Administración de Sistemas
DINAMICA: LECTURA REFLEXIVA LA SOPA DE PIEDRA.
There were eleven patients with anorectal malformation (see illustration in figure 3). Ten (90.9%) patients were male and one (9.1%) was a female. Their ages ranged between 12hours and 1 month at presentation. The mean age was 5.23days. Table 8 shows that 7 (63.7%) male patients had ARM with recto-urethral fistula, while 3(27.2%) male patients had covered anus with associated anocutaneous fistula, which were stenosed. The single female had absent anus with rectovestibular fistula. A male (10%) had associated coronal hypospadias and choanal atresia while another one had a left sacral hemi-vertebral. All patients had invertogram done which showed four (36.4%) patients with radiological characteristic of high ARM and were given temporary transverse loop colostomy. Four (36.4%) male patients had single stage posterior sagittal anorectoplasty (1-PSARP) without colostomy as shown in figure 4.
Three patients (27.3%) with stenosed anocutaneous fistula had cutback anoplasty.
Two (18.2%) patients had post-operative superficial wound dehiscence, 1(9.1%) patient had wound infection, while 2(18.2%) died from postoperative apnea and electrolyte imbalance. These were the patients with associated congenital anomalies (hypospadias, choanal atresia, sacral agenesis).
Figure 3: Anorectal malformation in a male child
Figure 4: Anal vent in one stage posterior sagittal anorectoplasty
Imperforate anus
Posterior sagittal wound
Syringe vent
Table 8: Summary of anorectal malformation(ARM)
Case no
Age Sex DOS DOA features Type Treatment Outcome Complication
1 38hrs M 38hrs 14 Anorectal
RUF
Interned iate
1-PSARP Alive Wound dehiscence
2 5/7 M 5/7 18 Anorectal
RUF
Inter-mediate
1-PSARP Alive Nil
3 3/7 M 3/7 7 Anorectal
RUF
High Colostomy Alive Nil
4 3/7 M 3/7 3 Anal
stenosis,co vered anus
Low Anoplasty Alive Nil
5 24hrs M 24hrs 13 ARM+RUF,
jaundice
High Colostomy Alive Nil
6 4/7 M 4/7 10 ARM+RUF
Inter-mediate
1-PSARP Alive Wound infection 7 ***30/7h
rs
M 28hrs 15 Anal
stenosis,co vered anus
Low Anoplasty Alive Nil
8 57hrs M 57hrs 4 Covered
anus
Low Anoplasty Alive Nil
9 4/7 F 4/7 12 RVF Interned
iate
1-PSARP Alive Wound dehiscence
10 12hrs M 12hrs 1 ARM,Hypo
spadias,ch oanal atresia
High Colostomy Died Apnea
11 39hrs M 39hrs 5 ARM,RUF
Sacral agenesis
Gangreno us bowel High
Colostomy Died Electrolyte imbalance, Necrotizing fascitis
Keys: 1 – PSARP = One stage posterior sagittal Anorectoplasty RUF = rectourethral fistula
DOS= duration of symptoms DOA= duration of admission RVF= recto vestibular fistula
Intussusception (IT)
There were 15 patients with intussusception (see figure 5). This constituted the highest cause of intestinal obstruction in the study.
There were 9 males and 6 females with a M:F of 1.5:1. The ages ranged from 2 months to 12 years with a median age of 5 months.
The mean duration of symptoms before presentation was 5.6 days with 6 (40%) of the patients presenting by 3 days. All the patients presented with abdominal pain and vomiting. Six (40%) patients presented with red currant jelly stool. A patient each had hematochexia and protrusion of intussusceptum through the anus.
Table 9 shows that 2 (13.3%) of the patients (cases 9 and 11) had pathological lead points. Eleven (73.3%) of IT were ileocolic, 2 (13.3%) were caecocolic, and 1 (6.6%) each was ileocaecal and colocolic. Four (26.6%) had bowel gangrene at laparotomy and right hemicolectomy was done in these cases. One (6.6%) patient with transverse colo-colic IT had lead point resected and a defunctioned colostomy constructed. Lead point histology confirmed a non- Hodgkins lymphoma. Five patients had complications giving a complication rate of 33%, with a case each of wound infection, prolonged ileus of more than 5 days, septicaemia, enterocutaneous fistula and postoperative seizure and hyperthermia. Three patients died accounting for a mortality rate of 20%.
