- Email: [email protected]
Chronic intestinal pseudoobstruction in young children
464
INTERNATIONAL ABSTRACTS GENERAL CONSIDERATIONS
ALIMENTARY TRACT
Buggery in Childhood--A Common Syndrome of Child Abuse. C.J.
When Push Comes to Shove: A Comparison Between Two Methods of Percutaneous Endoscopic Gastrostomy. R.A. Kozarek, T.J.
Hobbs and J.M. Wynne. Lancet I1:792-796, (October), 1986.
Eighteen girls and 17 boys, 14 months to 8 years, with a history and physical signs of buggery were selected from a large series of sexually abused children seen by two pediatricians in Leeds (child population 146,000) over 8 months. In 27 children disclosure of abuse by the child or perpetrator (most commonly the father) was recorded. Anal findings on inspection included fissures, dilatation and reflex dilatation, loss of sphincter, shortening and eversion of the anal canal, external venous congestion, and generalized reddening and thickening of perianal tissues. Vaginal signs of dilatation or marked redness were found in 14 girls, but penile penetration of the vagina was uncommon. Associated findings included nonaccidental injury, emotional deprivation and failure to thrive, developmental delay, and behavioral disturbance. Buggery in young children, including infants and toddlers, is a serious, common, and underreported type of child abuse.--Prem Puri
Faecal Metronidazole Concentrations During Oral and Intravenous Therapy for Antibiotic Associated Colitis Due to Clostridium Difficile. R.P. Bolton and M.A. Culshaw. Gut 27:1169-1172, (Octo-
ber), 1986. Fecal metronidazole and hydroxymetronidazole concentrations measured by high pressure liquid chromatography are reported during ten episodes of Clostridium difficile colitis in nine patients. Bactericidal fecal concentrations were present in all patients with acute disease receiving oral or intravenous metronidazole, and all responded to therapy. Metronidazole and hydroxymetronidazole concentrations fell as the diarrhea improved, and neither substance was detectable in the feces of five patients after recovery. This demonstration of intracolonic therapeutic concentrations of metronidazole supports the clinical experience of oral metronidazole being effective in the treatment of antibiotic associated diarrhea caused by C difficile. It also suggests a potential role for intravenous metronidazole in this disease.--Prem Puri
Bacteriological Study and Antibiotic Therapy for Peritonitis in Children. B.X. Jin, et al. Chin J Pediatr Surg 7:144-146, (June),
1986. This paper reports the bacteriological survey of 119 cases of acute peritonitis in children (1980 to 1984). One hundred and eleven cultures were positive (93.2%). One hundred and ten of 119 samples were aerobic (92.4%). There were 154 aerobic strains, mostly gram negative bacilli and gram positive cocci (especially E coli and various streptococcal species). Forty-eight of 69 samples were anaerobic organisms (68.8%) consisting of 68 strains. Most of these were gram negative bacilli, especially bacteroides fragilis. The majority of the cases were mixed infections of aerobic and anaerobic organisms. The isolation rate of anaerobic organisms in perforation of the upper alimentary tract was nil. In ileum it was 25%, in appendix 77%, and in colon 50%. Aerobic E coli was sensitive to aminoglycoside, while anaerobic bacteroides fragilis was sensitive to metronidazole, rifampin, and lincomycin. The authors conclude that a combination of ampicillin and aminoglycoside is the most effective therapeutic combination in cases of perforation of the upper gastrointestinal tract, and a combination of aminoglycoside and metronidazole or lincomycin in cases of perforation of the lower intestinal tract.--Zhang Jinzhe
Ball, and J.A. Ryan, Jr. Am J Gastroenterol 81:642-646, (August), 1986.
