Yee Ian Yik

Home transcutaneous electrical stimulation to treat children with slow-transit constipation ☆

PURPOSE This study aimed to test the effectiveness of home transcutaneous electrical stimulation (TES) when patients with slow-transit constipation (STC) were trained by a naive clinician. METHODS A surgeon was trained to teach the TES method to STC children who then self-administered at home (1 hour a day, 3-6 months) using a battery-powered interferential stimulator. Bowel diaries, PedsQL4.0 questionnaires, and radio-nuclear colonic transit studies were completed before and after treatment. RESULTS Thirty-two children (16 female; mean age, 8.3 years; range, 3-17 years) self-administered 3 to 6 months of TES. Three did not return diaries. Group 1 (n = 13) started with less than 3 bowel actions per week, and group 2 (n = 16), with more than 3 bowel actions per week. Defecation frequency increased in 69% of group 1 (mean, 1.4-3.0 per week; P = .02). Soiling frequency decreased in 50% of group 2 (5.4-1.9 per week, P = .04). Of 13 patients, 7 improved with development of urge-initiated defecation. Abdominal pain decreased in 48% (1.6 episodes per week to 0.9 per week, P = .06). Stool consistency improved in 56%. There was significant improvement in child-reported and parent-reported PedsQL Scores. Colonic transit improved in 13 of 25 patients. CONCLUSION Home TES provides a new treatment for STC children, with 50% of treatment-resistant patients benefited. Success requires clinician training and close patient contact. Transcutaneous electrical stimulation increased defecation and reduced soiling.

Long-term effects of transabdominal electrical stimulation in treating children with slow-transit constipation

AIMS Transcutaneous electrical stimulation (TES) was used to treat children with slow-transit constipation (STC) for 1 to 2 months in a randomized controlled trial during 2006 to 2008. We aimed to determine long-term outcomes, hypothesizing that TES produced sustained improvement. METHODS Physiotherapists administered 1 to 2 months of TES to 39 children (20 minutes, 3 times a week). Fifteen continued to self-administer TES (30 minutes daily for more than 2 months). Mean long-term follow-up of 30 of 39 patients was conducted using questionnaire review 3.5 years (range 1.9-4.7 years) later. Outcomes were evaluated by confidence intervals or paired t test. RESULTS Seventy-three percent of patients perceived improvement, lasting more than 2 years in 33% and less than 6 months in 25% to 33%. Defecation frequency improved in 30%. Stools got wetter in 62% after stimulation and then drier again. Soiling improved in 75% and abdominal pain in 59%. Laxative use stopped in 52%, and 43% with appendicostomies stopped washouts. Soiling/Holschneider continence score improved in 81% (P = .0002). Timed sits switched to urge-initiated defecations in 80% patients. Eighty percent of relapsed patients elected to have home stimulation. CONCLUSION TES holds promise for STC children. Improvement occurred in two thirds of children, lasting more than 2 years in one third, whereas symptoms recurred after 6 months in one third of children.

Phytobezoar: an unusual cause of intestinal obstruction.

Small bowel phytobezoars are rare and almost always obstructive. There have been previously reported cases of phytobezoars in the literature, however there are few reports on radiological findings for small bowel bezoars. Barium studies characteristically show an intraluminal filling defect of variable size that is not fixed to the bowel wall with barium filling the interstices giving a mottled appearance. On CT scan, the presence of a round or ovoid intraluminal mass with a ‘mottled gas’ pattern is believed to be pathognomonic. Since features on CT scans are characteristics and physical findings are of little assistance in the diagnosis of bezoar, the diagnostic value of CT needs to be emphasised.

Nuclear transit studies of patients with intractable chronic constipation reveal a subgroup with rapid proximal colonic transit

AIMS/BACKGROUND Nuclear transit studies (NTS) allow us to follow transit through the stomach and the small and large intestines. We identified children with chronic constipation with rapid proximal colonic transit and characterized their clinical features. METHODS We reviewed NTS from 1998 to 2009 to identify patients with chronic constipation and rapid proximal colonic transit, defined as greater than 25% of tracer beyond hepatic flexure at 6 hour and/or greater than 25% of tracer beyond end of descending colon at 24 hour. This was correlated with clinical symptoms and outcome from patient records. RESULTS Five hundred twenty children with chronic constipation underwent investigation by NTS, and 64 (12%) were identified with rapid proximal colonic transit. The clinical history, symptoms, and outcome in 55 of 64 available for analysis frequently showed family history of allergy (10.9%) and symptoms associated with food allergy/intolerance: abdominal pain (80%), anal fissure (27.3%), and other allergic symptoms (43.6%). Eighteen children were treated with dietary exclusion, with resolution of symptoms in 9 (50%). CONCLUSIONS Some children with intractable chronic constipation have rapid proximal colonic transit, have symptoms consistent with possible food allergy/intolerance, and may respond to dietary exclusion. The NTS can identify these patients with rapid proximal transit that may be secondary to food intolerance.

