166
established by ultrasonography and plain radiography. All children were treated as outpatients apart from a girl aged 16 months with bilateral nephrolithiasis who was admitted for 4 days. A 10-year-old boy, with partial staghom stones and chronic hydronephrosis with a parenchymal thickness of 56 mm, was referred for operation after we failed to introduce a double-J catheter; we felt the stone mass was too large for ESWL without a double-J stent. In 1 patient with a ureteropelvic stone, a rest stone (stone bed) was visible on radiography after 3 sessions of ESWL. Since no hindrance of the passage was seen with intravenous pyelography after treatment and no obstruction remained, endoscopy was not done. In another case ureterorenoscopy was successful for a persistent stone street. 1 patient is still having treatment. 47 of 49 (96%) kidneys were stone free. With the use of small focus piezoelectric lithotripters multiple session ESWL treatment is possible without the risk of pulmonary haemorrhage and with a lower risk of perirenal haematoma. We therefore feel that ESWL in children is the method of choice for the treatment of urinary calculi. We thank Dr K. Erdogan of Haydarpasa Numune, Prof F. Vatandaslar and Dr Z. Mete for GATA, and Dr A. R . Kural of Cerrahpasa Medical Faculty for their collaboration.
MAHMUT TOLON HASLIP EROL JUTTA TOLON ENGIN BAZMANOGLU AYLA ERKAN SELIM AMATO
BIOSAN Outpatient Clinic, Buyükdere Cad 15a, Sisli, Istanbul, Turkey
Mininberg DT, Steckler R, Riehle J Jr. Extracorporeal shock wave lithotripsy for children. Am J Dis Child 1988; 142: 279-82. 2. Charbit L, Terdjman S, Gendreau MC, et al. Interet de le lithortiptie extra corporelle par ondes de choc pour le traitement de la lithiase urinaire de l’enfant. J Urol 1989; 1.
Anorectal
pressures and
electrical activities of
sphincter
complex.
95: 393-95.
Upper: conscious contraction of EAS Lower: rectal distention with 100 ml air. Anorectal pressures recorded at ports 05,1 0, 20, 25, and 45 cm from anal verge and in balloon 5-11 cm from anal margin (channels 1-6) ML=mixed supranuclear and low spinal lesion; DD=desire to
Occult spinal lesions: cause
a common
undetected
SIR,-Faecal incontinence is
a common complication of cerebrospinal disease. In 10 male and 12 female patients with well characterised cerebrospinal disease and faecal incontinence, we could identify on anorectal manometric/electrophysiological criteria lesions in the low spinal cord or supranuclear lesions causing
faecal incontinence: Crderion
Consciously contract external anal sphincter (EAS) criterion EAS responses EAS responses
defaecate; EMG=electromyogram.
of faecal incontinence
rectal distension to increases in intra-abdominal pressure Impaired rectal sensation to
18 female and 9 male
Low
spinal Supranuclear
Yes No
No Enhanced
No Yes
Enhanced Yes
of a total of 250 patients (aged 19-78) of for faecal incontinence had referred patients investigation abnormalities similar to those with cerebrospinal lesions. 5 had evidence of a supranuclear lesion--a combination of an impaired ability to consciously contract the EAS (fig, upper), enhanced reflex activity of the EAS in response to rectal distension (fig, lower), increases in intra-abdominal pressure, and blunted rectal sensation. 17 patients had features compatible with a low spinal lesion-absent or very attenuated EAS responses to rectal distension (fig, lower) and increases in intra-abdominal pressure combined with blunted rectal sensation, but they could contract the EAS voluntarily (fig, upper). 5 had a combination of impaired conscious and reflex contraction of the external anal sphincter, and blunted rectal sensation, suggesting a mixed supranuclear and low spinal lesion (fig). None of the women gave a history of prolonged labour or forceps delivery, none of the patients complained of prolonged straining at stool, and none had abnormal perineal descent. Difficulties in micturition were found in 15% of patients, all of whom had features of low spinal or mixed lesions. None of them gave any history of spinal disease and none had difficulties in out
walking. Clinical neurological examination and spinal radiography revealed no evidence of cerebrospinal disease. We suspect that occult spinal disease may be the causal lesion in about 10% of patients referred to us for investigation for faecal incontinence. Similar figures have been recorded for suspected spinal disease patients with disorders of urinary incontinence. The recognition of these patients is important: first, the anorectal features may be an early feature of progressive neurological disease; and second, patients with spinal disease are unlikely to respond to surgery but may benefit from training to coordinate external sphincter contraction with rectal sensation and improve sphincter strength. Sub-department of Gastrointestinal Physiology and Nutrition, Royal Hallamshire Hospital, Sheffield S10 2JF, UK
W. M. SUN N. W. READ
Relevance of cerebral vasomotor reactivity prospects for successful endarterectomy
to
SiR,—The value of carotid endarterectomy remains controversial.’,2 Suggested indications focus on patients with atherosclerotic plaques, who are therefore at risk of thromboembolic stroke, and on patients with haemodynamiailly significant carotid artery stenosis, who are at risk of cerebral ischaemia.3 In North America, four clinical trials are under way comparing endarterectomy with medical therapy in patients with symptomatic or symptom-free carotid stenosis. 3-5 The Extracranial-Intracranial (EC-IC) Bypass Study showed that bypass did not prevent stroke in patients with carotid occlusion However, it has been argued that patients with abnormal
established by ultrasonography and plain radiography. All children were treated as outpatients apart from a girl aged 16 months with bilateral nephrolithiasis who was admitted for 4 days. A 10-year-old boy, with partial staghom stones and chronic hydronephrosis with a parenchymal thickness of 56 mm, was referred for operation after we failed to introduce a double-J catheter; we felt the stone mass was too large for ESWL without a double-J stent. In 1 patient with a ureteropelvic stone, a rest stone (stone bed) was visible on radiography after 3 sessions of ESWL. Since no hindrance of the passage was seen with intravenous pyelography after treatment and no obstruction remained, endoscopy was not done. In another case ureterorenoscopy was successful for a persistent stone street. 1 patient is still having treatment. 47 of 49 (96%) kidneys were stone free. With the use of small focus piezoelectric lithotripters multiple session ESWL treatment is possible without the risk of pulmonary haemorrhage and with a lower risk of perirenal haematoma. We therefore feel that ESWL in children is the method of choice for the treatment of urinary calculi. We thank Dr K. Erdogan of Haydarpasa Numune, Prof F. Vatandaslar and Dr Z. Mete for GATA, and Dr A. R . Kural of Cerrahpasa Medical Faculty for their collaboration.
