Surgical treatment of gastroesophageal reflux in children: a combined hospital study of 7467 patients

OBJECTIVE

To review retrospectively the combined clinical experience with the surgical treatment of persistently symptomatic gastroesophageal reflux (SGER) in childhood from seven large children's surgery centers in the United States.

DESIGN

During the past 20 years, 7467 children <18 years of age underwent antireflux operations for SGER at the seven participating hospitals. Fifty-six percent were neurologically normal (NN) and 44% were neurologically impaired (NI). The most frequent diagnostic studies were upper gastrointestinal series (68%), esophageal pH monitoring (54%), gastric emptying study (32%), and esophagoscopy (25%). The age at operation was under 12 months in 40% and 1 to 10 years in 48%. The type of fundoplication was Nissen (64%), Thal (34%), and Toupet (1.5%). A gastric emptying procedure was performed on 11.5% of NN patients and 40% of NI patients. Laparoscopic fundoplication was performed on 2.6% of patients.

RESULTS

Good to excellent results were achieved in 95% of NN and 84.6% of NI patients. Major complications occurred in 4.2% of NN and 12.8% of NI patients. The most frequent complications were recurrent reflux attributable to wrap disruption (7.1%), respiratory (4.4%), gas bloat (3.6%), and intestinal obstruction (2.6%). Postoperative death occurred in 0.07% of NN and 0.8% of NI patients. Reoperation was performed in 3.6% of NN and 11.8% of NI patients. The results and complications were similar among the participating hospitals and did not seem related to the type of fundoplication used.

CONCLUSION

The excellent results (94% cure) and low morbidity with gastroesophageal fundoplication with or without a gastric emptying procedure from a large combined hospital study indicate that operation should be used early for SGER in NN children and to facilitate enteral feedings and care in NI children.

Operative management of asphyxiating thoracic dystrophy after pectus repair

Pectus excavatum repair usually results in unchanged or improved pulmonary function. However, a small subset of patients will experience severely impaired pulmonary function after pectus repair caused by restrictive lung disease, and no adequate surgical approach has been described for this condition. A procedure is described that is a variation of an operation for Jeune's thoracic dystrophy, that resulted in marked respiratory improvement in this setting. A 14-year-old boy had undergone standard pectus excavatum repair at age 4, from which he recovered uneventfully. Beginning at age 10 to 12 years progressive restrictive pulmonary disease, recurrent pneumonia, and cor pulmonale developed, which resulted in almost constant shortness of breath and the need for continuous nasal positive pressure support. Pulmonary function test results were markedly abnormal and worsening. He underwent an operative procedure consisting of sternal split that was wedged open permanently with rib struts, opening of pleura bilaterally, and six rib resections bilaterally. His postoperative recovery was satisfactory, and his pulmonary functions have shown steady improvement. He is now completely off oxygen and pressure support, has improved exercise tolerance, and has returned to school. Severe restrictive lung disease after pectus repair can be successfully managed with aggressive operative procedures. Patients should have close follow-up after pectus repair for the development of this potentially debilitating disorder to allow earlier repair.

Early hypotension worsens neurological outcome in pediatric patients with moderately severe head trauma

PURPOSE

The objective of this study was to determine the morbidity associated with hypotension in the resuscitative phase of pediatric head trauma.

METHODS

A retrospective review (1990 to 1995) was performed at a level-1 pediatric trauma facility. Inclusion criteria included a Glasgow coma score (GCS) of 6 to 8 and absence of penetrating trauma or bleeding disorders. The GCS was assigned using a postresuscitation examination by a neurosurgeon. Hypotension was defined as a blood pressure reading of less than the fifth percentile for age that lasted longer than 5 minutes. Episodes were monitored from the onset of injury through the first 24 hours of hospitalization. Glasgow outcome scale (GOS) was assigned based on a 3-month follow-up evaluation. Analysis of variance (ANOVA) and contingency table analysis were performed on all groups, and a P value of less than .05 was taken to represent statistical significance.

RESULTS

Seventy-two patients met inclusion criteria. They had a mean GCS of 7.2 and a mean age of 6 years; 97% survived. Early hypotension was associated with worse neurological outcome (GOS) and prolonged hospitalization. There was no significant correlation between GOS and age, gender, injury mechanism, associated injuries, or transport time.

CONCLUSIONS

These data suggest that maintaining adequate blood pressure during the early resuscitation of pediatric blunt head trauma patients may improve neurological outcome.

