A comparison of the efficacy of pyloromyotomy and pyloroplasty in patients with gastroesophageal reflux and delayed gastric emptying

PURPOSE

Delayed gastric emptying (DGE) in children with gastroesophageal reflux (GER) is often treated with a gastric emptying procedure. Although pyloroplasty is the most common gastric emptying procedure performed, pyloromyotomy is easier to perform and is associated with less morbidity. The aim of this study was to compare the efficacy of pyloromyotomy and pyloroplasty in children with DGE and GER undergoing a fundoplication.

MATERIALS AND METHODS

We reviewed the charts of 54 patients with DGE who underwent pyloromyotomy (n = 29), or pyloroplasty (n = 25) along with a fundoplication. A technetium 99-labeled sulfur colloid liquid-phase gastric emptying study (GES) was performed in the pre- and early postoperative period (within 6 months after operation). Normal stomach emptying was defined as greater than 40% at 1 hour. Comparisons were made with regard to postoperative complication rate, incidence of redo fundoplication, length of postoperative hospital stay, and pre- and postoperative GES.

RESULTS

The pyloroplasty and pyloromyotomy group were comparable in terms of age, sex, operative indications, and neurological status. There was no significant difference in the GES between the two groups preoperatively. There was a trend toward a decreased incidence of early postoperative complications including gas bloat, wound infection, pneumonia, dysphagia, bowel obstruction and dumping syndrome in the pyloromyotomy (8, 28%) when compared with the pyloroplasty group (12, 48%, P = .10). The mean postoperative hospital stay was 10.6 +/- 1.4 days for the pyloroplasty group and 7.6 +/- 1.0 days for the pyloromyotomy group (P + .08). The incidence of a redo fundoplication was 8% in the pyloroplasty and 7% in the pyloromyotomy group. Postoperative gastric emptying increased significantly in both groups (pyloroplasty group, from 18.1 +/- 3.1 to 49.5 +/- 7.9%, P = .0005; pyloromyotomy group, from 19.3 +/- 2.1 to 41.2 +/- 3.7%, P = .0001). There was no significant difference in the postoperative GES between the two groups (P = .289).

CONCLUSION

Both pyloroplasty and pyloromyotomy performed in conjunction with a fundoplication resulted in a significant increase in early postoperative gastric emptying. There was no advantage of pyloroplasty over pyloromyotomy during this follow-up period. These data suggest that pyloromyotomy is an effective gastric emptying procedure in children with GER and DGE.

Efficacy of the transthoracic modified Heller myotomy in children with achalasia--a 21-year experience

From 1974 to 1995, 19 children with achalasia of the esophagus have been treated at our institution. Presenting symptoms included vomiting (n = 14), dysphagia (n = 13), failure to thrive (n = 6), and odynophagia (n = 1). Diagnosis was established by a barium swallow in 19, with eight also undergoing esophageal manometry. Six boys and 13 girls with an average age of 10 years (range, 1.3 to 17.6) underwent a transthoracic, modified anterior Heller esophagomyotomy (HM). Five underwent a concomitant, modified, Belsey fundoplication (BF). Follow-up ranging from 6 months to 21 years (mean, 9 years) was accomplished in all 19 patients by both office visits and telephone interviews. Early postoperative follow-up showed initial swallowing difficulty in two (14%) patients with a HM alone and in four out of five (80%) patients treated with a HM and BF. All patients (n = 5) with a HM and BF and one with a HM alone required one esophageal dilation during the first postoperative year. These initial swallowing difficulties resolved in all six patients during this first postoperative year. Late postoperative follow-up, however, indicates occasional, mild dysphagia in two out of five with an HM and BF resulting in complete relief of presenting symptoms in 17 of the 19 patients (90%). All patients rated their overall result as either excellent (68%) or good (32%) with none rating it as fair or poor. None of the 19 patients had clinical evidence of gastroesophageal reflux, although five patients had evidence of nonpathologic reflux noted during upper gastrointestinal x-ray. Recurrent vomiting, asthma, wheezing, or esophagitis symptoms have not been reported by any patients. No patients required reoperation, and there were no deaths or postoperative complications. Modified Heller esophagomyotomy is safe (0% mortality) and effective (90% relief of symptoms) in children with achalasia. A concurrent modified Belsey fundoplication results in early and late mild postoperative dysphagia that was responsive to esophageal dilation. The transthoracic, modified Heller esophagomyotomy without a fundoplication is currently our treatment of choice for achalasia in children.

