Spinal and Vertebral Anomalies Associated with Anorectal Malformations

ObjectiveThe associations between imperforate anus and spinal and vertebral abnormalities and neurologic deficits are well recognized; these neurologic deficits have been considered static rather than progressive. However, recent experience indicates that some patients may develop progressive neurologic problems due to spinal cord lesions that are amenable to neurosurgical correction.Materials & MethodsThe medical records of 105 patients with imperforate anus, operated on by us, were retrospectively reviewed from 1996 to 2005. Patient's sex, anorectal type lesion and vertebral or spinal anomalies were determined by ultrasound, excretory urography, voiding cystouretherography (VCUG) and  lumbosacral x-ray.ResultsA hundred and five cases, consisting 48 (45.7%) boys and 57 (54.3%) girls, with anorectal malformations were studied; 70 patients were in high and intermediate type level, and totally 25 patients (35.7%) with spinal and vertebral anomalies were found in this group.ConclusionAll patients with anorectal malformations (ARM) should be investigated for spinal and vertebral anomalies to improve treatment outcomes in ARM.

New surgical approaches to ulcerative colitis in children and adults

Ulcerative colitis continues to be a devastating disease for the child and the young adult. In spite of intensive medical therapy with sulfasalazine and corticosteroids, the majority of patients with universal ulcerative colitis will ultimately require a total colectomy. The standard operation of a total proctocolectomy and a permanent end ileostomy is probably still the best procedure for the definitive management of this disease because all diseased tissue is removed with this operation; however, the resultant abdominal stoma can create significant psychological trauma in many of these patients. For that reason, sphincter-saving operations were introduced in 1933 but were only marginally successful until 1977, when renewed interest in the endorectal pull-through occurred. Since that time, several centers around the world have gained significant experience with the endorectal procedure, with or without the use of an ileal reservoir. Although the ileal reservoir appears to have certain advantages over the straight endorectal pull-through, the procedure also is associated with a significant number of complications and is a far more complicated technical exercise . The experience at the University of Michigan with the straight endorectal pullthrough procedure in patients with ulcerative colitis and familial polyposis during the period from 1977 to 1984 is herein reported. All of the patients in our series are continent and experience a median stool frequency of 6 per 24 hours 1 year after the procedure. Patient satisfaction has been excellent with the majority of patients preferring their lifestyle without an ileostomy to that experienced with an ileostomy. At the present time, we can strongly recommend the endorectal pullthrough procedure to all patients with ulcerative colitis . La colite ulcéreuse reste une affection redoutable chez l'enfant et le jeune adulte. Malgré un traitement médical intense par la sulfasalazine et les corticoïdes la majorité des malades atteints de colite ulcéreuse diffuse devront subir une colectomie totale. L'opération standard, la coloprotectomie avec iléostomie terminale permanente reste probablement la meilleure méthode de traitement de cette affection car elle permet l'exérèse totale des lésions; cependant l'iléostomie peut être à l'origine d'un sévère traumatisme psychologique. Pour l'éviter les opérations respectant l'appareil sphinctérien ont été tentées dès 1933 mais avec un succès relatif jusqu'en 1977 moment ou se manifeste un nouvel intérêt pour l'abaissement endorectal de l'iléon. Depuis cette époque de multiples centres dans le monde lui ont donné la préférence que l'abaissement transanal s'accompagne ou non de la constitution d'un réservoir iléal. Bien que le réservoir iléal présente certains avantages sa constitution délicate s'accompagne de nombreuses complications. L'expérience de l'Université de Michigan concernant l'abaissement iléal transanal appliqué au traitement de la colite ulcéreuse et de la polypose familiale pendant la période s'étendant de 1977 à 1984 est rapportée par les auteurs. Tous les malades ainsi traités sont continents, le nombre moyen des selles par 24 heures s'élevant à 6. La satisfaction éprouvée par la majorité des opérés est supérieure à celle des malades qui ont subi une coloprotectomie totale avec iléostomie classique. A partir de ces faits, il est possible d'affirmer que l'exérèse globale du rectum et du colon avec abaissement transanal de l'iléon est l'opération de choix. La colitis ulcerativa sigue siendo una enfermedad devastadora para el niño y el adulto joven. A pesar de terapia médica intensa con sulfasalazina y corticosteroides, la mayoría de los pacientes con colitis ulcerativa universal, a la larga, requieren colectomía total. La operación estandar de proctocolectomía total e ileostomía permanente todavía es, probablemente, el mejor procedimiento para el manejo definitivo de esta enfermedad en virtud de que la totalidad del tejido enfermo puede ser removido mediante la operación; sinembargo, el estoma abdominal resultante puede crear un trauma psicológico significativo en muchos de estos pacientes. Para resolver este problema, en 1933 fueron introducidos los procedimientos de conservación de esfínter, los cuales apenas fueron marginalmente exitosos hasta 1977, cuando se desarrolló un renovado interés en los procedimientos endorrectales de “pullthrough.” Desde tal época algunos centros de diversos lugares del mundo han llegado a tener suficiente experiencia con el procedimiento endorrectal, con o sin el uso de reservorio ileal. Aun cuando el reservorio ileal parece poseer ciertas ventajas sobre el simple procedimiento de “pullthrough,” la operación también se halla asociada con un número importante de complicaciones y significa un ejercicio quirúrgico técnicamente bastante más complicado.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/41317/1/268_2005_Article_BF01656313.pd