Blunt intestinal injury in children. Diagnostic and therapeutic considerations

OBJECTIVES

To identify computed tomographic (CT) findings in children who have experienced blunt trauma and who have known intestinal injuries and to correlate these findings with the findings of the initial physical examination.

DESIGN

A retrospective review of children (aged < 18 years) known to have an intestinal injury as a consequence of blunt trauma.

SETTING

A university-affiliated children's hospital with a level 1 pediatric trauma center.

PATIENTS

Children younger than 18 years who were admitted for examination of injuries or for management of complications related to intestinal injuries.

INTERVENTIONS

Clinical and radiographic evaluation and laparotomy for intestinal injuries other than duodenal hematoma.

MAIN OUTCOME MEASURES

The identification and correlation of relevant findings during the physical examination, on the CT scan, and during surgery. The assessment of intervals from injury to diagnosis and intervention and the description of associated injuries.

RESULTS

Twenty-two patients sustained intestinal injuries as a result of blunt trauma. Most (15) of the patients were passengers injured in motor vehicle crashes; 14 of these patients were wearing seat belts. Focal blows to the abdomen from bicycle handlebars, hockey sticks, or falls onto blunt objects were implicated in the remaining patients. For 19 of the 22 patients, the initial physical examination was conducted at Cardinal Glennon Children's Hospital, St Louis, Mo, and 18 of the 19 patients underwent a concurrent CT evaluation. Peritonitis was found in 5 of these 18 patients. Tenderness on physical examination was noted in 9 of the 18 patients (tenderness was not noted in 3 patients, and 1 patient had unreliable examination findings due to a cervical spinal cord injury). Computed tomographic findings of pneumoperitoneum and extravasation of enteral contrast material were uncommon but diagnostic (in 5 patients). Free fluid in the pelvis in the absence of a solid organ injury, bowel wall thickening, and fluid-filled loops of bowel were more frequently useful signs of possible intestinal injury (in 9 of the 18 patients) and led to earlier exploration when used in conjunction with physical examination as an indication for surgery. Most injuries were treated with segmental resection or suture repair, but enterostomies were required in 2 patients. Complications (i.e., the need for enterostomy and fascial dehiscence) were seen as a result of late or missed diagnosis, which could occur as late as 4 to 6 weeks after injury as intestinal obstruction due to stricture.

CONCLUSIONS

The initial physical examination findings and CT evaluation can independently identify the presence of intestinal injury in approximately 25% of cases. In the remainder of cases, the awareness of the more subtle findings of bowel injury on a CT scan can complement the physical examination findings and potentially lead to a more timely intervention for bowel injury.

Stability and compatibility of anakinra with ceftriaxone sodium injection in 0.9% sodium chloride or 5% dextrose injection

The stability and compatibility of anakinra (recombinant human interleukin-1 receptor antagonist) with ceftriaxone sodium in 0.9% sodium chloride or 5% dextrose injection was determined during a 4-h period at ambient room temperature and light. Anakinra was diluted in 0.9% sodium chloride or 5% dextrose to the concentrations of 4 and 36 mg/ml. Anakinra, at each concentration was mixed with ceftriaxone sodium (20 mg/ml) in a 50:50 proportion and stored in plastic culture vials with polypropylene caps. The samples were collected at 0, 2 and 4 h after mixing. Anakinra and ceftriaxone concentrations were measured using stability-indicating HPLC methods. In 0.9% sodium chloride injection, the mean concentrations of anakinra and ceftriaxone exceeded 98% of initial concentrations at the end of the study period. In 5% dextrose, however, anakinra concentrations were below 90% of the expected initial concentration at the time of first analysis (within 0.5 h). Thus, anakinra appears to be stable and compatible with ceftriaxone sodium when diluted in 0.9% sodium chloride injection, but not in 5% dextrose injection over 4 h at ambient room temperature and light.

The influence of acculturation on attitudes toward alcohol and alcohol use within the Punjabi community: an exploratory analysis

A number of authors have found that acculturation and alcohol use are significantly related. In general, as a person becomes more acculturated within a new country, levels of use of alcohol and alcohol-related problems tend to become more similar to the host cultures. The purpose of this paper is to examine the relationship between the level of acculturation, attitudes toward alcohol, and the use of alcohol within the Punjabi community of Metropolitan Toronto, while taking a number of demographic variables into account. We found that increased levels of acculturation were associated with increased lifetime use of alcohol and more liberal attitudes toward the use of alcohol. In addition, those who had lower levels of acculturation were experiencing relatively more alcohol use-related problems. Finally, gender was also an important factor in predicting attitudes and behavior associated with alcohol, with women more likely to be abstainers and negative toward the use of alcohol.