The association of gut-associated lymphoid tissue and bacterial translocation in the newborn rabbit

The authors have previously demonstrated spontaneous bacterial translocation (BT) in newborn rabbits and its resolution with aging. It is hypothesized that this spontaneous BT was associated with an immature gut-associated lymphoid tissue (GALT). The aim of the present study was to characterize the cellular populations of the GALT in rabbits at various ages and to correlate this with the frequency of BT. Small bowel (SB) sections and mesenteric lymph nodes (MLN) were harvested and cultured (aerobically) from New Zealand White rabbits at 0, 6, 14, 28, and more than 90 days of age for determination of bacterial colonization (BC) and BT. Portions of ileum (n = 6 for each age) were simultaneously harvested for immunoperoxidase staining. Total T cells (CDS+), expressed as the number of positive cells/1000 nuclei and activated T cells (CD25+), expressed as the number of positive cells/1000 nuclei and as the ratio of CD25+/CD5+ cells, were analyzed for each tissue. Positive cells were counted in 30 villi by light microscopy. The incidence of BT rose as BC increased in the small bowel and peaked at 6 days of age; BT then decreased with age. CD5+ cells in the small bowel villi at 0 days of age were few (2.5 positive cells/1000 nuclei) and the number significantly increased with age (6 days, 6.5; 14 days, 19.0; 28 days, 31.6; adult, 136.6 positive cells/1,000 nuclei). The distribution of T cells started in the crypts, and with advancing age, cells were found all the way to the top of the villi. The number of CD25+ cells in the villi increased with age. The CD25+/CD5+ ratio in the small bowel villi peaked at 6 days of age. These results demonstrate an inverse relationship between the number of CD5+ cells in the intestinal villi and the incidence of bacterial translocation. The elevation of activated T cells (CD25+) at 6 days of age may be the result of an immunologic activation during the time of peak bacterial translocation. These data suggest that maturity of the GALT leads to a loss of spontaneous bacterial translocation in the newborn period. Modalities that supplement the GALT may help reduce bacterial translocation.

Effect of very delayed repair of congenital diaphragmatic hernia on survival and extracorporeal life support use

BACKGROUND

Since November 1992, operative repair in neonates with congenital diaphragmatic hernia (CDH) at this institution was delayed until respiratory insufficiency had resolved.

METHODS

A retrospective analysis was performed (n = 33) comparing delayed repair with our previously reported institutional experience with immediate repair from January 1988 to October 1992 (n = 66). Infants with severe genetic defects or moribund conditions or who were premature were not considered candidates for repair or extracorporeal life support (ECLS), but they were included in the survival analysis. Survival was defined as hospital discharge. Data were compared with an independent t test or Pearson chi-squared test.

RESULTS

Mean age at repair was 8.9 +/- 4.5 days (range, 3 to 20 days). Eleven infants in the study group were placed on ECLS (33% versus 68% in the comparison group; p = 0.001). Six of these infants survived (55% versus 58% in the comparison group; p = 0.846). Of these survivors, one patient was repaired while on ECLS, and the remainder underwent repair after decannulation from ECLS. All 20 of the remaining candidates for repair survived without need for ECLS. Overall survival was 79% versus 56% in the comparison group (p = 0.027).

CONCLUSIONS

Our current data suggest that very delayed repair of newborns with CDHs is associated with an increase in the overall survival and a decrease in the use of ECLS when compared with previous experience at this institution.

