Laparoscopic-assisted colectomy with Duhamel procedure for idiopathic megacolon in adults: a retrospective study.

BACKGROUND: Idiopathic megacolon (IMC) is an uncommon disease in adults. To date, only a few laparoscopic experiences and functional outcomes of IMC have been reported. This study was to retrospectively analyse our 12 year surgical experience and functional outcomes in adult patients with IMC. METHODS: A 12-year retrospective study from October 2006 to November 2018 was performed for patients with IMC who underwent surgical interventions. Patients who underwent laparoscopic-assisted colectomy and Duhamel procedure with ileorectal or colorectal anastomosis were collected. Clinical data of surgery and functional outcomes were analysed. RESULTS: A total of 13 patients who underwent surgical interventions were included in the study. Seven patients underwent laparoscopic total colectomy with ileorectal anastomosis (Duhamel procedure), one patient underwent laparoscopic total colectomy with end ileostomy because of acute intestinal obstruction, while five other patients underwent laparoscopic segmental colectomy with colorectal anastomosis (Duhamel procedure). The mean operative time was 181.6 min (range 150-246). The mean estimated blood loss was 75.6 ml (range 40-200). The mean postoperative hospital stay was 8.2 days (range 6-13). There was no conversion to an open procedure and no surgical mortality. Postoperative diarrhoea was the most prominent complaint during the early period after total colectomy. All patients showed adaptation to the defaecation frequency 3-6 months postoperatively, and had a good quality of life in long-term follow-up. CONCLUSION: Laparoscopic-assisted colectomy with Duhamel procedure is a safe and efficient technique for IMC in adults. The scope of colon resection and the type of anastomosis should be individually selected.

Lower urinary tract dysfunction in chronic Chagas disease: clinical and urodynamic presentation.

PURPOSE: To describe and give an estimation of the prevalence of urinary disorders in chronic Chagas disease, since most clinical research has been centered on the description of the cardiac and digestive forms. METHODS: To explore this topic, a cross-sectional study was conducted in 137 Bolivian adults of both sexes suffering from symptomatic chronic Chagas disease. All patients presenting confirmed chagasic cardiomyopathy, megacolon or both underwent a urologic symptom questionnaire, uroflowmetry, urinary tract ultrasonography and a creatinine assay. When urinary abnormality was detected, a complete urodynamic study was proposed including cystometry, pressure-flow studies and urethral pressure profile. RESULTS: Out of all study patients, 35 (26%) had a Chagas cardiomyopathy, 81 (59%) a megacolon, and 21 (15%) a megacolon associated with cardiomyopathy. In all, 63% presented urinary disorders defined by IPSS > 7 and/or ICIQ SF > 1. Among them, 62% were incontinent, mainly by bladder overactivity, and 45% presented grade 2 or 3 renal insufficiency. Of 49 patients, the urodynamic study identified 34 patients with detrusor overactivity (69%), mostly in those with Chagas megacolon. Median bladder functional capacity, urethral closure pressure and bladder compliance had normal values. Moreover, 36% of these patients presented moderate hypocontractility, without significant post-void residual. CONCLUSIONS: This study evidenced lower urinary tract dysfunction in a majority of chronic chagasic patients; those presenting megacolon were more likely to suffer from urinary incontinence. These results strongly suggest including routine urological clinical investigation in chronic Chagas patients, as urinary incontinence due to overactive bladder is frequently observed in this population.

Megacolon andino y vólvulo del sigmoides de la altura: Presentación de 418 casos entre 2008 - 2012 en el hospital C. Monge - Puno, Perú / Andean megacolon and sigmoid volvulus in the high altitude: Presentation of 418 cases between 2008 - 2012 at C. Monge Hospital, Puno, Peru