The effects of venous occlusion on cerebral blood flow characteristics during ECMO

Extracorporeal membrane oxygenation (ECMO) in the newborn usually requires occlusion of a jugular vein, and frequently a carotid artery. The acute effects of jugular vein occlusion on cerebral blood flow characteristics have received little investigation. Six newborns (age range, 0 to 5 days; weight, 2.4 to 3.1 kg) were treated with venoarterial ECMO, with additional placement of a cephalic venous catheter, for meconium aspiration (4) or persistent fetal circulation (2). Doppler duplex ultrasound evaluation of blood flow velocity and resistive index (RI) in the right (RMCA) and left (LMCA) middle cerebral arteries was performed just before ECMO, immediately after ECMO onset, and at 8,24, and 48 hours of ECMO. Arterial Po2 was maintained at 80 to 120 mm Hg. Pco2 at 35 to 45 mm Hg. and mean arterial pressure at 50 to 60 mm Hg. Flow velocity was measured with the cephalic venous catheter both open and closed. Closure of the cephalic venous cannula resulted in an abrupt, significant reduction in RMCA flow velocity and a significant increase in RI at the onset of ECMO and at 8 hours of ECMO. Opening the cannula restored the velocity and RI to normal. LMCA velocity and RI did not change with closure of the cephalic venous cannula. All infants survived ECMO, and five of the six are normal neurologically at 1 year of age. These data show that right carotid ligation alone did not change cerebral arterial blood flow velocity, but the addition of venous occlusion significantly decreased RMCA flow velocity, which was alleviated by cephalic venous drainage. After 24 hours of ECMO, this effect disappeared. This suggests that cephalic venous drainage may help prevent the neurological complications of ECMO by maintaining normal cerebral blood flow.

Critical analysis of the operative treatment of Hirschsprung's disease

OBJECTIVE

To critically analyze complications and long-term results of the operative treatment of Hirschsprung's disease.

DESIGN

Medical records of patients with Hirschsprung's disease were reviewed retrospectively. Follow-up was obtained using a standardized telephone questionnaire.

SETTING

Major pediatric referral center.

PATIENTS

Eighty-two infants and children (68 boys, 14 girls) were treated for Hirschsprung's disease during a 20-year period (1975 to 1994). The age at diagnosis was younger than 30 days in 47 neonates (57%), 30 days to 1 year in 22 infants (27%), and older than 1 year in 13 children (16%). Aganglionosis was limited to the rectosigmoid region in 66 patients (81%). Fifty-five Soave (endorectal) and 27 Duhamel (retrorectal) primary pull-through operations were performed.

MAIN OUTCOME MEASURES

Postoperative complications, reoperations, hospitalization, and current bowel habits.

RESULTS

Eighteen children (67%) undergoing the Duhamel operation recovered uneventfully compared with 33 children (60%) undergoing the Soave operation. The complications following the Duhamel operation included enterocolitis in five cases (19%), rectal achalasia in four cases (15%), and persistent rectal septum in two cases (7%). Additional operations, which included myomectomy, rectal septum division, diverting enterostomy, and sphincterotomy, were required in seven patients (26%). Only one patient required more than one reoperation. In contrast, complications following the Soave operation included enterocolitis in 15 cases (27%), rectal stenosis in 12 (22%), anastomotic leak in four (7%), late perirectal fistula in three (5%), rectal prolapse in one (2%), and recurrent severe constipation in one (2%). Sixteen patients (29%) required additional operations, including diverting enterostomy, myomectomy, redo pull-through, sphincterotomy, fistulectomy, and revision of rectal prolapse. In this group nearly two reoperative procedures per patient were required. Telephone follow-up (mean, 89.3 months) after pull-through operations in 61 patients (74%) showed a mean of 2.8 stools per day, with 13 patients (21%) requiring daily medications.

CONCLUSIONS

The most common operations (Soave and Duhamel) for Hirschsprung's disease result in an uneventful recovery in only 60% to 67% of patients. Although both Soave and Duhamel pull-through operations have nearly identical reoperation rates (26% vs 29%), complications after Soave pull-through operations often require multiple, more extensive procedures. Short-term total continence rates for both procedures are less than 50%, however, 100% became continent by 15 years after the pull-through procedure. Further refinement in operative technique and close follow-up are warranted.