An Analysis of Gut and Genito-Urinary Anomalies encountered in Emergency Surgery

INTRODUCTION: It is said that the abdomen is a Pandora’s Box, a Black Box, a Box of Surprises and so on….the list is endless. The general surgeon has to have in his armamentarium not only a good command of anatomy, but also of surgical physiology and pathology in even the most normal of cases. Even when no surprise is anticipated, one field where the surgeon has to be most careful and cautious is while performing emergency operations. In the rarest of rare circumstances, the surgeon is stumped by certain variations of normal anatomy. However, the biggest and most fascinating challenges in adult emergency surgery come when one encounters a certain aberration in embryological development, forcing the surgeon to improvise on the spot. This particular study deals with genitourinary and gut associated embryological anomalies encountered by us in Royapettah Hospital, Kilpauk Medical College during the period between June 2006 and October 2008. The unusual aspect of this study is the emphasis on emergency surgery. Another factor which is unique is that this study deals with adult patients that we have encountered in Royapettah Hospital, emphasizing the fact that a gut or genitourinary embryological anomaly is not within the purview of the pediatric surgeon alone. A good and competent general surgeon must be able to deal with and manage such cases with little mental preparation. The spectrum in this study varies from the humble and ubiquitous Meckel’s Diverticulum, which is invariably asymptomatic, to a rare case of Hirschsprung’s disease in an adult male, which presented as intestinal obstruction. The surgeon dealing with the problem must be familiar with a whole gamut of procedures from a simple obstruction release, to doing a Ladd’s procedure for gut malrotation! This study shows us the commonest embryological anomalies that we have encountered in the study period, their pattern of distribution, modes of presentation, and methods of management. AIMS OF THE STUDY: This study is a retrospective analysis of gut and genito-urinary anomalies encountered in abdominal emergency surgery from the period of July 2006 to October 2008 in a single institution. The study aims to identify the following: 1. To identify the most common embryological anomalies in adult emergency surgery. 2. To assess whether there is a difference between distribution of such anomalies between male and female patients. 3. To assess the most common modes of manifestation in such embryological gut/genitourinary anomalies. METHODS AND MATERIALS: Type of study: Retrospective study. Number of cases: 28. Male: Female : 18 male: 10 female. Period of study: June 2006 to October 2008. Institution: Department of General Surgery, Government Royapettah Hospital, attached to Kilpauk Medical College. Type of analysis: Clinical data analysis. Inclusion criteria: 1. Adult patients (above the age of 12 years). 2. Abdominal emergency surgery (surgery for appendicectomy, and laparotomies included). Exclusion criteria: 1. Pediatric cases (below the age of 12 years). 2. Elective surgeries and patients who were previously worked up suspecting such anomalies. SUMMARY: From the data mentioned earlier, the salient findings are made out: 1. The incidence of gut and allied anomalies in this study was found to be around 3%. 2. The number of males who presented with such anomalies out numbered females in a significant manner in the ratio 1.8:1. This suggests a strong tendency for such defects to be present in males. Similar studies done elsewhere have not shown any definite male predisposition, except in certain cases like Congenital Hypertrophic pyloric stenosis. 3. It was noted that most of these anomalies are asymptomatic, discovered during a laparotomy for some other reason. However, the incidence of intestinal obstruction in this series was quite high, being the next most common mode of manifestation. 4. Among the anomalies, Meckel’s diverticulum (36%) and anomalous peritoneal bands (39 %) were the most common, and with nearly equal incidence in the study. 5. Most Meckel’s diverticula were asymptomatic (70 %), while in the case of gut bands, the trend was reversed, with the possibility of a gut band being symptomatic being as high as 70%. 6. The incidence of Meckel’s diverticulum was found to be 1%, lower than the usual incidence of 2%. However, the rate mentioned in earlier series took into account the findings at autopsy. This being a study of only surgical patients, and specifically emergency surgeries, could possibly contribute to this lower rate encountered. 7. The incidence of midgut anomalies was the highest. We encountered no foregut anomalies. This may be due to the fact that a foregut anomaly is likely to present earlier, and possibly rectified earlier. 8. Similar studies do not exist for a satisfactory comparison. Other studies do not individually document incidence rates, except for the more common of these anomalies. Most of such cases are found in pediatric age group. CONCLUSION: Though the number of cases encountered by the general surgeon is not very many, these gut anomalies pose an interesting problem in management. The situation is very simple when these embryological defects get complicated. But the dilemma lies in the management of asymptomatic cases – to resect or not to resect? Several studies conclude that when there are no further comorbid factors influencing the outcome, it is better to remove these anomalies in lieu of anticipated problems. We also see that an anomalous band is more likely to cause a serious, life threatening problem than diverticula/duplications and the like. Another fact that stares at us is that the more distal the gut band, the more likely that it will stay asymptomatic and undiscovered for a longer period of time. In this series, most of the anomalies were dealt with at source. Those patients in whose case such defects were left alone were monitored. In the period of follow up, patients did not get readmitted or face further problems due to these. A final lesson learnt from this study is that every patient is a textbook and that it is impossible to rule out congenital anomalies in any patient, merely by his/her age