Objetivo: El presente estudio describe el manejo médico y quirúrgico del vólvulo de sigmoides debido a dolicomegacolon andino en un hospital a una altitud mayor a 3000 msnm. Material y métodos: Estudio descriptivo, observacional, transversal de 418 pacientes con diagnóstico de vólvulo de sigmoides; admitidos inicialmente por cuadros de obstrucción intestinal, en el Hospital de Juliaca Carlos Monge - Puno, Perú, durante el periodo 2008-2012. Los datos fueron procesados a través del programa SPSS versión 21. Resultados: Se registraron 418 pacientes, la media de edad fue de 60 años, rango 18-89 años, con una proporción hombre/mujer de 3,5/1. El manejo no quirúrgico se hizo en 64 (15,4%), el tratamiento empleado fue de enema salino 20 casos 31% y sonda rectal 44 (69%), se presentó recurrencia en 27 pacientes (45%), los cuales tuvieron cirugía con resección anastomosis primaria, de estos la mortalidad correspondió a 8 pacientes (30%). De los 354 pacientes sometidos a manejo quirúrgico de emergencia 325 fueron sometidos a sigmoidectomia con anastomosis primaria (92%), mientras 29 tuvieron colostomía a lo Hartmann (8%), la morbilidad para ambos procedimientos fue de 52 casos (14,7%), la mortalidad para ambos procedimientos fue de 45 casos (12,7%). Conclusiones: El vólvulo sigmoides debido a megacolon andino tuvo una edad media de 60 años. El 15,4% tuvo manejo no quirúrgico, la tasa de recurrencia fue de 45%, mortalidad de 30%. El 84,7% tuvo manejo quirúrgico; el 92% tuvo resección anastomosis primaria y 8% colostomía a lo Hartmann, la morbilidad fue de 14,7% y la mortalidad de 12,7%.

Objective: The present study describes the medical and surgical management of sigmoid volvulus due to Andean dolicomegacolon in a hospital at an altitude above 3000 m. Material and methods: A descriptive, observational, crosssectional study of 418 patients diagnosed with sigmoid volvulus; Admitted initially due to intestinal obstruction, in the Hospital of Juliaca Carlos Monge. Puno-Perú, during the period 2008-2012. The data were processed through the SPSS software version 21. Results: A total of 418 patients were enrolled, the mean age was 60 years, range 18-89 years, and the male/female ratio was 3.5/1. Nonsurgical management was done in 64 (15.4%), the treatment used was saline enema 20 cases (31%) and rectal catheter 44 (69%), recurrence was present in 27 patients (45%), who had surgery with primary anastomosis resection, of which the mortality corresponded to 8 patients (30%). Of the 354 patients undergoing emergency surgical management, 325 were submitted to sigmoidectomy with primary anastomosis (92%), while 29 had Hartmann's colostomy (8%), the morbidity for both procedures was 52 cases (14.7%), Mortality for both procedures was 45 cases (12.7%). Conclusions: In patients with sigmoid volvulus due to Andean megacolon the mean age was 60 years. The 15.4% had non-surgical management, the recurrence rate was 45%, and mortality 30%. Patients with surgical management was 84.7%, from this group; 92% had primary anastomosis resection and 8% Hartmann colostomy, morbidity was 14.7% and mortality was 12.7%.

The correlation between diverticulosis and redundant colon.

BACKGROUND: Diverticulosis and redundant colon are colonic conditions for which underlying pathophysiology, management and prevention are poorly understood. Historical papers suggest an inverse relationship between these two conditions. However, no further attempt has been made to validate this relationship. This study set out to assess the correlation between diverticulosis and colonic redundancy. METHODS: Redundant colon, diverticulosis and patient demographics were recorded during colonoscopy. Multivariate binary logistic regression was performed with redundant colon as the dependent variable and age, gender and diverticulosis as independent variables. Nagelkerke R 2 and a receiver operator curve were calculated to assess goodness of fit and internally validate the multivariate model. RESULTS: Redundant colon and diverticulosis were diagnosed in 31 and 113 patients, respectively. The probability of redundant colon was increased by female gender odds ratio (OR) 8.4 (95% CI 2.7-26, p = 0.00020) and increasing age OR 1.7 (95% CI 1.1-2.6, p = 0.017). Paradoxically, diverticulosis strongly reduced the probability of redundant colon with OR of 0.12 (95% CI 0.42-0.32, p = 0.000039). The Nagelkerke R 2 for the multivariate model was 0.29 and the area under the curve at ROC analysis was 0.81 (95% CI 0.73-0.90 p-value 3.1 × 10-8). CONCLUSIONS: This study found an inverse correlation between redundant colon and diverticulosis, supporting the historical suggestion that the two conditions rarely occur concurrently. The underlying principle for this relationship remains to be found. However, it may contribute to the understanding of the aetiology and pathophysiology of these colonic conditions.