Percutaneous endoscopic gastrostomy (PEG) is being used with increasing frequency in pediatric patients. There are now a variety of commercially available gastrostomy kits that generally fall into the push or pull technique. The push technique involves the use of a peel-away catheter sheath through which a trocar and gastrostomy catheter are inserted into the stomach under endoscopic control. The pull technique involves pulling a gastrostomy tube retrograde through the mouth and out through the stomach and abdominal wall. The authors studied 15 patients utilizing each technique and found that both methods were successful and both were associated with a low complication rate. The authors preferred the pull technique because it was technically easier.--Richard R. Ricketts
Nonspecific Jejunitis--A Challenging Problem in Children. A.K. Sharma, N.S. Shekhawat, S. Behari, et al. Am J Gastroenterol 81:428-431, (June), 1986.
The authors describe a specific disease entity characterized by severe abdominal colic, passage of altered blood per rectum, and varying degrees of shock and stages of necrosis of the bowel in 125 patients seen during a 12-year period in Jaipur, India. Males predominated and patients ranged in age from 5 to 13 years. Most of the patients came from poor socioeconomic status, but none had significant past medical history of chronic illnesses. Sixty-nine of the 125 patients required laparotomy. Forty-nine of these had involvement of the proximal jejunum starting from the duodenojejunal junction and progressing for a variable distance distally. Mesenteric lymph nodes were enlarged but arterial and venous anatomy was normal. Fifty-three patients had exploration and lymph node biopsy only; 14 had resection and reanastomosis; and two had bypass procedures. Microscopically, there were areas of focal as well as diffuse necrosis of the mucosa extending to a variable depth. A lymph node biopsy showed reactive hyperplasia. The mortality for medical treatment, which included nasogastric suction, rehydration, and antibiotics, was 32%. The mortality for patients who underwent surgery was 49.2%. The overall mortality was 42%. The etiology of this disease remains obscure, although the microscopic findings correlate with occlusion of microcirculation by fibrin thrombi, perhaps initiated by endotoxemia.--Richard R. Ricketts
Chronic Intestinal Pseudoobstruction in Young Children. S. Anu-
ras, F.A. Mitros, R.T. Soper, et al. Gastroenterology 91:62-70, (July), 1986.
Eight children (four boys and four girls) with chronic intestinal pseudoobstruction presenting at ages 1 day to five years are presented. All patients had constipation, abdominal distention, and pain, and all had recurrent urinary tract infections. All had marked dilatation of the entire gastrointestinal tract distal to the esophagus, including the stomach, small bowel, and colon. A dilated atonic esophagus was observed in only one patient. Megacystis was detected in all patients, and megaureters were detected in three patients. All patients underwent exploratory laparotomies, and in none was a mechanical obstruction detected. Four patients were subsequently treated with bethanechol and neostigmine without symptomatic improvement; two were treated with metoclopramide without benefit; four were treated with long-term parenteral nutri-
465
INTERNATIONAL ABSTRACTS
tion. Jejunal manometric studies in these patients revealed weak and infrequent contractions that were not accelerated after feedings. Five of the eight patients died. Histologic studies in five patients revealed normal mucosa, submucosa, muscularis, and submucosal and myenteric plexuses. In three patients, examination of the urinary bladders revealed isolation of individual smooth muscle cells by collagen fibers. Available evidence tends to point toward smooth muscle dysfunction as the underlying cause of chronic intestinal pseudoobstruction in these young children.--Richard R. Ricketts Hirschsprung's Disease and Idiopathic Megacolon in Adults and Adolescents. P.R.H. Barnes, J.E. Lennard-Jones, P.R. Hawley, el