Valoración de la ictericia en la estenosis hipertrofica de píloro en la infancia

Fac. de MedicinaTRUEProQuestpu

Valoración de la ictericia en la estenosis hipertrofica de píloro en la infancia

Fac. de MedicinaTRUEProQuestpu

Intensidade e velocidade da recuperação do relaxamento esfincteriano induzido pelo reflexo inibitorio retoanal e sua correlação com constipação por evacuação obstruida

Orientador: Juvenal Ricardo Navarro GoesTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: A constipação intestinal é uma queixa muito freqüente, sendo o motivo de um grande número de consultas médicas. No entanto, apesar dos avanços na compreensão da fisiologia anorretocólica, ainda representa um problema clínico nem sempre resolvido. O objetivo deste trabalho é identificar possível correlação entre dados fisiológicos presentes no RIRA e a constipação intestinal por evacuação obstruída. Para isso foram selecionados 69 exames de pacientes, que tinham sido submetidos, previamente, à manometria anorretal no Laboratório de Fisiologia Anorretal no Gastrocentro da FCM ¿ UNICAMP. Destes, após serem aplicados os critérios de exclusão e inclusão, foram selecionados 29 pacientes com constipação intestinal por evacuação obstruída, sendo 27 do sexo feminino e média de idade de 42,3 (19-73) anos. Da mesma forma, foram selecionados 13 indivíduos sem queixas funcionais anorretais, sendo oito do sexo feminino, com média de idade de 52,5 (28-73) anos. No RIRA foi analisada a pressão anal de repouso média (PARM), o ponto de máximo relaxamento (PMR) e a velocidade de recuperação (VR) até atingir a pressão basal, todos nos níveis proximal e distal do canal anal. A seguir foi realizado o estudo comparativo entre esses dados. Os resultados mostraram que o valor médio da PARM pré-indução do RIRA no nível proximal foi, nos pacientes constipados, de 61,8 mmHg e no nível distal, 81,7 mmHg, enquanto que nos assintomáticos encontrou-se 46,0 mmHg e 64,5 mmHg, respectivamente, para os níveis proximal e distal. A média da pressão no PMR nos pacientes constipados foi 29,0 mmHg no nível proximal do canal anal e 52,1 mmHg no nível distal, enquanto que no grupo de assintomáticos foi 17,8 mmHg e 36,3 mmHg respectivamente, no canal anal proximal e no distal. A média da diferença percentual entre a PARM e a pressão no PMR no nível proximal foi 54,1 % nos constipados e 54,3% nos assintomáticos. No nível distal, a média da diferença foi 35,6% nos constipados e 38,5% no grupo-controle. A média da VR no nível proximal foi 4,06 mm/seg. nos constipados e 2,98mm/seg nos assintomáticos, sendo a diferença entre as duas estatisticamente significativa. A média da velocidade de recuperação no grupo de constipados no nível distal do canal anal foi 3,9 mm/seg. e 2,98 mm/seg. nos normais, sendo a diferença entre as duas também significativa do ponto de vista estatístico. A análise dos resultados, obtidos da avaliação dos parâmetros do RIRA, mostrou que o relaxamento esfincteriano em pacientes constipados foi mais acentuado no canal anal proximal do que no distal, da mesma forma como o observado nos controles normais. A velocidade de recuperação da pressão anal de repouso em canal anal proximal e distal foi maior nos pacientes constipadosAbstract: Intestinal constipation is a very common complaint and is thus a common reason for consultations with physicians. The prevalence in the United State of America varies from 2 to 14.7% of the population. In Brazil there are no epidemiological studies on this subject, however it is known that there is a high incidence. Intestinal constipation occurs due to organic and functional factors. Functional constipation may either be associated with a functional alteration of the colon, which in this case is called colonic inertia, or an involvement of the voiding mechanism in the anorectal region, which is denominated constipation by obstructive evacuation. The latter, which is of interest in this study, can by diagnosed and evaluated through several tests, among which are the defecography and anorectal manometry. In anorectal manometry, the rectoanal inhibitory reflex (RAIR) is evaluated. The morphologic