[Andean megacolon and sigmoid volvulus in the high altitude. Presentation of 418 cases between 2008 - 2012 at C. Monge Hospital, Puno, Peru]. / Megacolon andino y vólvulo del sigmoides de la altura. Presentación de 418 casos entre 2008 - 2012 en el hospital C. Monge Puno, Perú.

OBJECTIVE: The present study describes the medical and surgical management of sigmoid volvulus due to Andean dolicomegacolon in a hospital at an altitude above 3000 m. MATERIAL AND METHODS: A descriptive, observational, crosssectional study of 418 patients diagnosed with sigmoid volvulus; Admitted initially due to intestinal obstruction, in the Hospital of Juliaca Carlos Monge. Puno-Perú, during the period 2008-2012. The data were processed through the SPSS software version 21. RESULTS: A total of 418 patients were enrolled, the mean age was 60 years, range 18-89 years, and the male/female ratio was 3.5/1. Nonsurgical management was done in 64 (15.4%), the treatment used was saline enema 20 cases (31%) and rectal catheter 44 (69%), recurrence was present in 27 patients (45%), who had surgery with primary anastomosis resection, of which the mortality corresponded to 8 patients (30%). Of the 354 patients undergoing emergency surgical management, 325 were submitted to sigmoidectomy with primary anastomosis (92%), while 29 had Hartmann's colostomy (8%), the morbidity for both procedures was 52 cases (14.7%), Mortality for both procedures was 45 cases (12.7%). CONCLUSIONS: In patients with sigmoid volvulus due to Andean megacolon the mean age was 60 years. The 15.4% had non-surgical management, the recurrence rate was 45%, and mortality 30%. Patients with surgical management was 84.7%, from this group; 92% had primary anastomosis resection and 8% Hartmann colostomy, morbidity was 14.7% and mortality was 12.7%.

The burden of Chagas disease: estimates and challenges.

Chagas disease, caused by infection with the protozoa Trypanosoma cruzi is transmitted most often by Triatominae insect vectors, but also through blood transfusion, organ transplant, and congenital transmission. Between 5 and 18 million people are currently infected and the infection is estimated to cause more than 10,000 deaths annually. The disease has 3 phases: acute, indeterminate, and chronic. The acute phase immediately follows infection. It is typically asymptomatic but produces fever and malaise in up to 5% of people. The indeterminate phase is asymptomatic. More than one-half of those infected will remain in this phase for life and never experience long-term sequelae. After a decade or more, 20% to 30% of people will experience chronic cardiovascular Chagas disease with sequelae including heart failure, arrhythmias, and thromboembolism. Another 15% to 20% will experience chronic digestive sequela including megaesophagus and megacolon. A complete accounting of the burden of Chagas disease requires estimating the prevalence of the infection, the prevalence of each of its sequelae among those with the infection, and the number of deaths attributable to the infection. Attempts to estimate Chagas disease prevalence are complicated by several challenges imposed by the disease's extreme spatial heterogeneity, quickly evolving temporal trends, the decades-long lag between infection and symptomatic disease, biased prevalence data, incomplete recognition of Chagas-attributable deaths, limited data on sequela, and a near total absence of data outside of endemic countries. Even though researchers have found methodological approaches to dealing with these challenges, there is a need for better data.

[Megacolon and sigmoid volvulus: incidence and physiopathology]. / Megacolon y vólvulo de sigmoides: incidencia y fisiopatología.