Early improvement in intestinal function after isoperistaltic bowel lengthening

Isoperistaltic bowel lengthening (the Bianchi procedure) has been used increasingly in the management of infants and children with short bowel syndrome. Although clinical improvement is observed frequently, few studies document the early effects of the Bianchi procedure on nutrient absorption and transit time. Five infants and children (aged 3 months to 4 years) with profound short bowel syndrome (< 50 cm of small bowel) underwent isoperistaltic bowel lengthening (10 to 40 cm) when their bowel was greater than 3 cm in diameter. One to 2 weeks preoperatively, the following were obtained for each patient: 24-hour stool counts, transit time (charcoal), intestinal clearance of barium, and nutrient absorption (fat balance and D-xylose). The studies were repeated 1 and 6 months postoperatively. The mean stool count per 24 hours decreased from eight preoperatively to four and three at 1 and 6 months postoperatively. Transit time increased from 52 minutes to 135 and 205 minutes, and clearance of barium improved from 4.5 hours to 2.4 and 2.6 hours, respectively. Results of D-xylose absorption and dietary fat balance studies, both abnormal preoperatively, also normalized at 1 and 6 months. These data show that the Bianchi procedure provides short- and intermediate-term improvement in intestinal and nutrient absorption, which should allow more rapid weaning from parenteral nutrition.

Management of thoracic duct injury associated with fracture-dislocation of the spine following blunt trauma

Thoracic duct injuries accompanying blunt thoracic trauma are rare. A significant number of these lesions, however, are associated with fracture-dislocation of the spine. In this report, we discuss the surgical management of chylothorax in this setting.

A prospective analysis of factors influencing outcome after fundoplication

Fundoplication remains a common operation in the brain-damaged pediatric patient, but recent reports suggest a poor outcome in these patients. The factors that might be associated with complications or recurrence after fundoplication have not been extensively examined. Fifty-six brain-damaged children, aged 6 months to 12 years, with documented gastroesophageal (GE) reflux underwent preoperative nutritional evaluations (percentage of ideal weight, albumin, nutrition risk index [NRI]) and documentation of medications (dexamethasone for bronchopulmonary dysplasia) before standard Nissen fundoplication. Hospital stay, intensive care unit (ICU) stay, and time on ventilator, as well as major postoperative complications (wound infection/dehiscence, pneumonia) were prospectively analyzed. Survival and recurrence rates 1 to 3 years postoperatively were also assessed. Eighty-two percent of patients were < 90% ideal weight, and 50% had NRI < 90 (normal = 100) and 29% had albumin < 3.5 g/dL. Albumin < 3.5 was significantly (P < .01) associated with prolonged hospitalization (26.8 + 2.2 versus 15.1 + 1.1 days) and ICU stay (13.8 + 1.0 versus 4.4 + .5 days) and time on ventilator (8.0 + 1.0 versus 1.8 + .4 days). NRI < 90 showed similar significant differences (P < .01). Ideal body weight < 90% was not significant. Major complications developed in 54% of patients; only two or more preoperative nutritional deficiencies, or a nutritional deficiency plus dexamethasone were significantly associated (P < .01). Recurrence occurred in 21% of patients and was significantly correlated with preoperative dexamethasone alone (P < .01), and especially when dexamethasone plus a nutritional deficit were present (low albumin, P < .001; low NRI, P < .005).(ABSTRACT TRUNCATED AT 250 WORDS)

Enteral feeding increases sepsis in infants with short bowel syndrome

Sepsis secondary to bacterial translocation is common in infants with short bowel syndrome (SBS). Although early feeding is advocated to enhance adaptation in SBS, the effects of feeding on sepsis in SBS patients have not been examined. Twenty-one infants and children (aged 2 months to 3 years) with SBS (< 80 cm small bowel length) from a variety of causes (15 necrotizing enterocolitis, 2 atresia, 2 gastroschisis, 2 volvulus) had follow-up prospectively for septic episodes before and after feedings were initiated, while still receiving total parenteral nutrition. The incidence and number of septic episodes and microbiology (blood cultures) were tabulated and compared with those of 20 patients with similar ages, and diagnoses without SBS. Statistically significant differences among infants with SBS were noted with respect to sepsis incidence (6 of 21 [29%] NPO v 16 of 21 [76%] feeding) number of septic episodes (1.3 +/- .2 NPO v 4.2 +/- .4 feeding), and presence of gram-negative rods causing bacteremia (1 of 6 [17%] NPO v 13 of 16 [81%] feeding) (all: P < .05). There were similar differences between SBS and non-SBS infants. These data show that enteral feeding increases the incidence and number of episodes of sepsis in SBS infants, but not in matched non-SBS patients. The predominance of gram-negative organisms in sepsis in SBS suggests increased gut bacterial translocation in these patients, implying that selective gut decontamination may reduce the episodes of bacteremia.