alterations detected in the various phases of RAIR have been associated with the genesis of constipation by obstructive evacuation. The aim of this work is to identify a possible correlation between the physiological data present in RAIR and constipation by obstructive evacuation. A total of 69 patients with intestinal constipation, who had previously been submitted to anorectal manometry in the Physiological Anorectal Laboratory in the Gastrocentro of FCM ¿ Unicamp, Brazil were investigated. After the inclusion and exclusion criteria were applied, 29 patients suffering from constipation by obstructive evacuation were selected. Of these 27 were female and the mean age was 42.3 (19-73) years. In the same way a control group of a total of thirteen individuals without anorretal symptoms were evaluated, eight of whom were male and the mean age was 52.5 (28-73) years. The Average Resting Anal Pressure (ARAP), the Maximum Relaxation Point (MRP) and the Recovery Velocity until reaching the base pressure, both at the proximal and distal regions of the anal tract were analyzed during RAIR. After this a comparative study of the results was performed. The results demonstrated that the pre-induced ARAP at RAIR at the proximal level was 61.8 mmHg and at the distal level it was 81.7 mmHg in constipated patients. In asymptomatic individuals, however, the ARAP was 46.0 mmHg and 64.5 mmHg at the proximal and distal levels respectively. The mean MRP in constipated patients was 29 mmHg at the proximal level of the anal tract and 52.1 mmHg at the distal level, when in the control group it was 17.8 mmHg and 36.3 mmHg respectively at the proximal and distal levels. The differences between the ARAP and MRP at the proximal level in constipated patients was 54.1% and in asymptomatic individuals it was 54.3%. At the distal level the difference was 35.6% and 38.5% in the experimental and control groups respectively. The recovery velocity at the proximal level was 4.06 mm/second in constipated patients and 2.98 mm/second in the asymptomatic group with a statistically significant difference. At the distal level the recovery velocity of constipated individuals was 3.9 mm/second whilst for the control group the rate was 2.98 mm/second again giving a statistically significant difference. An analysis of the results obtained from the analysis of the RAIR showed that sphincter relaxation in constipated individuals was more stressed at the proximal level of the anal canal than at the distal level which was also observed in controls. The recovery velocity of the resting anal pressure at both the proximal and distal levels was greater in constipated patients than in controlsDoutoradoCirurgiaDoutor em Cirurgi

Dor pelviperineal

Pelviperineal pain is very common, specially in women. Very often the occurrence of visceral disturbances is not the reason for chronic pelvic pain. In many patients, pain is the result of muscleskeletal abnormalities or neuropathies. The removal of the possible causes, and the prescription of analgesics and adjuvants agents, physical medicine and psychotherapy are the usual procedures for treatment of this condition. Anaesthetic blocks and neurosurgial procedures seldom are necessary for tretament of these patients.Dor pelviperineal crônica é condição comum especialmente nos indivíduos do sexo feminino. Muito freqüentemente,anormalidades viscerais eventualmente identificadas aos exames complementares não justificam a sua ocorrência. Em grande número de enfermos, afecções músculo-esqueleticas, especialmente as síndromes dolorosas miofasciais do assoalho pélvico e da parede abdominal e neuropatias são a razão da ocorrência de dor pelviperineal crônica. O tratamento da dor pélvica crônica visa à remoção das causas possíveis e ao controle funcional da condição sintomática. Medicamentos analgésicos e adjuvantes, procedimentos de medicina física e de psicoterapia são freqüentemente indicados no tratamento das álgicas crônicas pelviperineais. As intervenções neuroanestésicas e neurocirúrgicas são indicadas em casos especiais

An investigation of the mechanisms by which opiates affect the motility of the gut