Hernia survey of the Section on Surgery of the American Academy of Pediatrics

The members of the Section on Surgery of the American Academy of Pediatrics were surveyed to determine the practice of North American pediatric surgeons in infants with inguinal hernia (IH). Case-scenario multiple-choice-design questionnaires regarding hernias and hydroceles were sent to all members of the Surgical Section, and responses were received from 292 (50%). In healthy full-term infant boys with asymptomatic reducible IH, 82% of responders perform repair electively, no matter what the age or weight. In full-term girls with a reducible ovary, 59% perform surgery at the next available time; if the ovary is nonreducible but asymptomatic, 44% operate emergently or urgently and 42% at the next elective slot. In former preemies, the pattern of repair is as follows. (1) For those recently discharged after 2 months in the neonatal intensive care unit (NICU) with reducible IH, 65% perform the repair when convenient. (2) A general anesthetic is used in 70%; 15% use spinal anesthesia, and 11% use caudal block with sedation. (3) If the repair is done in the hospital outpatient (same-day) unit, 36% wait until 50 weeks postconception (PC) and 33% wait until 60 weeks PC. (4) if the baby's weight is at least 1,000 g. 71% perform the repair before discharge. The pain control choice after childhood IH repair is Tylenol for 30%, local infiltration biquivacaine for 30%, caudal block for 22%, regional block for 11%, and Tylenol/codeine combined for 7%. In 6-week-old full-term infants with communicating hydroceles without definite "hernia," two thirds treat as an IH with elective repair as soon as possible. With respect to contralateral exploration in infants with unilateral IH, 65% perform it in males if they are < or = 2 years of age and 84% use it in females of up to 4 years of age. This approach is not influenced by presenting side, presence of hydrocele, or history of prematurity. Laparoscopic evaluation of the contralateral IH is performed by only 6% of responders, 40% of whom use the open ipsilateral sac for laparoscope introduction.

Maximal oxygen consumption and stress performance in children operated on for congenital diaphragmatic hernia

The long-term follow-up of patients operated on for congenital diaphragmatic hernia (CDH) at birth has been extensively evaluated, both clinically and with respect to respiratory function. However, little is known about the sports practice and stress performance of these subjects. Fifteen of 107 patients operated on for CDH underwent exercise stress testing with a stepwise increase in workload. A questionnaire was provided, which requested information on sports practice and lifestyle. Maximal oxygen consumption [Vo2 max] was measured along with dynamic lung volumes. Clinical examination included a whole-body assessment (height, weight, skinfolds) and vital parameters (heart rate and blood pressure). Fifteen healthy children who practiced regular physical activity (2 to 4 hours/week) served as controls. All the CDH patients experienced a good lifestyle, but only 8 of them were participating in sports. Exercise duration and Vo2 max were significantly lower for the CDH patients, and were lowest for the sedentary patients. Therefore, the reduced Vo2 max of these otherwise healthy children most likely represents a lower degree of physical fitness rather than decreased respiratory function. Fitness is an expression of well-being; thus, there is evidence that these patients could safely participate in competitive motor activities.

Acute hypoxia does not increase bacterial translocation in newborn rabbits

PURPOSE

We have previously demonstrated that spontaneous bacterial translocation (BT) occurs in newborn rabbits and correlates strongly with small bowel colonization (BC). Birth stress, specifically hypoxia, is believed to increase this pathologic process and thus lead to sepsis. This study investigated the relationship between BT and acute hypoxia in newborn rabbits.

METHODS

Four hundred seventeen rabbit pups (aged 0, 2 to 4, 6, and 28 days) were divided into four groups according to the type of hypoxic stress: 9% O(2) for 1 hour, 9% O(2) + 12% CO(2) for 1 or 4 hours, and 21% O(2) (control animals). The animals were killed 1.5 or 20 hours after the stress. Sterile specimens of mesenteric lymph nodes (MIN), spleen, liver, small bowel, and large bowel were incubated aerobically at 37 degrees C for 24 hours in thioglycolate broth, and subsequently plated on both MacConkey and Colistin Naladixic Acid media. After 24 hours, the growth on both plates was recorded. X(2) analysis was used, and P values of less than .05 were considered significant.

RESULTS

BC of the small bowel and BT to the MLN were low in the first 4 days of life in the hypoxic groups (range, 0% to 21% BC, 0% to 6% BT) and the control group (range, 4% to 30% BC, 3% to 12% BT). After an increase in BC at 6 days of age, the rate of BT increased to 25% to 29% in control animals. The rate of BT in the hypoxic groups (25%) did not differ significantly from that of the controls (P > .05). Additionally, killing at 20 hours (v 1.5 hours) was not associated with an increase in the incidence of BT. None of the stress groups had a significant increase in BT compared with the controls. Importantly, although 4 hours of 9% O(2) + 12% CO(2) resulted in a 30% mortality rate, the incidence of BT was no higher than that of the control animals (13% v 29%; P > .05).