Thoracoscopic debridement of loculated empyema thoracis in children

The appropriate management of multiloculated empyema thoracis remains controversial. During a 7-month period, we have managed multiloculated empyema with early thoracoscopic debridement in three consecutive pediatric patients. Chest tubes were removed 7 +/- 1 (mean +/- standard deviation) days after thoracoscopy and discharge from hospital was on postoperative day 8 +/- 1. We suggest that early thoracoscopic debridement of multiloculated empyema thoracis in children is safe and efficacious.

Enterostomy and its closure in newborns

OBJECTIVES

To examine the morbidity and mortality in 109 newborns who required enterostomy for intestinal necrosis, perforation, or obstruction and to analyze the complications associated with enterostomy closure.

DESIGN

Data were collected retrospectively from hospital and office charts. Follow-up was 1 to 6 years.

SETTING

Tertiary care, newborn intensive care unit at a children's hospital.

PATIENTS

A referred sample of 109 newborns (aged 0 to 28 days) with bowel necrosis, obstruction, or perforation, who underwent enterostomy as part of their therapy.

INTERVENTIONS

Operative formation of any enterostomy during laparotomy for bowel necrosis, obstruction, or perforation and subsequent closure.

MAIN OUTCOME MEASURES

Morbidity and mortality associated with newborn enterostomy and its closure.

RESULTS

Patients underwent jejunostomy (n = 31), ileostomy (n = 62), or colostomy (n = 16) for necrotizing enterocolitis (n = 79), atresia (n = 15), idiopathic perforation (n = 8), volvulus (n = 4), or meconium ileus (n = 3). Seventeen (16%) died postoperatively of sepsis, respiratory distress, further necrotizing enterocolitis, or intraventricular hemorrhage. Complications developed in 10 (34%) of the remaining 29 patients who underwent jejunostomy, whereas in 13 (26%) of 50 patients who underwent ileostomy and three (23%) of 13 patients who underwent colostomy, complications requiring revision developed. Ninety-two patients underwent enterostomy closure 14 to 65 days after enterostomy. Four later died of continuing respiratory distress and liver failure. Fifteen (56%) of 27 jejunostomies, 28 (57%) of 49 ileostomies, and nine (75%) of 12 colostomies were closed uneventfully, whereas two jejunostomy and eight ileostomy closures dehisced, requiring repeated enterostomy and secondary closure. All 10 children with anastomotic dehiscence had necrotizing enterocolitis originally, showed poor weight gain (< 30% per month), and had low serum albumin levels (22 +/- 3 g/L) compared with children with successful primary closure (> 30% weight gain per month; serum albumin level, 37 +/- 6 g/L; both Ps < .05).

CONCLUSION

These data show that enterostomy is a potentially morbid condition in the newborn and is prone to complications but should be closed only when the child is in satisfactory nutritional condition.

Stability and compatibility of anakinra with intravenous cimetidine hydrochloride or famotidine in 0.9% sodium chloride injection

We designed a study to evaluate the stability and compatibility of anakinra (recombinant human interleukin-1 receptor antagonist) with cimetidine hydrochloride or famotidine in 0.9% sodium chloride injection during a 4-h period at room temperature (22 degrees C) and light. Anakinra was diluted in 0.9% sodium chloride to concentrations of 4 and 36 mg/ml. At each concentration, anakinra was mixed with 3 mg/ml cimetidine or with 1 mg/ml famotidine, in a 50:50 proportion and stored in plastic culture vials with polypropylene caps. The mean concentrations of anakinra, cimetidine hydrochloride, and famotidine exceeded 95% of initial concentrations throughout the study. No changes were noted in the physical appearance, pH, or the chromatograms during the study period. Thus, anakinra appears to be stable and compatible with cimetidine hydrochloride or famotidine when diluted into 0.9% sodium chloride injection for 4 h at ambient room temperature and light.

