolonged treatment in the Intensive Care Unit. Death occurred 34 days after the operation for secondary infection of peritoneal effusion. Discussion: Main clinical features of SV pertain to abdominal compartment while in the present case acute respiratory distress was the prominent symptom;in the same time the severity of the case was due to the association of high abdominal pressure together with a toxic megacolon. Postoperative treatment consisted in ventilatory support, with a progressive shift from asssisted to spontaneous ventilation;repeated sessions of haemodialysis were necessary to manage renal failure up to recovery of the urine output. Bacterial trans location due to toxic megacolon was responsible of late infection of ascitic fluid. In spite of multiple antibiotic association according to bacterial cultures, intra-abdominal abscesses eventually developed causing fatal outcome 34 days after the first intervention. Conclusion: Severe clinical presentation required a prolonged and demanding postoperative course which was focused on the recovery of respiratory, cardiac and renal function even if fatal outcome was due to septic complications. Suspicion of late infection of ascitic fluid could arise from persistently high values of inflammation indexes and drive to an earlier drainage of the abdominal abscesses.

关键词： Sigmoid Volvulus Toxic megacolon Abdominal Compartment Syndrome

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Current status of surgical treatment for fulminant clostridium difficile colitis

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World Journal of Gastrointestinal Surgery 2013年第6期5卷 167-172页

作者： Andrew J Klobuka Alexey Markelov Department of Surgery Easton HospitalDrexel University College of MedicineEastonPA 18042United States

Mortality rates attributable to fulminant Clostridium difficile(***) colitis remain high and are reported to be 38%-80%.Historically,the threshold for surgical intervention has been judged empirically because level I evidence to guide decision making is *** of the surgical management of *** infection have been limited by small sample size and the lack of a standard definition of *** small and medium-sized series have examined the surgical management of ***,because of a lack of prospective,randomized studies,it has been difficult to identify the optimal point for surgical intervention in patients with severe fulminant *** *** goal was to analyze the existing body of literature in an attempt to define host constellations,which would predict the development of the more aggressive form of this disease and hence justify an early or earlier surgical intervention.A Pubmed search was conducted using the keywords "fulminant","clostridium difficile","surgery",and "colitis".Reviews and Meta-analyses proposing indications for surgical consultation or operative management in patients with *** colitis were *** analyzing current literature,we identified a number of parameters that are associated with unfavorable *** parameters include age greater than 65 years old,peritoneal signs on physical examination,abdominal distension,signs of end-organ failure,hypotension less than 90 mmHg systolic blood pressure,tachycardia greater than 100 bpm,vasopressor requirement,elevated WBC count of greater than at least 16 × 10 9 /μL,serum lactate of greater than 2.2 mmol/L,and lastly,radiologic findings suggestive of pancolitis,ascites,megacolon,or colonic *** though fairly strong evidence exists in contemporary literature,we recommend use of these identified parameters with caution in clinical practice when it comes to the actual decision to treat certain patients more aggressivel

关键词： Fulminant Clostridium difficile Colitis Toxic megacolon Total colectomy Surgical management

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