Modified Duhamel Retrorectal Pull-Through for Hirschsprung’s Disease

Objectives: To evaluate the post-operative complications and short-term outcomes of modified Duhamel retrorectal pull-through procedure for Hirschsprung’s disease. Design: Prospective descriptive study Place and Duration of Study: Department of Paediatric Surgery Sahiwal Teaching Hospital Sahiwal from 1stJanuary 2018 to 31st December 2020. Methodology: Thirty seven histologically confirmed cases of Hirschsprung’sdisease having previous decompressing colostomy/stoma age between 1 to 12 years of agewere included. Children under one year of age, with sever comorbidities like Down syndrome and cardiac abnormalities, and those who require re-do pull through procedure were excluded. Modified Duhamel retrorectal pull-through procedure was performed in all cases. The demographic information included age, sex, proximal level of aganglinosis, complications of definite procedure, length of hospitalization andmortality. Other information recorded included long term complications like obstructive symptoms, enterocolitis, incontinence and soiling at follow up. Krickenbeck classification was used to evaluate faecal incontinence and constipation. Kelly’s clinical score was used to assess the anal sphincter. Bowel habits were assessed only in children above three years of age. Results: Twenty six (70.27%) were males and 11 (29.72%) females with male to female ratio 2.3:1 and mean age at operation was 2.89±1-9 years. Twenty nine (78.37%) children were ≤3 years of age and 8 (21.62%) were >3 years. Mean weight was 12.91 kgs, operation time was 126.81 time, fasting time was 6.67 days and hospital stay was 11.91 days. Length of aganglionic segment was short segment 27 (72.97%), long segment 9 (24.32%) and total colonic 1 (2.7%). Hirschsprung associated enterocolitis 7 (18.91%) and wound infection 6(16.21%) were most common reported complications. Constipation in 5(13.51) and soiling with retentive constipation was present in 3 (8.10%) patients. Out of total 31 patients who reached toilet training age, 28 (90.32%) developed satisfactory voluntary bowel habits. Conclusion: Modified Duhamel pull-through procedure was found to be safe, applicable and with lower associated complications and satisfactory short term functional outcomes in our settings. Key words: Hirschsprung’s disease, Modified Duhamel pull-through procedure, Complications, Outcomes

Bowel habits and gender correlate with colon length measured by CT colonography

Purpose CT colonography enables three-dimensional measurement of colon length. However, previous studies using CT colonography have not examined the association with gender, age, physique, a history of laparotomy and bowel habits, all possible contributory factors to colon length. The aim of this study is to investigate factors associated with colon length. Materials and methods We conducted a post hoc analysis based on data obtained from a previous multi-center trial including 321 patients with positive fecal immunochemical tests who underwent CT colonography. Colon length was measured using a computer-generated center line and was divided at the iliac crest level into the distal and proximal colons. Bowel habits were classified into three groups: A—daily; B—once every 2 or 3 days; and C—less than once in 3 days. Statistical comparison was made using one-way ANOVA with Bonferroni’s correction. Results A total of 295 patients were analyzed. The entire colon length (cm, mean ± standard deviation) of individual patients was 150.3 ± 18.5 cm and ranged from 109.7 to 195.9 cm. The female colon was significantly longer than the male colon (154.3 ± 18.1 cm vs. 147.1 ± 18.3 cm; p = 0.022). Colon length showed trends associated with age (p = 0.18) and a history of laparotomy (p = 0.14). According to bowel habits, the entire colon measured 147.4 ± 17.9 in group A, 154.7 ± 18.5 in group B and 158.6 ± 18.3 in group C, and significant differences were observed for “A vs. C” (p = 0.002) and “A vs. B” (p = 0.014). In subgroup analysis by colon segment, the proximal colon trended similarly to the entire colon while there were no trends for the distal colon. Conclusions This study has clearly demonstrated that bowel habits and gender both correlate with the length of the entire colon measured by CT colonography, and in particular, the proximal colon. Secondary abstract Using CT colonography, we measured the colon length in 295 patients. The entire colon length was 150.3 ± 18.5 cm on average. Females and constipated (less frequent defecation) patients have a significantly longer colon, and in particular, the proximal colon. Colon length showed trends associated with age and a history of laparotomy.