Predictive capabilities of preoperative and postoperative pulmonary function tests in delayed repair of congenital diaphragmatic hernia

To improve the survival of newborns with congenital diaphragmatic hernia (CHD), preoperative stabilization with conventional ventilatory therapy and extracorporeal membrane oxygenation (ECMO) have been used. Measurements that quantify pulmonary function may allow an accurate assessment of lethal pulmonary hypoplasia and predict outcome. Pulmonary function tests (PFTs) were obtained in 20 infants preoperatively and postoperatively; these included measurements of compliance, dynamic compliance, and tidal volume. Overall survival was 75%. Six surviving infants were initially managed with ventilator therapy alone, followed by repair (group 1). The remaining 14 patients, who were moribund at presentation or whose initial ventilator therapy failed, were placed on ECMO and received repair during bypass; nine survived (group 2), and five died (group 3). Compliance, dynamic compliance, and tidal volume obtained at initial presentation and immediately preoperatively were significantly higher for group 1 as compared with groups 2 and 3. Infants whose initial compliance was greater than 0.25 mL/cm H2O/kg and initial tidal volume was greater than 3.5 mL/kg did not require ECMO. Ultimate improvement in compliance was noted in 5 of 6 patients in group 1, 8 of 8 patients in group 2, and 5 of 5 in group 3. This improvement followed an initial decline in compliance in 9 of 14 survivors, from 15% to 76%. All six patients in group 1 had tidal volumes of more than 4 mL/kg, as did 7 of 9 patients in group 2. Only one patient among the ECMO nonsurvivors (group 3) had a postoperative tidal volume of this magnitude. These data suggest that initial PFTs may predict which infants will require ECMO.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital hemangiopericytoma: an unusual vascular neoplasm of infancy

BACKGROUND

Hemangiopericytoma is an uncommon tumor of infants, which originates from the vascular pericytes. Although generally considered to benign, metastases can occur.

METHODS

Five cases of congenital hemangiopericytoma were seen in infants; all were found in females. The mean age at diagnosis was 7 weeks (range, birth to 10 weeks). The lesions were located in the neck, the parotid, the axilla, and the retroperitoneum. One neck lesion was detected prenatally by ultrasonography. Each lesion was resected. The diagnosis of congenital hemangiopericytoma was established only after histologic examination.

RESULTS

No evidence of recurrence has been found in four of the children. However, intrathoracic and intracranial metastases developed in one child with a neck lesion 28 months after the original resection, and the child was treated with chemotherapy, but she died of progressive disease.

CONCLUSIONS

We advocate the consideration of congenital hemangiopericytoma in the newborn infant with a vascular mass. Because congenital hemangiopericytoma is unresponsive to steroid therapy, unlike other vascular malformations, resection is the treatment of choice. Long-term postoperative follow-up is essential for the early detection of metastases.

Growth-related gene expression in early cholestatic liver injury

BACKGROUND

Extrahepatic biliary obstruction initiates cholestasis, bile duct proliferation, periportal fibrosis, and, eventually, lethal biliary cirrhosis. Little is known about the genetic regulation of the cellular proliferation and differentiation that begins with the onset of bile duct obstruction. To focus this and future gene expression studies, we sought to determine the time frame for growth-related gene expression and questioned whether the in vivo expression of the protooncogenes H-ras and c-myc was altered after bile duct obstruction.

METHODS

Female Fisher rats underwent ligation and division of the common bile duct or sham laparotomy.

RESULTS

After obstruction, serum bilirubin and gamma-glutamyl transpeptidase rose to 24% and 30%, respectively, of maximum levels by 10 days after ligation. Morphologic evidence of proliferation of bile duct epithelial cells was first evident after 3 days. After hybridization to c-DNA probes, densitometry for H-ras and beta-actin revealed an immediate and parallel increase in steady-state levels of expression after 24 hours of cholestasis. Levels of c-myc messenger RNA were elevated during the first 3 days of cholestasis; however, at 7 and 10 days c-myc expression was depressed 16% and 60%, respectively.

CONCLUSIONS

These profiles of expression show an oncogene response induced by early cholestasis. These data showed that elevations in H-ras and c-myc steady-state expression accompany the proliferative response of bile duct epithelial cells. Decreased levels of c-myc after initial elevation infer that ductal proliferation may continue independently of its steady-state expression, a response usually seen in vitro rather than in in vivo proliferation.