CONCLUSION

Severe hypoxic stress in newborn rabbits does not increase the incidence of BT. Because the incidence of BT correlates with that of BC, and because BC is the same in the control and hypoxic animals, the sepsis observed in hypoxic newborns probably is not related to an increased incidence of BT.

Peritoneal migration of an abdominally implanted epicardial pacemaker: a cause of intestinal obstruction

We report the case of a 10-year-old child with an abdominally implanted epicardial pacemaker that eroded through the peritoneum and migrated to an intraperitoneal location, resulting in partial and then complete intestinal obstruction. This potentially life-threatening complication should be considered when a patient with an abdominally implanted pacemaker presents with abdominal pain.

Physical fitness testing in children operated on for tracheoesophageal fistula

The maximal physical activity capacity of children operated on for tracheoesophageal fistula (TEF) has not been clearly defined. Eight patients (average age, 12 years) successfully operated on for TEF at birth underwent maximal exercise stress testing on a treadmill, according to the Bruce protocol, to test physical work capacity. Heart rate (HR), oxygen consumption (VO2), and pulmonary ventilation (VE) were measured by a portable lightweight telemetric device. Nine healthy children served as controls. Exercise duration was significantly lower for TEF subjects than for controls (11.6 +/- 1.7 minutes v 15.1 +/- 2.3 minutes; P < .01). Mean HR at rest and during exercise did not differ between the groups. All children reached the maximum HR according to their age; however, for the majority of TEF patients, this occurred at an earlier stage than in the controls. No differences were seen in mean VO2 at rest and on exertion between TEF and control children. However, maximal VO2, as measured at the end of exercise, was significantly different when normalized per kilogram of body weight (VO2/kg = 52.3 +/- 5.8 v 33.3 +/- 6.6; P < .005). The physical rehabilitation of TEF children usually takes into account only respiratory and nutritional factors. However, complete assessment of their cardiac and respiratory function, at rest and on exertion, also should be performed, because this may show that some patients have reduced motor performance; evidence is now accumulating that these children can safely participate in the same physical activities of their healthy peers.

Neonatal soft tissue sarcomas: the influence of pathology on treatment and survival. Children's Cancer Group Surgical Committee

INTRODUCTION

A multi-institutional study was conducted by the Children's Cancer Group (CCG) to evaluate all soft tissue sarcomas diagnosed within the first month of life.

METHODS

A retrospective study by 11 CCG institutions of patient records from 1971 to 1991 were reviewed for demographic data, pathology, therapy, and outcome.

RESULTS

32 neonates with soft tissue sarcomas were identified. There were 21 boys and 11 girls. Pathology was equally divided into three groups: Congenital fibrosarcoma (CFS) (12), rhabdomyosarcoma (RMS) (11), and non-RMS soft tissue sarcomas (NRSTS) (9). Anatomic sites consisted of head/neck (11), extremity (9), trunk (8), pelvis (3), and unknown (2). Overall survival rate was 59% (19/32).

CONCLUSION

Soft tissue sarcomas in the neonate comprise three general groups with survival rates dependent on pathology and extent of disease.

Dermatoglyphic patterns in children with chronic constipation

Analysis of the fine ridge configurations on the digits of the palms and soles (dermatoglyphics) may sometimes help in the diagnoses of certain medical disorders. Dermatoglyphic patterns have been reported to be associated with congenital anomalies, such as congenital heart disease, duodenal ulcer, abdominal pain, and constipation. The palmar dermatoglyphic patterns of 77 children with constipation (39 functional and 38 organic constipation) were recorded. The control group consisted of 84 children with inguinal hernia. Those patients with at least one arch identified on any digit of either hand were termed arch positive. There was no significant correlation between arch positivity and constipation (functional or organic), or inguinal hernia (chi square, P = 0.9211). Therefore, the presence of palmar arches cannot be used as a screening device for children with chronic constipation, especially of organic etiology.