The impact of transcutaneous electrical stimulation therapy on appendicostomy operation rates for children with chronic constipation—a single-institution experience

PURPOSE Appendicostomy for antegrade continence enema is a minimally invasive surgical intervention that has helped many children with chronic constipation. At our institution, since 2006, transcutaneous electrical stimulation (TES) has been trialed to treat slow-transit constipation (STC) in children. This retrospective audit aimed to determine if TES use affected appendicostomy-formation rates and to monitor changes in practice. We hypothesized that appendicostomy rates have decreased for STC but not for other indications. METHODS Appendicostomy-formation rate was determined for the 5 years before and after 2006. Children were identified as STC or non-STC from nuclear transit scintigraphy and patient records. RESULTS Since 1999, 317 children were diagnosed with STC using nuclear transit scintigraphy with 121 during 2001 to 2005 (24.2/year) and 147 during 2006 to 2010 (29.4/year). Seventy-four children had appendicostomy formation. For 2001 to 2005, appendicostomy-formation rates for STC and non-STC children were similar: 5.4 per year (n = 27) and 4.8 per year (n = 24), respectively. For 2006 to 2010, appendicostomy-formation rates were 1.2 per year (n = 6) for STC and 3.2 per year (n = 16) for non-STC (χ(2), P = .04). CONCLUSION Since 2006, appendicostomy-formation rates have significantly reduced in STC but not in non-STC children at our institute, coinciding with the introduction of TES as an alternative treatment for STC. Transcutaneous electrical stimulation has not been tested on non-STC children in this period.

How common is colonic elongation in children with slow-transit constipation or anorectal retention?

PURPOSE Colonic elongation is reported as a possible cause for slow colonic transit, as it is observed in patients with slow-transit constipation (STC). This study aimed to determine the frequency of colonic elongation in children with STC or anorectal retention using radioimaging. We hypothesized that transverse colon elongation may occur in patients with STC, whereas sigmoid colon elongates in patients with anorectal retention. METHODS Nuclear transit scintigraphy performed for chronic constipation (1999-2011) was analyzed qualitatively for elongated transverse colon or sigmoid colon. Three major colonic transit patterns were identified: slow transit in the proximal colon (STC), normal proximal colonic transit with anorectal retention (NT-AR), and rapid proximal transit ± anorectal retention (RT). χ(2) Test was used for statistical analysis (P < .05 significant). RESULTS From 1999 to 2011, 626 children had nuclear transit scintigraphy. Transverse colon elongation occurred more frequently in STC (73/322, or 23%) compared with NT-AR (9/127, or 7%) and RT (5/177, or 3%; P < .0001). Sigmoid colon elongation was equally common in NT-AR (8/127, or 6%) compared with RT (10/177, or 6%) and STC (14/322, or 4%; P < .9). CONCLUSION Transverse colon elongation is more common in STC (23%), whereas sigmoid colon elongation is not more common in anorectal retention. Colonic elongation may be the cause or the result of the underlying slow colonic transit.

Osteosarcoma of the rib.

This case describes the radiological-surgical correlation of a rare case of osteosarcoma of the rib in a 15-year-old boy. Successful repair of his chest wall defect using a wire mesh following extensive surgical resection of the tumour is highlighted, such a procedure being the first instituted at our centre.

Management of Hirschsprung's disease with reference to one-stage pull-through without colostomy☆

BACKGROUND/PURPOSE The authors evaluated the safety and benefits of 1-stage pull-through in comparison with staged repair of Hirschsprungs disease under circumstances prevailing in a developing country. METHODS Forty-nine patients were treated for Hirschsprungs disease during a 7-year period between January 1991 and March 1998 at our institution, which is a tertiary referral center. Nine patients were excluded from the study, and the medical records of the remaining 40 patients were reviewed. RESULTS Eighteen patients including 7 neonates underwent 1-stage pull-through, and 22 patients underwent staged correction. There was no mortality for patients undergoing one-stage treatment, but there was 1 death caused by anastamotic leak after a 2-stage repair. There was no substantial difference in the incidence of complications (38.8% v 45.45%) and the need for additional surgical procedures (33.5% v 45.45%) between the 2 groups. Seventy-one percent after 1-stage treatment and 80% after staged treatment had a satisfactory functional result, and the incidence of incontinence was 14% and 10%, respectively. Overall, the incidence of postoperative enterocolitis was low (7.5%). CONCLUSIONS One-stage correction of Hirschsprungs disease is a safe procedure in all age groups. It offers economical and social advantages to families in developing countries. Benefits of 1-stage treatment include avoidance of multiple operations, elimination of complications associated with a colostomy, shorter duration of hospital stay, and completion of treatment at an earlier age. It is advisable to continue postoperative anal dilatation for a minimum period of 6 months to 1 year to reduce the incidence of enterocolitis.

Home Transcutaneous Electrical Stimulation Therapy to Treat Children With Anorectal Retention: A Pilot Study

As transcutaneous electrical stimulation (TES) increased defecation in children and adults with Slow‐Transit Constipation (STC), we performed a pilot study to test if TES can improve symptoms (defecation and soiling) in children with chronic constipation without STC and transit delay in the anorectum.

Targeting the Causes of Intractable Chronic Constipation in Children: The Nuclear Transit Study (NTS)

Chronic constipation is a symptom and not a disease! It is a common and major health problem affecting both adults and children. It is a difficult health issue for the patients and their treating physicians, with major psycho-socio-economic impacts. As the underlying cause varies, there is no standard therapy for chronic constipation. Many investigations have been used in the past, both invasive and non-invasive to study colonic physiology and pathophysiology to identify the underlying cause(s) for chronic constipation, but none of these tests have been able to provide reliable information for satisfactory treatment of this complex problem. The nuclear transit study (NTS) has begun to gain acceptance in both adults and children in recent years. At our institute (The Royal Children’s Hospital, Melbourne, Victoria, Australia), nuclear transit studies were initially used to investigate total colonic transit time and to define the site where slowing occurs in children with intractable chronic constipation (Cook et al. 2005), leading to the description of slow-transit constipation (STC) in children in 1998 (Southwell et al. 2009). In addition to colonic transit, gastric emptying and small bowel transit can be characterised producing a complete picture of gastrointestinal tract dynamics. This study reviews NTS collected over 12 years (1999-2010) at our tertiary children’s hospital to identify sites of hold-up or delay in children with chronic constipation not responding to medical treatment.