Nitrogen balance in patients treated with extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) is a commonly used technique in the management of newborn respiratory failure. However, few studies have addressed the optimal nutritional support of these critically ill neonates. Eleven newborns undergoing ECMO for respiratory failure were studied at various levels of intravenous caloric and nitrogen intake, using nitrogen balance techniques, to assess optimal nutritional support necessary to achieve positive nitrogen balance. Nonprotein nitrogen calories > 60 kcal/kg/d, and nitrogen > 240 mg/kg/d were necessary to achieve positive nitrogen balance, while maximum positive balance was seen with nitrogen intake > 400 mg/kg/d. These data suggest that newborns treated with ECMO can achieve positive nitrogen balance with modest amounts of caloric and nitrogen intake.

Battered children with duodenal avulsion and transection

Two cases of severe duodenal injury following child abuse are presented. One avulsion injury required pyloric exclusion. Both 2-year-old children survived without anastomotic complications. Survival after these injuries rests on the ability to apply multiple techniques for duodenal reconstruction, as well as the recognition of individual cases of abuse-associated malnutrition. A high index of suspicion following abuse-associated blunt abdominal trauma will prevent diagnostic delay in children with retroperitoneal duodenal injuries.

A clinical-pathological study of nonsurvivors of newborn ECMO

Extracorporeal membrane oxygenation (ECMO) is an important means of supporting newborns with respiratory failure. While short- and long-term follow-up of ECMO survivors has been thoroughly addressed, there is no systematic study of nonsurvivors. Nineteen nonsurvivors of newborn ECMO with autopsy results are divided into two groups: group 1: 12 patients who had intracranial lesions as the primary cause of death (hemorrhage 8, encephalomalacia 2, infarct 2); and group 2: 7 patients with nonintracranial primary causes of death. Patients in group 1 were significantly more acidotic, hypotensive, and smaller in age and birth weight pre-ECMO. Among group 2 patients, two with diaphragmatic hernia died of primary pulmonary disease (diffuse alveolar damage, pulmonary hypoplasia and necrosis, bronchopneumonia). One of 2 patients with persistent fetal circulation (PFC) was treated with massive doses of tolazoline and suffered fatal gastrointestinal hemorrhage and ischemic necrosis of heart, spleen, testes, and adrenals. The other PFC patient had severe pulmonary interstitial fibrosis. Two patients with meconium aspiration and a patient with streptococcal sepsis had diffuse pulmonary damage and multiple organ failure (renal medullary necrosis, and infarcts of adrenal, spleen, liver). In this series, intracranial pathology was the most common cause of death in ECMO patients, related to gestational age, acidosis, hypoxia, and size, but probably unrelated to carotid ligation.

Congenital duodenal obstruction: a 32-year review

Although survival in infants with congenital intestinal obstruction has improved, duodenal obstruction continues to present unique challenges. One hundred thirty-eight newborns and infants (aged 0 to 30 days) were treated for congenital duodenal obstruction. Sixty-five were boys and 73 were girls. Sixty-one (45%) were premature. Forty-six had an intrinsic defect (atresia, web, stenosis, or duplication), 64 had an extrinsic defect (annular pancreas or malrotation with congenital bands), while 28 had various combinations of these. Presenting signs included vomiting (90%, bilious in 66%), abdominal distention (25%), dehydration (24%), and weight loss (17%). Although plain film abdominal x-ray was diagnostic in 58%, upper and/or lower gastrointestinal contrast studies were obtained in 71% of infants to confirm diagnosis. Thirty-eight percent of patients had associated anomalies, including Down's syndrome (11%), cardiac defects, other atresia, other trisomy syndrome, imperforate anus, and central nervous system anomalies. Fourteen patients (10%) had 3 or more other anomalies, many of which required additional surgical therapy. The operative repair of the various defects included Ladd's procedure for malrotation (31%), duodenoduodenostomy (14%), duodenojejunostomy (22%), gastrojejunostomy or gastroduodenostomy (4%), excision of the web and duodenoplasty (3%), or combination of the above (22%). Gastrostomy was placed in 61%. One hundred twenty-eight patients survived (93%). The causes of death were combinations of sepsis, pneumonia, brain hemorrhage, short bowel, and cardiac anomaly. Eight of 10 (80%) who died had other serious anomalies. Twenty patients (14%) required reoperation 5 days to 4 years postoperatively for obstructing lesions (5), wound dehiscence (3), anastomotic leak or dysfunction (6), other atresias (2), choledochal cyst (1), pyloric stenosis (1), and gastroesophageal reflux (2).(ABSTRACT TRUNCATED AT 250 WORDS)

Extracorporeal membrane oxygenation in children after cardiac surgery

BACKGROUND

From August 1982 to May 1991, 65 children (32 boys), 1 day to 14 years old, received extracorporeal membrane oxygenation (ECMO) 0-50 hours after cardiac surgery. Forty-four (67.7%) were weaned, with 23 (35.4%) survivors.