(1) The object of this study was to investigate the effect and mechanisms by which morphine and the opioid peptides affect gut motility. Emphasis was placed on the examination of the neuronal basis of these effects, particularly the involvement of a tonic non-adrenergic, non-cholinergic inhibitory mechanism postulated to be responsible for the suppression of myogenic activity and the release of 5-hydroxytryptamine (5-HT) and acetylcholine (ACh) by these drugs. Alternative explanations of these effects were also sought. (2) The preparation chosen for this study was the rat isolated colon, which permits demonstration of the responses to opioids and other drugs in vitro. (3) The isolated colon of the rat contracts rhythmically to morphine and other opioid peptides. These rhythmic contractions could be divided into the initial contraction and the subsequent waves of contractions. The 5-HT antagonist, methysergide, non-competitively antagonised the initial response but had no effect on the waves of rhythmic contractions. In contrast, the specific opioid antagonist, naloxone, competitively antagonised the initial contraction and abolished the rhythmic contractile activity. (4) The rhythmic waves of contractions were unaffected by pretreatment with parachlorophenylalanine (PCPA) which depleted the intestinal 5-HT as measured spectrofluorometrically. Contractions were still produced in tissues made subsensitive to 5-HT by a process of autodesensitisation and were not abolished by atropine, casting doubt on the 5-HT/ACh hypothesis. The ineffectiveness of reserpine in depleting the 5-HT content of the colon was also confirmed in the study. (5) Several other drugs having in common the ability to block conductance in neural pathways or neuro-effector transmission, i. e. tetrodotoxin (TTX), apamin, tolazoline, phentolamine, oxprenolol and clonidine, produced similar patterns of rhythmic contractile activity in the rat colon. This suggested that the inherent myogenic activity of the colonic muscle might normally be suppressed by nervous influence. (6) Electrical field stimulation of the colon provided evidence about the innervation of this tissue. It was demonstrated that there is a motor cholinergic response to nerve stimulation which was reduced or abolished by atropine or morphine and potentiated by 6-hydroxydopamine pretreatment or apamin. Indirect evidence for the presence of an inhibitory adrenergic influence was provided. The inability of adrenergic and cholinergic antagonists to block inhibitory responses of the colon to nerve stimulation provided evidence for the existence of non-adrenergic, non-cholinergic (NANC) inhibitory nerves in the colon. In addition, the optimum frequency of stimulation of the inhibitory response was less than that characteristic of either an adrenergic or cholinergic mechanism. (7) The observation that this NANC inhibitory, nerve-mediated response to electrical field stimulation could still be elicited in the presence of drugs producing rhythmic waves of contractions, made it unlikely that the removal of a non-adrenergic, non-cholinergic inhibitory mechanism was responsible for producing the. rhythmic contractile activity in the colon. (8) The similarity between the effects of the opioids, the adrenergic neurone blocker and adrenoceptor antagonists, clonidine and apamin, raised the possibility that the actions of these drugs might be mediated through adrenergic neurones. This possibility was examined using the techniques of High Performance Liquid Chromatography (HPLC) with electrochemical detection and also in tritium efflux studies. (9) Preliminary experiments with the HPLC were concerned with the optimisation of the conditions necessary for chromatographic separation. It was demonstrated that changes in the electrode potential voltage, mobile phase composition and flow rate affected the detection and separation of catecholamines. The catecholamine content of the rat colon, mouse, guinea-pig and rat vasa deferentia were also measured. Transmitter overflow from the mouse and guinea-pig vasa deferentia occurring spontaneously and in response to electrical field stimulation were measured. No spontaneous release of noradrenaline or its metabolites was demonstrated in the rat colon. (10) Morphine, clonidine and TTX did not affect tritium efflux at concentrations at which they produce rhythmic waves of contractions in the colon. (11) The implications of these results for the hypothesis previously postulated and the one suggested in this study to explain the rhythmic contractions are discussed

Clínica e terapêutica da doença de Chagas: uma abordagem prática para o clínico geral

Um verdadeiro tratado clínico e terapêutico sobre Chagas, que reúne os maiores especialistas na enfermidade. Os autores pretendem a difusão dos conhecimentos e práticas que habilitam o manejo adequado desta parasitose contidos neste 'manual', principalmente entre aqueles que vivem e trabalham nas áreas endêmicas de ocorrência, na busca de minimizar os sofrimentos que a tripanossomíase tem imposto a populações. Com esse objetivo, a obra vem mostrar que não só a doença pode e deve ser prevenida, bem como é possível diagnosticá-la entre os já infectados e dar a estes uma atenção específica capaz de atenuá-la ou mesmo de curá-la em certas circunstâncias