Is high amplitude propagated contraction present after transanal endorectal pull-through for Hirschsprung's disease?

The transanal endorectal pull-through (TAEPT) procedure is now widely performed for Hirschsprung's disease (HD), however, the colorectal function after TAEPT has not yet been adequately assessed. We evaluated the postoperative clinical outcome and colorectal function based on lower colonic manometry after TAEPT. Twenty-one cases of HD underwent TAEPT from 1998 to 2005. We examined the clinical outcome based on the requirement of enemas/suppositories, the number of defecations per day, the severity of perianal erosion, and the incidence of enterocolitis requiring hospital stay. Using a three-channel Dentsleeve catheter and UPS-2020 measuring device, we performed postoperative colonic manometry at three locations: (1) the anal canal, (2) 5 cm proximal to the anal canal, and (3) 10 cm proximal to the anal canal, during defecation, and then we measured the appearance of high-amplitude contraction (HAC) (duration >/=10 s, amplitude >/=100 cmH(2)O). Four of 21 cases were treated with enemas/suppositories no longer than 1 year. The number of defecations decreased gradually from 4 to 5 per day in the early postoperative period, reaching 2 to 3 per day about 1 year postoperatively. Perianal erosion was noted in 3 of 21 cases but it disappeared within three postoperative years. Two cases had enterocolitis. Lower colon manometry was performed in eight cases. Manometry during defecation was successfully monitored in six cases. HAC occurred in five of six cases (83.3%). The clinical outcomes after TAEPT were satisfactory in almost all cases. These good outcomes were possibly due to the occurrence of HAC during defecation, though HAC did not fill the definition of high amplitude propagated contractions (HAPCs). The occurrence of HAC after TAEPT might be caused by keeping any damage to the mesenteric ascending cholinergic nerve to a minimum during surgery. Further long-term observations are still required to make an adequate assessment of such cases.

Postoperative neuroleptic malignant syndrome that occurred repeatedly in a patient with cerebral palsy.

A wide variety of neuroleptic agents are associated with neuroleptic malignant syndrome (NMS). However, the association between general anesthesia and NMS is uncertain. We report a case of a patient with cerebral palsy, who showed signs of NMS only after repeated general anesthesia. The patient received general anesthesia three times in a period of 9 months. The first anesthetic passed uneventfully. NMS symptoms were observed only after the second and third anesthetics. The NMS was effectively treated with IV dantrolene and the patient recovered on both occasions. Inhalational anesthetics, muscle relaxants and fentanyl were suspected as possible triggering factors for NMS. After examining the three anesthesia records and previous publications, we surmized that a nondepolarizing muscle relaxant was associated with NMS in this patient.

A case report of anesthetic management of the minimally invasive Nuss operation for pectus excavatum.

We describe the anesthetic management of a patient with pectus excavatum, receiving the minimally invasive Nuss operation, which corrects chest wall deformity by insertion of a convex steel bar (pectus bar). An 8-year-old female patient was scheduled for the Nuss operation. The manipulation of the bar in the thorax was guided by thoracic endoscopy. Anesthesia was maintained with a combination of general and epidural anesthesia. The intraarterial catheter and epidural catheter were inserted after the induction of general anesthesia. During the manipulation of the pectus bar in the anterior mediastinum, a sudden decrease in arterial pressure might occur due to the compression of the heart. Therefore, the intraarterial line was essential for continuous monitoring of arterial pressure. The pectus bar causes severe postoperative pain, and the patient was required to remain at bed rest for several days. Continuous epidural infusion of ropivacaine and morphine eliminated the postoperative pain and enabled the patient to maintain bed rest. For the anesthetic managements of patients undergoing the Nuss operation, close monitoring of arterial pressure intraoperatively and postoperative analgesia are important.