The etiology of Megacolon is multiple. One of these causes and the most frequent is Chagas disease. Its complication: sigmoid volvulus was de main diagnosis in the admitted patients at the Bolivian and Japanese Gastroenterological Institute of Cochabamba Bolivia. It usually affects people of a low economic income. In this Gastroenterological Hospital a transversal and prospective study has been done, in order to know the real incidence and the physiopathology of this disease. In a six year period, from 2000 to 2006, 8.954 patients were admitted to the Hospital: of these, 814 (9.09%), where diagnosticated as lower intestinal obstruction. In 608 (74.7%) the final diagnosis was sigmoid torsion. Radiological diagnosis was made in 84% of the patients and endoscopic decompression was successful in 88.7%. As reported in the medical literature, the main cause of megacolon in this part of the world is Chagas disease. In our investigation 22% (98 patients), were serology positive to Chagas disease, and another 21.44% (95 patients) were serology negative. They were coca leaf chewers. One of coca leaf compounds is cocaine which blocks the adrenaline and noradrenaline degradation by mean of monoamine oxidase inactivation. These two hormones stay a long term of time in the target organ: the large bowel. By this mean chronic and persistent vessel constriction develops intestinal wall atrophy and lower resistance to the intraintestinal pressure.

Loop versus divided colostomy for the management of anorectal malformations.

PURPOSE: The purpose of this study was to compare the clinical outcomes of loop and divided colostomies in patients with anorectal malformations (ARM). METHODS: We performed a retrospective cohort study reviewing the medical records of all patients with ARM managed with diverting colostomies between 2000 and 2010 at our institution. Independent variables and outcomes of stoma complications were analyzed by parametric measures and logistic regression. RESULTS: One hundred forty-four patients managed with a colostomy for ARM were evaluated (37.5% females, 50.7% loop, 49.3% divided). The incidence of patients with loop and divided colostomies who developed stoma-related complications was 31.5 and 15.5%, respectively (p=0.031). The incidence of prolapse was 17.8 and 2.8%, respectively (p=0.005). Multivariable-logistic regression controlling for other significant independent variables found loop colostomies to be positively associated with the development of a stoma complication (OR 3.13, 95%CI (1.09, 8.96), p=0.033). When individual complications were evaluated, it was only stoma prolapse that was more likely in patients with loop colostomies (OR 8.75, 95%CI (1.74, 44.16), p=0.009). CONCLUSION: Because of the higher incidence of prolapse, loop colostomies were found to be associated with a higher total incidence of complications than divided stomas. The development of other complications, including urinary tract infections (UTIs) and megarectum, were independent of the type of colostomy performed.

The significantly reduced number of interstitial cells of Cajal in chagasic megacolon (CM) patients might contribute to the pathophysiology of CM.

In addition to neurons, interstitial cells of Cajal (ICC) play an important role in coordinating intestinal motility with a pacemaker function. This study aimed to quantitatively analyze ICC, neurons, and muscular area, the latter to correct for quantitation errors resulting from dilation in case of a megacolon and from the dispersion of ICC that can be attributed to muscular hypertrophy. We analyzed 30 colon samples: ten chagasic megacolon (CM), ten chagasic colons without megacolon (CXM), and ten nonchagasic control patients (NC). We measured the area of muscularis propria and counted the number of neurons of the myenteric plexus in a histological section of an intestinal ring and the number of ICC at the level of the myenteric plexus and circular muscle layer, the latter in a section immunohistochemically stained for CD117. Muscular hypertrophy occurred only in the CM group. Compared to the NC group, we found in the CM group a statistically significant reduction of 80 % in the number of neurons, 60 % in the number of ICC in the myenteric plexus, and 38 % in the area of circular muscle. In the CXM group, these numbers were highly variable, and their reduction, less pronounced. We conclude that the number of ICC is significantly reduced in CM patients, and that this might contribute to the pathophysiology of CM. However, the development of CM requires severe denervation, whereas CXM generally exhibits less than 50 % denervation, favoring the hypothesis that the reduction in ICC number is, in part, a consequence of denervation.

Selective survival of calretinin- and vasoactive-intestinal-peptide-containing nerve elements in human chagasic submucosa and mucosa.