al. Gut 27:534-541, (May), 1986. Twenty-nine patients with Hirschsprung's disease, which was diagnosed and treated for the first time after the age of 10 years, are compared with 65 patients with non-Hirschsprung's megacolon. The barium enema was suggestive of Hirschsprung's disease in 22 of the 29 patients. The rectal biopsy had typical changes in 24 of 27 patients with Hirschsprung's disease; the remainder were diagnosed by operative specimens. The rectal biopsy was normal in 52 of 54 patients with non-Hirschsprung's megacolon and in two the biopsy was equivocal. Manometry was typical of Hirschsprung's disease in 18 of 19 patients studied. It was also abnormal in 7 of 41 patients with non-Hirschsprung's megacolon, all of whom had normal histology on biopsy. Most patients with Hirschsprung's disease had onset of symptoms at birth or in the early neonatal period, although five patients dated their symptoms to early childhood (<5 years of age). Patients with non-Hirschsprung's megacolon developed symptoms at a mean age of 3.4 years. All of the patients with Hirschsprung's disease reported constipation as the predominant symptom and only two reported fecal soiling. Patients with idiopathic megacolon also complained of severe constipation. However, fecal soiling was also troublesome in 28 of 34 patients questioned. Patients with Hirschsprung's disease had good results following a Duhamel or Soave procedure in most cases. Most patients with idiopathic constipation were managed successfully with medical treatment, although 9 of 35 patients with onset in childhood required surgical treatment. Surgical therapy for idiopathic megacolon in childhood varied as did the results.--Richard R. Ricketts Suction Rectal Biopsy in the Diagnosis of Hirschsprung's Disease and Chronic Constipation. T.Z. Polley, Jr, A.G. Coron, K.P.
Heidelberger, et aL Pediatr Surg Int 1:84-89, (June), 1986. Suction rectal biopsy has gained increased acceptance as the means of definitively diagnosing Hirschsprung's disease, as well as excluding this diagnosis when evaluating the child with chronic constipation. During the l 1-year period from July 1974 through June 1985, 309 suction rectal biopsy specimens were evaluated. Of these, 293 were done for the evaluation of chronic constipation and/or Hirschsprung's disease. The remaining 16 were performed as a part of the workup in patients with neuromuscular, glycogen storage, inflammatory bowel, or other diseases. Forty-two (14%) of the 293 patients were diagnosed as having Hirschsprung's disease at an average age of 14.4 months. This diagnosis was ruled out in the remaining 251 patients, whose age at biopsy averaged 2.7 years. There was one false-negative reading representing an incidence of 0.3%, with no false-positives. There were no complications. The suction rectal biopsy is a bedside or clinic procedure that reliably provides pathologic material adequate for the accurate diagnosis or exclusion of Hirschsprung's disease and offers a number of advantages over manometric, radiographic, histochemical, and open fullthickness biopsy techniques.--Prem Purl
Twenty Year Experience With Familial Polyposis Coil in Cape Town. R.J. Aitken, M.S. Elliot, M. Torrington, et al. Br J Surg
73:210-213, (March), 1986. Forty-nine patients undergoing surgery for familial polyposis coli over a 20-year period are reviewed. Thirty-six were descendants of a single marriage in 1871. Forty-three patients underwent total colectomy with an ileorectal anastomosis. Five of these subsequently developed a rectal carcinoma. The earliest occurred 8 years after surgery and the incidence appears to increase with time. Sixteen of these patients required fulguration of developing rectal adenomas on 1 to 6 occasions. Postoperative complications were common with 17% developing adhesion obstruction and 7% desmoid tumors. Upper gastrointestinal pathology was detected in only one of nine patients examined. The problem of screening a widely distributed and closely knit community are considerable. Total colectomy with ileorectal anastomosis is the operation of choice for the majority of patients, although meticulous follow-up is required. Total colectomy with ileal reservoir and ileoanal anastomosis is appropriate as the initial operation in some cases where follow-up is unlikely and is the operation of choice following the development of premalignant pathology in the rectal mucosa.--Tony Sparnon Generalized Juvenile Polyposis CoIL J.L. Grosfeld and K, IV. West,