Table 9: Pattern and management of intussusception
Case no
Age (month)
Sex DOS (days)
DOA (days)
Clinical features
Investigation s
Operation finding
Treatment Outcome Complication
1 12 F 3 4 Red currant
stool
USS+ve Ileo-cecal Reduction Died Post operative Convulsion, Hypertherm ia
2 4 M 5 16 Abdominal
distension
USS+ve, Hypokalae mia
Ileo-colic,Gangre nous bowel
Right Hemicolect omy
Alive Nil
3 3 F 7 12 Abdominal
distension
USS+ve, Hypokalae mia
Ileo-colic,Bowel perforation
“ Alive Wound
infection
4 8 M 7 8 Anal
protrusion
USS—ve ileocolic Reduction Alive Nil
5 5 M 4 8 “ “ “ “ “ “
6 5 M 3 30hrs Red currant
stool
No USS “ Reduction died “
7 4 F 3 8 Anemia, red
currant stool
USS +ve. “ Reduction alive “
8 4 M 5 21 “ USS,
hypokalae mia
“ “ “ Prolong
ileus, bronchopne umonia
9 36 M 14 10 Diarrhea,
hematochexi a
USS +ve Colocolic, non- Hodgkins
Resection +
colostomy
Alive nil
10 12 M 3 8 Diarrhea USS +ve,
hypokalae mia
Ileocolic, gangrenous bowel
Right hemicolect omy
Alive nil
11 144 M 14 21 Bilious
vomiting
USS +ve Ileocolic, abdominal Tuberculosis
Reduction + anti-Kochs
alive nil
12 5 M 6 8 Red currant
stool
USS +ve cecocolic reduction alive “
13 5 F 3 8 USS +ve ileocolic “ “
14 12 F 3 3 Red currant
stool
USS +ve “ “ died Septicemia,
renal failure
15 2 F 4 22 Vomiting
excessive cry
USS +ve, Cecocolic, gangrenous cecum
Right hemicolecto my
alive Enterocuta neous fistula
DOS-duration of symptoms, DOA- duration of admission
Fig. 5 : Ileocolic Intussusception brought out of laparotomy incision
intussusception
Table 10: Summary of other mechanical intestinal obstruction(MIOB)
Case no
Age Sex DOS DOA Features Investigatio n
Diagnosis Treatment Outcome complication
1 1mth M 1day 4days Right
scrotal swelling
PCV Obstructed
RISH, non-viable testis
Herniotomy Alive nil
2 6yrs M 1day 8day “ “ Strangulated
small bowel
Herniotomy + resection and
anastomosis
“ Wound
infection
3 18day
s
M 4hrs 5days Right Groin swelling
Strangulated right testis
Herniotomy “ Nil
4 1yr M 3days 8 days Left. Groin swelling
Obstructed LISH
Herniotomy Alive “
5 4yrs M 9hrs Umbilical
swelling
Incarcerated small bowel
Mayo’s repair
“ “
6 2
days
F 36hrs 20day s
Bilious vomiting, HIV +ve
USS, AbdXR, barium meal
Jejunal atresia type I
Laparotomy +gastrojejun ostomy
“ Prolong ileus wound infection
7 3
days
M 3days 18 days
Bilious vomiting
AbdxR, USS
Ileal atresia type IV
Laparotomy + resection + anastomosis
Alive nil
8 7
days
M 7 days 2 days “ “ “ “ Died Respiratory
failure
9 1 day M 14hrs 25
days
“ “ Ileal atresia
type IIIA
“ Alive Wound
infection
10 11
days
M 10
days 12 days
Bilous vomiting
USS, abdxR
Jejunal mesenteric cyst
Laparotomy +resection + anastomosis
“ Wound
infection 11 2yrs F 3 days 13
days
“ “ Multiple
jejunal mesenteric cysts
“ “ nil
12 2mth M 2days 13day
s
“ “ Midgut
volvulus,Gan grenous bowel
“ Died Anastomotic
leak
13 2mth M 1 day 9days “ “ Malrotation Laparotomy
+ Ladd
procedure
Alive Prolonged ileus
14 12yrs M 6hr 2week
s
Previous lap. Abd.
Pain, vomiting
AbdxR Post
operative Adhesive band
Laparotomy +
adhesiolysis
“ nil
15 3yrs F 3days 8days “ “ “ “ Alive “
16 3yrs M 2days 12
days
“ “ “ “
“
17 5mth M 14days Constipatio
n, abd.
distention
Abd. XR, rectal biopsy
Hirschsprun g’s disease
Colostomy “ “
18 1.5yrs M
Marasmic-kwarsiokor,
constipation “ “ “ Alive
Burst abdomen
DOS- duration of symptoms DOA- duration of admission,
RISH-:Right inguinoscrotal hernia. USS : Ultrasound.
Abd.xR- Abdominal X- Rays
Table 11:
Morbidity and mortality pattern among the causal factors of PSAE Causal factors No of
patients
Morbidity rate
duration of hospital stay (days)
Median duration of hospital stay
Case fatality
Simple appendicitis
8 (0%) 3-8 4days 0
Complicated appendicitis
7 2(28.6%) 5-14 9days 0
Typhoid perforation
22 10(42%) 5-35 12days 2(9.1%)
Intussusception 15 5 (33.3%) 1-22 11days 3(20%)
Abdominal trauma
7 2(28.6%) 2-17 9.5days 2(28.6%)
Anorectal malformation
11 4(36.4%) 1-23 10days 2(18.2%)
Intestinal atresia
4 3 2-25 16.5days 1(25%)
Midgut volvulus 1 - 13 1(100%)
Post-operative adhesion
3 0- 8- 14 12 days 0
Table 11 shows the morbidity and mortality pattern among the various causal factors of PSAE. The overall median hospital stay is 10days. Eighty-nine (89%) patients were discharged home, while 11(11%) died.
The mortality was significantly affected by a younger age of patients (p= 0.016) and presence of guarding (p= 0.008) signifying peritonitis. There were 4(4%) patients out of those discharged who
were awaiting definitive procedures. These were the patients on colostomy. All patients were followed up for a minimum of 3 months