Chronic Chagas' disease is frequently characterized by massive myenteric neuron loss resulting in megacolon with severely and irreversibly disturbed motility. Here, we focused on two submucosal neuron populations, immunoreactive for calretinin (CALR) or somatostatin (SOM), and their respective mucosal nerve fibres in chagasic megacolon. Surgically removed megacolonic segments of seven chagasic patients were compared with seven age- and region-matched non-chagasic control segments. Evaluation included immunohistochemical triple-staining of cryosections for CALR, SOM and peripherin or for CALR and vasoactive intestinal peptide (VIP) and of submucosal whole-mounts for CALR, SOM and the pan-neuronal marker anti-HuC/D. Submucosal neuron counts in chagasic tissue revealed neuron numbers reduced to 51.2 % of control values. In cryosections, nerve fibre area measurements revealed 8.6 % nerve fibre per mucosal area in control segments, but this value decreased to 1.5 % in megacolonic segments. In both evaluations, a disproportionate decrease of SOM-reactive nerve elements was observed. The proportions of SOM-positive neurons related to the total neuron number declined to 2 % (control 10 %) and the proportion of SOM-reactive mucosal nerve fibres related to the whole mucosal area to 0.014 % (control 1.8 %)in chagasic tissue. The second set of cryosections revealed extensive colocalization of CALR with VIP in both surviving submucosal perikarya and mucosal nerve fibres. We suggest that VIP, a neuroprotective and neuroeffectory peptide typically contained in submucosal neurons, allows both the VIP-containing neurons to endure and the patients to survive by maintaining their mucosal barrier, despite the almost complete loss of colonic motility for decades.

Chronic Chagas disease with cardiodigestive involvement and the TcVI infective form of Trypanosoma cruzi. A case report.

We report a patient with megacolon associated with TcVI infective lineage form of Trypanosoma cruzi. Although this megacolon was considered idiopathic, Chagas disease was suspected and diagnosed because of the concomitant cardiovascular involvement. Based on this case, we discuss the suitability of Chagas diagnosis in patients with tract motility involvement.

[Radiological study on megacolon cases in an endemic area for Chagas disease]. / Estudo radiológico do megacólon em área endêmica de doença de Chagas.

INTRODUCTION: A radiological study on the colon of patients from an endemic Chagas disease zone was conducted using the simplified opaque enema technique of Ximenes et al. METHODS: The study involved 291 individuals with a mean age of 48.8 ± 12.5 years-old, of whom 222 were seropositive for Chagas disease. Anteroposterior, posteroanterior and left lateral view radiographs were analyzed by visual inspection and measurement of the largest rectal and sigmoid diameters. RESULTS: From the visual inspection, megacolon was diagnosed in 14 (6.3%) Chagas disease patients. The mean diameter of the rectal ampulla among the Chagas patients was 6.3 ± 1.0 cm, similar to the measurement in non-Chagas individuals: 6.2 ± 1.0 cm (p= 0.391). The mean sigmoid loop diameter in the Chagas patients was 5 ± 1.6 cm, which was larger than among the non-Chagas individuals: 4.4 ± 0.8 cm (p= 0.001). CONCLUSIONS: excluding the evident and probable megacolon cases, the Chagas disease population continued to present a significantly larger mean sigmoid diameter than that observed among non-Chagas individuals (p= 0.003).

Estudo radiológico do megacólon em área endêmica de doença de Chagas / Radiological study on megacolon cases in an endemic area for Chagas disease