Arch Surg 121:530-534, (May), 1986. Five patients with generalized junveile polyposis coli were managed over a 13-year period; there were 4 boys (18 months to 16 years of age) and 1 girl (12 years of age). Clinical findings included abdominal pain, weakness, rectal bleeding, diarrhea, rectal prolapse, intussusception, clubbing, and. failure to thrive. Laboratory findings included anemia, hypoalbuminemia, hypokalemia, and skin test anergy. Diagnosis was achieved by double contrast enema, endoscopy, and biopsy. Management consisted of subtotal colectomy and ileoproctostomy (4) and sphincter-saving rectal mucosectomy and ileoanalendorectal pull-through procedure (1). All five patients are currently alive and well. An increased risk for development of gastrointestinal tumors is noted in family members, and screening is recommended. An aggressive surgical posture is advocated because of potentially life-threatening complications that can occur in patients with generalized juvenile polyposis.--George A. Rowe Temporary Antimesenteric Stomas Without a Skin Bridge in
Infants. J.N.L. Simson and R.J. Brereton. Ann Roy Coil Surg Engl 67:363-365, (November), 1985. Thirty-four loop stomas without a skin bridge were created in 33 infants. Twenty-six of these stomas were fashioned in the laparotomy wound. Compared with loop colostomies over a tissue bridge, these stomas appeared to be associated with less infection and skin excoriation but with a higher incidence of prolapse. Wound dehiscence occurred in three patients in the earlier part of the study when absorbable sutures of polyglycolic acid were used to suture the seromuscular layer to the abdominal wall muscles. Because of the risk of overspill, these stomas are unsuitable for use as permanent defunctioning stomas or following necrotizing enterocolitis or the colitis of Hirschsprung's disease.--B.A. Madarikan Results of the Smooth-Muscle Fold-Over Oouble-plasty (SMFD).
S. Hofmann-von Kap-herr, R. Grussner, and J.L. Koltai. Pediatr Surg Int 1:43-45, (March), 1986. Since 1980, when the authors developed a substitute for the internal anal sphincter, the smooth-muscle fold-over double-plasty (SMFD-plasty), they have operated on seven children using this method. Usually it is done in combination with the pull-through
INTERNATIONAL ABSTRACTS GENERAL CONSIDERATIONS
ALIMENTARY TRACT
Buggery in Childhood--A Common Syndrome of Child Abuse. C.J.
When Push Comes to Shove: A Comparison Between Two Methods of Percutaneous Endoscopic Gastrostomy. R.A. Kozarek, T.J.
Hobbs and J.M. Wynne. Lancet I1:792-796, (October), 1986.
Eighteen girls and 17 boys, 14 months to 8 years, with a history and physical signs of buggery were selected from a large series of sexually abused children seen by two pediatricians in Leeds (child population 146,000) over 8 months. In 27 children disclosure of abuse by the child or perpetrator (most commonly the father) was recorded. Anal findings on inspection included fissures, dilatation and reflex dilatation, loss of sphincter, shortening and eversion of the anal canal, external venous congestion, and generalized reddening and thickening of perianal tissues. Vaginal signs of dilatation or marked redness were found in 14 girls, but penile penetration of the vagina was uncommon. Associated findings included nonaccidental injury, emotional deprivation and failure to thrive, developmental delay, and behavioral disturbance. Buggery in young children, including infants and toddlers, is a serious, common, and underreported type of child abuse.--Prem Puri
Faecal Metronidazole Concentrations During Oral and Intravenous Therapy for Antibiotic Associated Colitis Due to Clostridium Difficile. R.P. Bolton and M.A. Culshaw. Gut 27:1169-1172, (Octo-
ber), 1986. Fecal metronidazole and hydroxymetronidazole concentrations measured by high pressure liquid chromatography are reported during ten episodes of Clostridium difficile colitis in nine patients. Bactericidal fecal concentrations were present in all patients with acute disease receiving oral or intravenous metronidazole, and all responded to therapy. Metronidazole and hydroxymetronidazole concentrations fell as the diarrhea improved, and neither substance was detectable in the feces of five patients after recovery. This demonstration of intracolonic therapeutic concentrations of metronidazole supports the clinical experience of oral metronidazole being effective in the treatment of antibiotic associated diarrhea caused by C difficile. It also suggests a potential role for intravenous metronidazole in this disease.--Prem Puri