Enterocolitis associated with Hirschsprung's disease: a clinical histopathological correlative study

Enterocolitis associated with Hirschsprung's disease (HEC) remains a major source of morbidity and even mortality, both before and after definitive surgical treatment. This study was undertaken to investigate whether histopathologic mucosal changes, in the absence of clinical manifestations of HEC, could predict the subsequent development of this complication. The clinical data and histopathology of 25 patients who eventually developed clinical HEC were compared with a control group of 25 age- and sex-matched patients with Hirschsprung's disease (HD) but with no clinical HEC either preoperatively or postoperatively. The histopathologic findings of tissue obtained by rectal biopsy or during laparotomy were graded from 0 to V according to severity and compared with the eventual clinical course. This study showed that (1) histopathologic findings of HEC appear to predict the clinical development, but not the severity, of future episodes of clinical HEC; (2) a histological grade of > or = II (> or = 2 crypt abscesses per high power field) should raise suspicion for subsequent occurrence of HEC, whereas a grade of > or = III (multiple crypt abscesses) places a child at high risk for development of clinical HEC; and (3) contrary to what is generally thought, histopathologic changes of HEC occur in both ganglionic and aganglionic segments. Based on these findings, it is recommended that histopathologic documentation of HEC and its grade should be an integral part of the tissue diagnosis of HD.

Determinant of bacterial translocation in the newborn: small bowel versus large bowel colonization

This study investigated the relationship between bacterial translocation (BT) and small and large bowel bacterial colonization in the neonatal rabbit. The authors have previously shown that spontaneous BT occurs in rabbits during the first week of life, but is less frequent before the third day of life. The authors have also shown that bacterial colonization of the small bowel, is delayed until 3 to 5 days of age, and is preceded by colonization of the large bowel. Therefore, the authors hypothesizes that BT is dependent on small bowel, not large bowel, colonization. New Zealand White rabbit pups (n = 255) were divided into four groups, formula-fed (FF), formula-fed plus antibiotic (FFAB), breast-fed (BF) and unfed controls (UC). Animals from each group were killed on day 1 to 4 of life. Small bowel (SB) and large bowel (LB) specimens, mesenteric lymph nodes (MLN), spleen (SPL), and liver (LIV) were obtained from each rabbit, incubated for 24 hours in thioglycolate broth, and plated on both MacConkey and Colistin Naladixic Acid media in an aerobic environment. After 24 hours, growth on either plate was recorded. Bacterial colonization was significantly greater in FF versus UC, BF, and FFAB rabbit groups. In addition, large bowel colonization was significantly increased compared with small bowel colonization in all feeding groups (P < .05). Bacterial translocation to MLN, SPL, and LIV ranged from 10% to 27% in all groups. Gram-negative bacteria predominated over gram-positive bacteria in translocation to the various tissues sampled.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis, management, and outcome of cervicofacial teratomas in neonates: a Childrens Cancer Group study

The management of cervicofacial teratomas in neonates is often complicated and may result in significant morbidity and death. A Childrens Cancer Group (CCG) retrospective study was conducted to evaluate a multiinstitutional experience with the treatment of these extremely rare neoplasms. Twenty neonates with cervicofacial teratomas, presenting from 1971 to 1994, were identified from nine CCG institutions. Fourteen neonates had cervical teratomas, and six had orofacial teratomas. There were 12 males and eight females. A diagnostic prenatal ultrasound examination was performed in six cases. Life-threatening airway obstruction occurred in seven infants (35%) in the early postnatal period. Two neonates died in the delivery room without ever having their airway secured. Two other infants with a prenatal diagnosis survived only because tracheostomies were performed by pediatric surgeons who were in the delivery room. Three other patients were orally intubated, one after sustaining hypoxic cardiac arrest. Eighteen infants had their primary tumor excised. Three patients required tracheostomy. After resection, two patients had evidence of unilateral recurrent laryngeal nerve injury, and two required prolonged thyroid hormone replacement. Histological examination showed eight mature and seven immature teratomas. Four infants (20%) clearly had malignant lesions. Pulmonary metastases occurred in two patients and contributed to one late death at 6 months of age. The overall survival rate was 85%, and the mean follow-up period was 5 years (range, 2 months to 16 years). Twelve of 17 surviving patients (70%) have had an excellent functional and cosmetic outcome. Four children have varying degrees of developmental delay and mental retardation. Hypoxia at birth was believed to have contributed to these problems in two cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Enterocolitis associated with Hirschsprung's disease: a clinical-radiological characterization based on 168 patients