INTRODUÇÃO: Foi realizado estudo radiológico do cólon em pacientes de zona endêmica da doença de Chagas usando-se a técnica do enema opaco simplificado de Ximenes e cols. MÉTODOS: Participaram 291 pacientes, com idade media de 48,8 (±12,5) anos, sendo 222 soropositivos para doença de Chagas. Fizeram radiografias na posição ântero-posterior, póstero-anterior e perfil lateral esquerdo, que foram analisadas por inspeção visual e medida do maior diâmetro em centímetros do reto e sigmoide. RESULTADOS: À inspeção visual, foi possível diagnosticar megacólon em 14 (6,3 por cento) pacientes chagásicos. A média do diâmetro da ampola retal dos chagásicos 6,3 (±1,0)cm foi semelhante a dos não-chagásicos 6,2 (±1,0)cm (p=0,391) e o diâmetro médio da alça sigmoide dos chagásicos 5 (±1,6)cm foi maior que o dos não chagásicos 4,4 (±0,8 )cm, (p=0,001). CONCLUSÕES: Excluindo-se os casos de megacólon evidente e de provável megacólon, a população chagásica continuou com o diâmetro médio do sigmoide significantemente maior (p=0,003) que a não chagásica.

INTRODUCTION: A radiological study on the colon of patients from an endemic Chagas disease zone was conducted using the simplified opaque enema technique of Ximenes et al. METHODS: The study involved 291 individuals with a mean age of 48.8(±12.5) years-old, of whom 222 were seropositive for Chagas disease. Anteroposterior, posteroanterior and left lateral view radiographs were analyzed by visual inspection and measurement of the largest rectal and sigmoid diameters. RESULTS: From the visual inspection, megacolon was diagnosed in 14 (6.3 percent) Chagas disease patients. The mean diameter of the rectal ampulla among the Chagas patients was 6.3 (±1.0)cm, similar to the measurement in non-Chagas individuals: 6.2 (±1.0) cm (p= 0.391). The mean sigmoid loop diameter in the Chagas patients was 5 (±1.6)cm, which was larger than among the non-Chagas individuals: 4.4 (±0.8)cm (p= 0.001). CONCLUSIONS: excluding the evident and probable megacolon cases, the Chagas disease population continued to present a significantly larger mean sigmoid diameter than that observed among non-Chagas individuals (p= 0.003).

Chagas' disease and ageing: the coexistence of other chronic diseases with Chagas' disease in elderly patients / Doença de Chagas e envelhecimento: a associação de outras enfermidades crônicas em pacientes idosos chagásicos

This study aimed to identify the main comorbidities in elderly chagasic patients treated in a reference service and identify possible associations between the clinical form of Chagas' disease and chronic diseases. Ninety patients aged 60 years-old or over were interviewed and their clinical diagnoses recorded. The study population profile was: women (55.6 percent); median age (67 years); married (51.1 percent); retired (73.3 percent); up to four years' education (64.4 percent); and earning less than two minimum wages (67.8 percent). The predominant forms of Chagas' disease were the cardiac (46.7 percent) and mixed forms (30 percent). There was a greater proportion of mild cardiac dysfunction (84.1 percent), frequently in association with megaesophagus. The mean number of concurrent diseases was 2.856 ± 1.845, and 33 percent of the patients had four or more comorbidities. The most frequent were systemic arterial hypertension (56.7 percent), osteoporosis (23.3 percent), osteoarthritis (21.2 percent) and dyslipidemia (20 percent). Positive correlations were verified between sex and comorbidities and between age group and comorbidities.

Este trabalho objetivou avaliar o perfil sociodemográfico e identificar as principais co-morbidades de idosos chagásicos, buscando associação entre forma clínica da doença de Chagas e enfermidades crônicas. Foi realizada entrevista e levantamento dos diagnósticos clínicos de 90 chagásicos com idade > 60 anos. Encontrou-se: mulheres (55,6 por cento), mediana de 67 anos, casados (51,1 por cento) e renda mensal inferior a dois salários-mínimos (67,8 por cento). A forma clínica predominante foi a cardíaca (46,7 por cento), seguida da mista (30 por cento). Houve maior proporção de cardiopatia leve (84,1 por cento), sendo frequente a associação com megaesôfago. Trinta e três por cento apresentavam quatro ou mais co-morbidades, dentre elas: hipertensão arterial (56,7 por cento), osteoporose (23,3 por cento), osteoartrite (21,2 por cento) e dislipidemia (20 por cento). Obteve-se correlação positiva entre gênero e co-morbidades, faixa etária e co-morbidades.