Bacteriological Study and Antibiotic Therapy for Peritonitis in Children. B.X. Jin, et al. Chin J Pediatr Surg 7:144-146, (June),
1986. This paper reports the bacteriological survey of 119 cases of acute peritonitis in children (1980 to 1984). One hundred and eleven cultures were positive (93.2%). One hundred and ten of 119 samples were aerobic (92.4%). There were 154 aerobic strains, mostly gram negative bacilli and gram positive cocci (especially E coli and various streptococcal species). Forty-eight of 69 samples were anaerobic organisms (68.8%) consisting of 68 strains. Most of these were gram negative bacilli, especially bacteroides fragilis. The majority of the cases were mixed infections of aerobic and anaerobic organisms. The isolation rate of anaerobic organisms in perforation of the upper alimentary tract was nil. In ileum it was 25%, in appendix 77%, and in colon 50%. Aerobic E coli was sensitive to aminoglycoside, while anaerobic bacteroides fragilis was sensitive to metronidazole, rifampin, and lincomycin. The authors conclude that a combination of ampicillin and aminoglycoside is the most effective therapeutic combination in cases of perforation of the upper gastrointestinal tract, and a combination of aminoglycoside and metronidazole or lincomycin in cases of perforation of the lower intestinal tract.--Zhang Jinzhe
Ball, and J.A. Ryan, Jr. Am J Gastroenterol 81:642-646, (August), 1986.
Percutaneous endoscopic gastrostomy (PEG) is being used with increasing frequency in pediatric patients. There are now a variety of commercially available gastrostomy kits that generally fall into the push or pull technique. The push technique involves the use of a peel-away catheter sheath through which a trocar and gastrostomy catheter are inserted into the stomach under endoscopic control. The pull technique involves pulling a gastrostomy tube retrograde through the mouth and out through the stomach and abdominal wall. The authors studied 15 patients utilizing each technique and found that both methods were successful and both were associated with a low complication rate. The authors preferred the pull technique because it was technically easier.--Richard R. Ricketts
Nonspecific Jejunitis--A Challenging Problem in Children. A.K. Sharma, N.S. Shekhawat, S. Behari, et al. Am J Gastroenterol 81:428-431, (June), 1986.
The authors describe a specific disease entity characterized by severe abdominal colic, passage of altered blood per rectum, and varying degrees of shock and stages of necrosis of the bowel in 125 patients seen during a 12-year period in Jaipur, India. Males predominated and patients ranged in age from 5 to 13 years. Most of the patients came from poor socioeconomic status, but none had significant past medical history of chronic illnesses. Sixty-nine of the 125 patients required laparotomy. Forty-nine of these had involvement of the proximal jejunum starting from the duodenojejunal junction and progressing for a variable distance distally. Mesenteric lymph nodes were enlarged but arterial and venous anatomy was normal. Fifty-three patients had exploration and lymph node biopsy only; 14 had resection and reanastomosis; and two had bypass procedures. Microscopically, there were areas of focal as well as diffuse necrosis of the mucosa extending to a variable depth. A lymph node biopsy showed reactive hyperplasia. The mortality for medical treatment, which included nasogastric suction, rehydration, and antibiotics, was 32%. The mortality for patients who underwent surgery was 49.2%. The overall mortality was 42%. The etiology of this disease remains obscure, although the microscopic findings correlate with occlusion of microcirculation by fibrin thrombi, perhaps initiated by endotoxemia.--Richard R. Ricketts
Chronic Intestinal Pseudoobstruction in Young Children. S. Anu-
ras, F.A. Mitros, R.T. Soper, et al. Gastroenterology 91:62-70, (July), 1986.