MAHMUT TOLON HASLIP EROL JUTTA TOLON ENGIN BAZMANOGLU AYLA ERKAN SELIM AMATO
BIOSAN Outpatient Clinic, Buyükdere Cad 15a, Sisli, Istanbul, Turkey
Mininberg DT, Steckler R, Riehle J Jr. Extracorporeal shock wave lithotripsy for children. Am J Dis Child 1988; 142: 279-82. 2. Charbit L, Terdjman S, Gendreau MC, et al. Interet de le lithortiptie extra corporelle par ondes de choc pour le traitement de la lithiase urinaire de l’enfant. J Urol 1989; 1.
Anorectal
pressures and
electrical activities of
sphincter
complex.
95: 393-95.
Upper: conscious contraction of EAS Lower: rectal distention with 100 ml air. Anorectal pressures recorded at ports 05,1 0, 20, 25, and 45 cm from anal verge and in balloon 5-11 cm from anal margin (channels 1-6) ML=mixed supranuclear and low spinal lesion; DD=desire to
Occult spinal lesions: cause
a common
undetected
SIR,-Faecal incontinence is
a common complication of cerebrospinal disease. In 10 male and 12 female patients with well characterised cerebrospinal disease and faecal incontinence, we could identify on anorectal manometric/electrophysiological criteria lesions in the low spinal cord or supranuclear lesions causing
faecal incontinence: Crderion
Consciously contract external anal sphincter (EAS) criterion EAS responses EAS responses
defaecate; EMG=electromyogram.
of faecal incontinence
rectal distension to increases in intra-abdominal pressure Impaired rectal sensation to
18 female and 9 male
Low
spinal Supranuclear
Yes No
No Enhanced
No Yes
Enhanced Yes
of a total of 250 patients (aged 19-78) of for faecal incontinence had referred patients investigation abnormalities similar to those with cerebrospinal lesions. 5 had evidence of a supranuclear lesion--a combination of an impaired ability to consciously contract the EAS (fig, upper), enhanced reflex activity of the EAS in response to rectal distension (fig, lower), increases in intra-abdominal pressure, and blunted rectal sensation. 17 patients had features compatible with a low spinal lesion-absent or very attenuated EAS responses to rectal distension (fig, lower) and increases in intra-abdominal pressure combined with blunted rectal sensation, but they could contract the EAS voluntarily (fig, upper). 5 had a combination of impaired conscious and reflex contraction of the external anal sphincter, and blunted rectal sensation, suggesting a mixed supranuclear and low spinal lesion (fig). None of the women gave a history of prolonged labour or forceps delivery, none of the patients complained of prolonged straining at stool, and none had abnormal perineal descent. Difficulties in micturition were found in 15% of patients, all of whom had features of low spinal or mixed lesions. None of them gave any history of spinal disease and none had difficulties in out
walking. Clinical neurological examination and spinal radiography revealed no evidence of cerebrospinal disease. We suspect that occult spinal disease may be the causal lesion in about 10% of patients referred to us for investigation for faecal incontinence. Similar figures have been recorded for suspected spinal disease patients with disorders of urinary incontinence. The recognition of these patients is important: first, the anorectal features may be an early feature of progressive neurological disease; and second, patients with spinal disease are unlikely to respond to surgery but may benefit from training to coordinate external sphincter contraction with rectal sensation and improve sphincter strength. Sub-department of Gastrointestinal Physiology and Nutrition, Royal Hallamshire Hospital, Sheffield S10 2JF, UK
W. M. SUN N. W. READ
Relevance of cerebral vasomotor reactivity prospects for successful endarterectomy
to
SiR,—The value of carotid endarterectomy remains controversial.’,2 Suggested indications focus on patients with atherosclerotic plaques, who are therefore at risk of thromboembolic stroke, and on patients with haemodynamiailly significant carotid artery stenosis, who are at risk of cerebral ischaemia.3 In North America, four clinical trials are under way comparing endarterectomy with medical therapy in patients with symptomatic or symptom-free carotid stenosis. 3-5 The Extracranial-Intracranial (EC-IC) Bypass Study showed that bypass did not prevent stroke in patients with carotid occlusion However, it has been argued that patients with abnormal