Chagas' disease and ageing: the coexistence of other chronic diseases with Chagas' disease in elderly patients.

This study aimed to identify the main comorbidities in elderly chagasic patients treated in a reference service and identify possible associations between the clinical form of Chagas' disease and chronic diseases. Ninety patients aged 60 years-old or over were interviewed and their clinical diagnoses recorded. The study population profile was: women (55.6%); median age (67 years); married (51.1%); retired (73.3%); up to four years' education (64.4%); and earning less than two minimum wages (67.8%). The predominant forms of Chagas' disease were the cardiac (46.7%) and mixed forms (30%). There was a greater proportion of mild cardiac dysfunction (84.1%), frequently in association with megaesophagus. The mean number of concurrent diseases was 2.856 +/- 1.845, and 33% of the patients had four or more comorbidities. The most frequent were systemic arterial hypertension (56.7%), osteoporosis (23.3%), osteoarthritis (21.2%) and dyslipidemia (20%). Positive correlations were verified between sex and comorbidities and between age group and comorbidities.

Colonic motility and functional assessment of the patients with anorectal malformations according to Krickenbeck consensus.

BACKGROUND/PURPOSE: In this study, the patients operated on for anorectal malformations (ARM) were evaluated in terms of segmental (SCTT) and total colonic transit times (TCTT) and clinical status according to Krickenbeck consensus before and after treatments. METHODS: Forty-one patients with ARM (28 males/13 females) older than 3 years (median age, 7.7 years; range, 3-25) who had no therapy before were assessed for voluntary bowel movements (VBM), soiling (from 1 to 3), and constipation (from 1 to 3), retrospectively. Distribution of the patients were rectourethral fistula (17), perineal fistula (PF; 8), vestibular fistula (VF; 8), cloaca (3), rectovesical fistula (1), rectovaginal fistula (1), pouch colon with colovestibular fistula (1), no fistula (1), and unknown (1). The patients ingested daily 20 radiopaque markers for 3 days, followed by a single abdominal x-ray on days 4 and 7 if needed. The results were compared with the reference values in the literature. RESULTS: Mean follow-up period was 36 months (range, 1-108.5 months). All patients but 1 had soiling in different degrees. Twenty-one patients who had VBM were divided into group 1, with constipation (n = 9), and group 2, without constipation (n = 12). The other 19 patients who had no VBM were divided into group 3, with constipation (n = 14), and group 4, without constipation (n = 5). The longest TCTT and rectosigmoid SCTT were found in group 3 (69.5 and 35.2 hours, respectively). Group 1 had long SCTT in rectosigmoid but normal TCTT (27.8 and 47.4 hours, respectively). Groups 2 and 4 had normal SCTT and TCTT, and there was no significant difference between them. After the appropriate treatment, of the patients, 45% (18/40) had no soiling, and the soiling score decreased to grade 1 in 27.5% (11/40) and to grade 2 in 10% (4/40). Four had unchanged soiling score, and 3 were excluded from the study because of follow-up problems. Half of the patients in group 3 (4 VF, 2 rectourethral fistula, PF) gained VBM without soiling after laxative treatment. Only four of 23 patients had decreased constipation score (2 cloaca, PF, VF). CONCLUSIONS: In this study, ARM patients complaining of constipation with or without VBM had prolonged SCTT in the rectosigmoid region. Percentage of the improvement in soiling scores was more conspicuous than that of constipation scores. The dismal figure observed at the first examination in the assessment of VBM was not associated with an unfavorable improvement with laxative treatment. So, it is suggested that assessment of VBM initially may be deceptive for clinical status.

Evidence of prolonged orocecal transit time and small intestinal bacterial overgrowth in acromegalic patients.