Eight children (four boys and four girls) with chronic intestinal pseudoobstruction presenting at ages 1 day to five years are presented. All patients had constipation, abdominal distention, and pain, and all had recurrent urinary tract infections. All had marked dilatation of the entire gastrointestinal tract distal to the esophagus, including the stomach, small bowel, and colon. A dilated atonic esophagus was observed in only one patient. Megacystis was detected in all patients, and megaureters were detected in three patients. All patients underwent exploratory laparotomies, and in none was a mechanical obstruction detected. Four patients were subsequently treated with bethanechol and neostigmine without symptomatic improvement; two were treated with metoclopramide without benefit; four were treated with long-term parenteral nutri-
465
INTERNATIONAL ABSTRACTS
tion. Jejunal manometric studies in these patients revealed weak and infrequent contractions that were not accelerated after feedings. Five of the eight patients died. Histologic studies in five patients revealed normal mucosa, submucosa, muscularis, and submucosal and myenteric plexuses. In three patients, examination of the urinary bladders revealed isolation of individual smooth muscle cells by collagen fibers. Available evidence tends to point toward smooth muscle dysfunction as the underlying cause of chronic intestinal pseudoobstruction in these young children.--Richard R. Ricketts Hirschsprung's Disease and Idiopathic Megacolon in Adults and Adolescents. P.R.H. Barnes, J.E. Lennard-Jones, P.R. Hawley, el
al. Gut 27:534-541, (May), 1986. Twenty-nine patients with Hirschsprung's disease, which was diagnosed and treated for the first time after the age of 10 years, are compared with 65 patients with non-Hirschsprung's megacolon. The barium enema was suggestive of Hirschsprung's disease in 22 of the 29 patients. The rectal biopsy had typical changes in 24 of 27 patients with Hirschsprung's disease; the remainder were diagnosed by operative specimens. The rectal biopsy was normal in 52 of 54 patients with non-Hirschsprung's megacolon and in two the biopsy was equivocal. Manometry was typical of Hirschsprung's disease in 18 of 19 patients studied. It was also abnormal in 7 of 41 patients with non-Hirschsprung's megacolon, all of whom had normal histology on biopsy. Most patients with Hirschsprung's disease had onset of symptoms at birth or in the early neonatal period, although five patients dated their symptoms to early childhood (<5 years of age). Patients with non-Hirschsprung's megacolon developed symptoms at a mean age of 3.4 years. All of the patients with Hirschsprung's disease reported constipation as the predominant symptom and only two reported fecal soiling. Patients with idiopathic megacolon also complained of severe constipation. However, fecal soiling was also troublesome in 28 of 34 patients questioned. Patients with Hirschsprung's disease had good results following a Duhamel or Soave procedure in most cases. Most patients with idiopathic constipation were managed successfully with medical treatment, although 9 of 35 patients with onset in childhood required surgical treatment. Surgical therapy for idiopathic megacolon in childhood varied as did the results.--Richard R. Ricketts Suction Rectal Biopsy in the Diagnosis of Hirschsprung's Disease and Chronic Constipation. T.Z. Polley, Jr, A.G. Coron, K.P.