To Study the Outcome of Posterior Sagittal Anorectoplasty in Anorectal Malformations

Aim: To assess the effectiveness of posterior sagittal anorectplasty for the repair of anorectal malformations in terms of postoperative complications and functional outcomes. Study design: Descriptive prospective study. Place and duration of study: Sahiwal Teaching Hospital, Sahiwal. From 1st January 2016 to 31st December 2019. Methodology: Forty-two children with high/intermediate anorectal malformations, who underwent posterior sagittal anorectoplasty, were included in the study. Patients with low variety anorectal malformations, recto vestibular/ano vestibular fistula, persistent cloaca and patients with sacral dysraphism, spinal dysraphism, myelomeningocele spina bifida occulta and menifesta were excluded. Demographic information included age, gender, weight, type of anorectal malformation, type of surgery performed, operation time and hospital stay. Immediate post-operative complications were also noted. Bowel habits, constipation and faecal incontinence were evaluated in all patients during the follow up period. Results: Thirty-one (73.80%) were males and 11(26.19%) were females and mean age was 1.72 years. The mean weight at the time of operation was 11.00 kg. High variety anorectal malformations were 14(33.33%) and intermediate were 28(66.66%). Rectourethral fistula 25(59.52%) was most common variety seen in males. Recto bulber urethral fistula in 17(40.47%) and recto prostatic urethral fistula in 8(19.04%) patients were seen. Anal agenesis without fistula 7(16.66%) was most common anomaly in females. Overall complication rate was 15(35.71%). Constipation 11(26.19%) was most common post-operative complication. True fecal incontinence was seen in 3(7.14%) patients. Strong and effective squeeze of anal sphincter was seen in 39 (92.85%) patients and satisfactory bowel habits were present in 37 (88.08%) patients. Conclusion: Posterior sagittal anorectplasty is a useful procedure in the management of high/intermediate anorectal malformations, precise identification and reconstruction of muscle complex result in good anatomical and functional outcome. Immediate post-operative complication rate is also low. Keywords: Anorectal malformations, Posterior Sagittal Anorectoplasty, Postoperative complications, Functional outcomes

1123 An Audit of Pick-Up Rate of Random Colonic Biopsies

Aim We aimed to evaluate optimal random biopsy criteria are being followed in our institution to increase the diagnostic yield of a subsequent histopathological examination and to reduce the number of unnecessary biopsies in which histopathology is unlikely to deliver clinically useful information and causing a burden on health resources in terms of cost and manpower. Method Our study was a retrospective on 419 random colonoscopy biopsies performed over 6 months. Data collection included variables such as age, gender, indications, request of urgency, and histology findings. Data analysis was done descriptively. Results Out of 419 random biopsies, only 10.02% had positive findings. The total number of histology results with microscopic colitis was 10. The main indication of the random colonic biopsy was a change in bowel habits (328 cases) followed by significant diarrhea greater than 50 years in 20 cases. In patients with a change in bowel habits, 2.44% of histopathology specimens revealed microscopic colitis. The percentage of random colonic biopsy histology in patients greater than 50 years with significant diarrhea showed microscopic colitis was 10%. Conclusions Our study revealed random biopsy during colonoscopy should only be done in selected patients otherwise it has low diagnostic yields biopsy and should only be reserved for patients with risk factors for optimum utilization of health resources and to reduce the cost burden. A scoring system may be helpful to risk-stratify patients in low and high risk for MC to determine which patients qualify for RCB.

Clinicopathological profile of colorectal carcinoma in a tertiary care teaching hospital in Pokhara, Nepal

Introduction: Colorectal cancer is the most common malignancy of the gastrointestinal tract. They are common after 50 years of age and present with bleeding per rectum, altered bowel habits, anemia, pain abdomen, and weight loss. The objective of this study was to evaluate the demographic profile, clinical presentation, colonoscopy and histopathology findings of colorectal cancer. Methods: A descriptive cross-sectional study was conducted. Cases were studied from the departmental records. Clinical presentation, CT abdomen, colonoscopy, and histopathology findings of colorectal carcinoma were studied. Data entry was done in SPSS version 20. Results: The mean age of subjects was 56 ± 11.42 years (range of 34 – 80 years) with male predominance (M: F=3:2). Changes in bowel habits (92.3%), chronic abdominal pain (84.6%), generalized weakness (80.7%), rectal bleeding (46.2%), and significant weight loss (42.3%) were the most common presenting symptoms. Rectal carcinoma was the most common (35%) followed by carcinomas of ascending colon (14%) and descending colon (10 %). The most common morphology was proliferative growth (61.5%). All colorectal carcinomas were adenocarcinoma, and the majority was moderately differentiated (51.9%). Conclusion: Colorectal cancers are seen above 50 years of age and common in males. Changes in bowel habits, chronic abdominal pain, generalized weakness, rectal bleeding, and weight loss are the most common form of presentations. These patients usually present late with advanced disease and unfavorable histopathology. Screening colonoscopy >50 years is strongly recommended.