CONTEXT: Gastrointestinal abnormalities in acromegaly include dolichomegacolon, slow colonic transit, and increased prevalence of colonic polyps. Conversely, no data are available on the small intestine. OBJECTIVE: The aim of the study was to investigate the orocecal transit time (OCTT) and the presence of small intestinal bacterial overgrowth (SIBO). PATIENTS: A total of 41 acromegalic patients and 30 sex- and age-matched control subjects entered the study. Acromegalic patients were classified according to the medical treatment with somatostatin analogs as "treated" (n = 22) and "untreated" (n = 19), whereas according to the disease control, as "controlled" (n = 17), "uncontrolled" (n = 10), and "partially controlled" (n = 14). Patients and controls completed a questionnaire and underwent a standardized 10-g lactulose hydrogen breath test to determine the OCTT and presence of SIBO. SIBO-positive patients underwent eradication with rifaximine. RESULTS: An increased prevalence of SIBO (18 of 41 vs. 1 of 30; P < 0.0001) and a significantly delayed OCTT (169.53 +/- 8.15 vs. 107.25 +/- 6.56 min; P < 0.0001) were evidenced in patients compared with controls. No significant statistical differences were found between "treated" or "untreated" patients positive for SIBO or between "controlled," "partially controlled," and "uncontrolled" patients. OCTT was significantly delayed in "treated" vs. "untreated" patients (183.21 +/- 9.01 and 158.89 +/- 6.38, respectively; P = 0.02) and in patients compared with controls (105.75 +/- 6.34; P < 0.0001). Rifaximine eradicated SIBO in more than 50% of patients who underwent treatment. CONCLUSIONS: These data demonstrate for the first time that SIBO occurs more frequently in acromegalic patients, however, it can be successfully treated by a specific antibiotic. Medical therapy with somatostatin analogs does not affect SIBO prevalence. OCTT resulted significantly prolonged in both "treated" and "untreated" patients, suggesting that acromegaly determines per se an impairment of the intestinal motility. Indeed, disease control seems irrelevant on the delayed OCTT, suggesting that this alteration might be an irreversible complication of acromegaly, probably related to an autonomic intestinal disorder, as we have previously demonstrated at the cardiac level.

Systematic review of surgical options for idiopathic megarectum and megacolon.

OBJECTIVE: A subgroup of patients with intractable constipation has persistent dilatation of the bowel, which in the absence of an organic cause is termed idiopathic megabowel (IMB). The aim of this systematic review was to evaluate the published outcome data of surgical procedures for IMB in adults. METHODS: Electronic searches of the MEDLINE (PubMed) database, Cochrane Library, EMBase, and Science Citation Index were performed. Only peer-reviewed articles of surgery for IMB published in the English language were evaluated. Studies of all surgical procedures were included, providing they were performed on 3 or more patients, and overall success rates were documented. Studies were critically appraised in terms of design and methodology, inclusion criteria, success, mortality and morbidity rates, and functional outcomes. RESULTS: A total of 27 suitable studies were identified, all evidence was low quality obtained from case series, and there were no comparative studies. The studies involved small numbers of patients (median 12, range 3-50), without long-term follow-up (median 3 years, range 0.5-7). Inclusion of subjects, methods of data acquisition, and reporting of outcomes were extremely variable. Subtotal colectomy was successful in 71.1% (0%-100%) but was associated with significant morbidity related to bowel obstruction (14.5%, range 0%-29%). Segmental resection was successful in 48.4% (12.5%-100%), and recurrent symptoms were common (23.8%). Rectal procedures achieved a successful outcome in 71% to 87% of patients. Proctectomy, the Duhamel, and pull-through procedures were associated with significant mortality (3%-25%) and morbidity (6%-29%). Vertical reduction rectoplasty (VRR) offered promising short-term success (83%). Pelvic-floor procedures were associated with poor outcomes. A stoma provided a safe alternative but was only effective in 65% of cases. CONCLUSIONS: Outcome data of surgery for IMB must be interpreted with extreme caution due to limitations of included studies. Recommendations based on firm evidence cannot be given, although colectomy appears to be the optimum procedure in patients with a nondilated rectum, restorative proctocolectomy the most suitable in those with dilatation of the colon and rectum, and VRR in those patients with dilatation confined to the rectum. Appropriately designed studies are required to make valid comparisons of the different procedures available.