Heidelberger, et aL Pediatr Surg Int 1:84-89, (June), 1986. Suction rectal biopsy has gained increased acceptance as the means of definitively diagnosing Hirschsprung's disease, as well as excluding this diagnosis when evaluating the child with chronic constipation. During the l 1-year period from July 1974 through June 1985, 309 suction rectal biopsy specimens were evaluated. Of these, 293 were done for the evaluation of chronic constipation and/or Hirschsprung's disease. The remaining 16 were performed as a part of the workup in patients with neuromuscular, glycogen storage, inflammatory bowel, or other diseases. Forty-two (14%) of the 293 patients were diagnosed as having Hirschsprung's disease at an average age of 14.4 months. This diagnosis was ruled out in the remaining 251 patients, whose age at biopsy averaged 2.7 years. There was one false-negative reading representing an incidence of 0.3%, with no false-positives. There were no complications. The suction rectal biopsy is a bedside or clinic procedure that reliably provides pathologic material adequate for the accurate diagnosis or exclusion of Hirschsprung's disease and offers a number of advantages over manometric, radiographic, histochemical, and open fullthickness biopsy techniques.--Prem Purl
Twenty Year Experience With Familial Polyposis Coil in Cape Town. R.J. Aitken, M.S. Elliot, M. Torrington, et al. Br J Surg
73:210-213, (March), 1986. Forty-nine patients undergoing surgery for familial polyposis coli over a 20-year period are reviewed. Thirty-six were descendants of a single marriage in 1871. Forty-three patients underwent total colectomy with an ileorectal anastomosis. Five of these subsequently developed a rectal carcinoma. The earliest occurred 8 years after surgery and the incidence appears to increase with time. Sixteen of these patients required fulguration of developing rectal adenomas on 1 to 6 occasions. Postoperative complications were common with 17% developing adhesion obstruction and 7% desmoid tumors. Upper gastrointestinal pathology was detected in only one of nine patients examined. The problem of screening a widely distributed and closely knit community are considerable. Total colectomy with ileorectal anastomosis is the operation of choice for the majority of patients, although meticulous follow-up is required. Total colectomy with ileal reservoir and ileoanal anastomosis is appropriate as the initial operation in some cases where follow-up is unlikely and is the operation of choice following the development of premalignant pathology in the rectal mucosa.--Tony Sparnon Generalized Juvenile Polyposis CoIL J.L. Grosfeld and K, IV. West,
Arch Surg 121:530-534, (May), 1986. Five patients with generalized junveile polyposis coli were managed over a 13-year period; there were 4 boys (18 months to 16 years of age) and 1 girl (12 years of age). Clinical findings included abdominal pain, weakness, rectal bleeding, diarrhea, rectal prolapse, intussusception, clubbing, and. failure to thrive. Laboratory findings included anemia, hypoalbuminemia, hypokalemia, and skin test anergy. Diagnosis was achieved by double contrast enema, endoscopy, and biopsy. Management consisted of subtotal colectomy and ileoproctostomy (4) and sphincter-saving rectal mucosectomy and ileoanalendorectal pull-through procedure (1). All five patients are currently alive and well. An increased risk for development of gastrointestinal tumors is noted in family members, and screening is recommended. An aggressive surgical posture is advocated because of potentially life-threatening complications that can occur in patients with generalized juvenile polyposis.--George A. Rowe Temporary Antimesenteric Stomas Without a Skin Bridge in
Infants. J.N.L. Simson and R.J. Brereton. Ann Roy Coil Surg Engl 67:363-365, (November), 1985. Thirty-four loop stomas without a skin bridge were created in 33 infants. Twenty-six of these stomas were fashioned in the laparotomy wound. Compared with loop colostomies over a tissue bridge, these stomas appeared to be associated with less infection and skin excoriation but with a higher incidence of prolapse. Wound dehiscence occurred in three patients in the earlier part of the study when absorbable sutures of polyglycolic acid were used to suture the seromuscular layer to the abdominal wall muscles. Because of the risk of overspill, these stomas are unsuitable for use as permanent defunctioning stomas or following necrotizing enterocolitis or the colitis of Hirschsprung's disease.--B.A. Madarikan Results of the Smooth-Muscle Fold-Over Oouble-plasty (SMFD).
S. Hofmann-von Kap-herr, R. Grussner, and J.L. Koltai. Pediatr Surg Int 1:43-45, (March), 1986. Since 1980, when the authors developed a substitute for the internal anal sphincter, the smooth-muscle fold-over double-plasty (SMFD-plasty), they have operated on seven children using this method. Usually it is done in combination with the pull-through