Detection of cancers and advanced adenomas in asymptomatic participants in colorectal cancer screening: a cross-sectional study

ObjectivesTo assess detection rates for colorectal cancer (CRC) and advanced adenomas in asymptomatic CRC screening participants and bowel symptoms in association with CRC and advanced adenoma.DesignCross-sectional study.SettingTwo screening centres.Participants42 554 men and women, aged 50–74 years, participating in a randomised CRC screening trial. 36 059 participants underwent a sigmoidoscopy (and follow-up colonoscopy if positive sigmoidoscopy) and 6495 underwent a colonoscopy after a positive faecal immunochemical test (FIT).Primary and secondary outcome measuresProportion of asymptomatic participants diagnosed with CRC or advanced adenomas. Prevalence of bowel symptoms (rectal bleeding, change in bowel habits, diarrhoea, constipation, bloating, alternating bowel habits, general symptoms, other bowel symptoms) recorded by the endoscopist and their association with CRC and advanced adenomas.ResultsAmong sigmoidoscopy participants, 7336 (20.3%) reported at least one symptom. 120 (60%) out of 200 individuals with screen-detected CRC and 1301 (76.5%) out of 1700 with advanced adenoma were asymptomatic. Rectal bleeding was associated with detection of CRC and advanced adenoma (OR 4.3, 95% CI 3.1 to 6.1 and 1.8, 95% CI 1.5 to 2.1, respectively), while change in bowel habits only with CRC detection (OR 3.8, 95% CI 2.4 to 6.1). Among the FIT positives, 2173 (33.5%) reported at least one symptom. Out of 299 individuals with screen-detected CRC and 1639 with advanced adenoma, 167 (55.9%) and 1 175 (71.7%) were asymptomatic, respectively. Detection of CRC was associated with rectal bleeding (OR 1.8, 95% CI 1.4 to 2.3), change in bowel habits (OR 2.2, 95% CI 1.4 to 3.5) and abdominal pain (OR 1.8, 95% CI 1.2 to 2.7).ConclusionsSome bowel symptoms increased the likelihood of being diagnosed with CRC or advanced adenoma. However, the majority of individuals with these findings were asymptomatic. Asymptomatic individuals should be encouraged to participate in CRC screening.Trial registration numberClinicaltrials.gov Identifier: NCT01538550.

Improvement in Food Intolerance Symptoms after Pretreatment with Antibiotics Followed by Faecal Microbiota Transplantation: A Case Report

Irritable bowel syndrome (IBS) is a chronic gastrointestinal condition characterized by abdominal pain and altered bowel habits. Non-immune food reactions or food intolerances affect up to 20% of the general population and are commonly seen in patients with IBS. Faecal microbiota transplantation (FMT) has been described as an emerging, effective treatment for IBS. To date, there have been no reports on changes in food intolerances in patients with IBS treated with FMT. A 35-year-old female presented with an 18-month history of nausea, abdominal pain, alternating bowel habits, headaches/migraines, brain fog, and fatigue. The patient described severe food intolerances to dairy, gluten, egg, and soy. Extensive investigation identified no pathology, and IBS was diagnosed. The patient underwent treatment with antibiotics followed by treatment with FMT enema infusions decreasing in frequency for 12 months. At 12-week follow-up during FMT infusions, the patient reported an 80–90% improvement in her symptoms with formed bowel motions 1–2/day, occasional abdominal pain, and nausea and improved energy levels. The patient reported progressive improvements in her food tolerance from approximately 2 months into the FMT treatment. At week 24, she was tolerating gluten and dairy foods in her diet. At week 52, she was including gluten and dairy in her diet with no symptoms. This case demonstrates that antibiotics, followed by FMT may be an effective treatment for IBS and food intolerances pointing to the gut microbiome as a potential target for treatment.