The authors have used sophisticated mathematics and a sophisticated model to prove whatmany of us have suspected all along. Because the resolution rate is only about 17% annually forlow volume reflux and only 4% to 5% annually for higher volume reflux, spacing out VCUGs savesthe child the trauma of the study, with only a modest increase in exposure to antibiotics.

Douglas A. Canning, M.D.

Cecal Volvulus: A Report of Two Cases Occurring After the Antegrade Colonic Enema Procedure

E. R. KOKOSKA, C. D. HERNDON, D. E. CARNEY, M. LERNER, J. L. GROSFELD, R. C. RINK AND K. W. WEST, Sectionsof Pediatric Surgery and Pediatric Urology, J.W. Riley Hospital for Children, Indianapolis, Indiana

J Pediatr Surg, 39: 916–919, 2004

Permission to Publish Abstract Not Granted

Editorial Comment: The authors add to the literature 2 cases of cecal volvulus followingcreation of an antegrade colonic enema (ACE). The first child presented with abdominal painand difficulty intubating the site. Gradually, with observation, the pain worsened and at lapa-rotomy a cecal volvulus with associated bowel necrosis was observed. Resection of the affectedbowel and appendix was required. Subsequently, a new ACE procedure was performed with acolonic flap. The second child presented with shock and an acute abdomen. In this case thesurgeons resected the damaged intestine including the ACE stoma, and performed an ileostomyand Hartmann pouch. In both cases the bowel rotated around the ACE site.

A previous report by Griffiths and Malone, cited by the authors, demonstrated 3 of 21 childrenrequiring laparotomy for obstruction or cecal torsion.1 Van Savage and Yohannes reported 1case among 16 with colonic volvulus requiring segmental resection.2 Although cecal fixationshould logically decrease the risk of volvulus, both patients in this report had cecal fixation.

This review and the other 2 studies remind us that patients who have undergone ACEprocedures are at risk for cecal volvulus and should be followed carefully. Those presentingwith abdominal pain should be watched with particular vigilance to identify volvulus if present.

Douglas A. Canning, M.D.1. Griffiths, D. M. and Malone, P. S.: The Malone antegrade continence enema. J Pediatr Surg, 30: 68, 19952. Van Savage, J. P. and Yohannes, P.: Laparoscopic antegrade continence enema in situ appendix proce-

dure for refractory constipation and overflow fecal incontinence in children with spina bifida. J Urol,164: 1084, 2000

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