METHODS AND RESULTS

Analysis of 29 pre-ECMO factors including diagnosis, age, sex, blood gas data, systemic pressures, atrial pressures, ventricular function, and renal function was performed. Preoperative systemic ventricular shortening fraction was statistically less in survivors. The need for dialysis and length of support were predictors of survival once ECMO was initiated. There were five late deaths 6 days to 5 years after discharge; none were related to ECMO. The remaining 18 patients have been followed for a mean of 37.5 months (range, 1-85 months). Seventeen are New York Heart Association functional class I, with one patient still hospitalized.

CONCLUSIONS

ECMO allows for myocardial recovery in the majority of patients with refractory postcardiotomy failure and permits some patients to survive who would not have otherwise.

Prolonged extracorporeal support for nonneonatal respiratory failure

Extracorporeal membrane oxygenation (ECMO) is effective for newborns with pulmonary failure unresponsive to conventional therapy. However, ECMO for the older child and adult has been controversial and not widely utilized. Over 4 years, 24 patients (aged 4 months to 16 years; 11 boys, 13 girls) underwent venoarterial ECMO (duration, 7 to 19 days) for respiratory failure. The diagnoses were: viral pneumonia (7), hydrocarbon aspiration (6), sepsis with adult respiratory distress syndrome (ARDS) (2), bacterial pneumonitis (2), tracheal stenosis (1), bilateral pulmonary contusion (1), diaphragmatic hernia with ARDS (1), ketoacidosis with ARDS (1), pulmonary artery injection of hydrocarbon (1), drowning (1), and epiglottis with barotrauma (1). Pre-ECMO blood gas ranges (and means) were PO2 18 to 65 (46), and PCO2 47 to 112 (65). Nineteen patients received dopamine, dobutamine, or other inotrope for associated cardiac and/or renal failure. Cannulation for ECMO was through neck or groin vessels in 17, and sternotomy in 7. ECMO flow rates were 150 to 250 mL/kg/min, to maintain PO2 greater than 100 and PCO2 less than 40. Nine patients (41%) survived ECMO, with eight long-term survivors, (4 hydrocarbon aspiration or injection, 1 pulmonary contusion, 1 viral pneumonia, 1 ARDS, 1 barotrauma), three of whom have mild neurological deficit. All patients with sternotomy, and 8 of 15 with neck and/or groin cannulation, required 1 to 5 explorations for hemorrhage while on ECMO. All survivors had primarily pulmonary failure; patients with combinations of pulmonary, cardiac, and renal failure did not survive. ECMO can be life-saving in the child with isolated pulmonary failure, but its efficacy in patients with multiorgan failure is uncertain.

The risk of abdominal operations in children with ventriculoperitoneal shunts

Ventriculoperitoneal (VP) shunts are the operations of choice for patients with hydrocephalus in most pediatric hospitals. Children with VP shunts frequently undergo abdominal operations unrelated to their shunts, which might lead to shunt infections or to malfunctions related to adhesions. Although prophylactic antibiotics are usually used in this setting, there are few data to support their use, or to assess other risks to the shunt from the abdominal procedures. Consequently, we reviewed the records of 37 children with VP shunts who underwent a total of 44 abdominal operations. In 8 cases, the genitourinary (GU) tract was opened (ureteral reimplantation, bladder augmentation, nephrectomy), whereas in 18 patients the gastrointestinal (GI) tract was opened (appendectomy, gastrostomy, small/large bowel resection). In 18 operations neither GI nor GU tract was opened (lysis of adhesions, herniorrhaphy, orchiopexy). Antibiotic coverage was highly variable: 9 received no antibiotics, 9 received antibiotics only postoperatively, 4 were given antibiotics only preoperatively, and in 22 cases antibiotics were given both preoperatively and postoperatively. One shunt that was involved in a periappendiceal abscess was exteriorized and later successfully replaced. In the remaining cases, no episodes of shunt infection or malfunction occurred in 1 to 10 years of follow-up. Likewise, no abdominal cerebrospinal fluid pseudocysts formed as a result of abdominal adhesions. These data demonstrate that children with VP shunts can safely undergo abdominal operations, even when the GI or GU systems are opened, with minimal risk of shunt infection or malfunction. Rigid protocols of prophylactic antibiotics cannot be supported by this series.