The enterocolitis associated with Hirschsprung's disease (HD) has not been clearly characterized. This study was undertaken to analyze the clinical and radiological findings of Hirschsprung's enterocolitis (HEC) in 168 patients treated from July 1974 through October 1992. HEC occurred in 57 patients (33.9%), either preoperatively (13; 7.7%) or postoperatively (36; 21.4%). In eight patients (4.8%), it occurred pre- and postoperatively. The number of bouts of HEC per patient ranged from one to six (mean, 2.2). The major presenting features were abdominal distension (83%), explosive diarrhea (69%), vomiting (51%), fever (34%), lethargy (27%), rectal bleeding (5%), and colonic perforation (2.5%). There were no deaths directly related to HEC. The analysis of 150 plain x-rays of the abdomen, taken at the onset of HEC or in between bouts, showed that colonic dilatation was the most sensitive radiological finding (90% sensitivity), but it had poor specificity (24%). However, an intestinal cutoff sign (gaseous intestinal distension with abrupt cutoff at the level of the pelvic brim) was both sensitive (74%) and specific (86%) for HEC. Barium enema was of limited value in the diagnosis of HEC bouts because most of the radiographic findings persisted for prolonged periods after cessation of such bouts. The authors conclude that (1) HEC can be characterized as abdominal distension and explosive diarrhea associated with the intestinal cutoff sign and (2) the occurrence of explosive diarrhea in any patient with HD is suggestive of HEC, even in the absence of systemic symptoms, and should be treated to avoid the morbidity and potential mortality of HEC.

Oxidized glutathione as a marker of ischemia reperfusion associated with single lung transplantation

BACKGROUND

Previous data have shown that glutathione (GSH), an endogenous antioxidant, is converted to its oxidized form (GSSG) after oxidative ischemia-reperfusion events. As GSSG is toxic to cells and is extruded through an active mechanism dependent on intracellular GSSG levels, substance appears in plasma.

STUDY DESIGN

Single lung transplantation was performed upon 18 puppies, 3 to 5 kg, with a two hour ischemic time for the donor lung before reimplantation. Recipient animal plasma was obtained after anesthesia induction, pulmonary artery ligation, recipient pneumonectomy, reestablishment of blood flow to the donor lung, completion of transplant, and one, two, and three hours postoperatively. Donor lung bronchoalveolar lavage fluid (BALF) was obtained at the time of harvest, after perfusion of the donor lung with EuroCollins, immediately pretransplant, and after completion of the vascular anastomoses. Oxidized and total GSH levels in plasma and BALF samples were determined by a spectrophotometric assay.

RESULTS

After reimplantation of the ischemic donor lung, there was a statistically significant increase in both GSSG and GSH in plasma samples, and a statistically significant increase in GSSG in the BALF.

CONCLUSIONS

Compartmental differences between arterial and venous plasma, as well as the increase in GSSG in the BALF, implicated the lung that was transplanted as the source of oxygen free radical generation and GSSG release. Plasma GSSG levels seem to provide a sensitive, noninvasive, repeatable measure of ongoing tissue response and oxygen free radical production.

Colonization of intestinal bacteria in the normal neonate: comparison between mouth and rectal swabs and small and large bowel specimens

Seventy-four New Zealand white rabbit pups were divided into four groups: group I, 2 days of age (n = 9); group II, 3 to 5 days of age (n = 24); group III, 6 to 8 days of age (n = 27); and group IV, 10 to 13 days of age (n = 14). Mouth swabs (MS), rectal swabs (RS), small bowel specimens (SB), and large bowel specimens (LB) were obtained from each rabbit, incubated for 24 hours in thioglycolate broth, and plated on blood agar in aerobic and anaerobic environments. After 24 hours, growth on blood agar plates were observed. All MS specimens and all but one RS specimen showed positive growth. Growth of both LB and SB specimens increased significantly with age (P < .04). In addition, SB growth was significantly less than RS or MS growth in groups I, II, and III (P < .05). LB growth was significantly less than RS or MS growth in group I (P < .01) and tended to be less in groups II and III (62.5% v 100% and 93% v 100%, respectively). These data show that nearly half of normal rabbits under 6 days of age have sterile small and large intestines despite almost 100% growth from rectal and mouth swabs. These findings partially explain the absence of spontaneous bacterial translocation in young rabbit pups (under 4 days of age) and have important implications for the prophylaxis and treatment of neonatal sepsis.

Resolution of splenic injury after nonoperative management

Numerous studies have demonstrated success with nonoperative management of splenic injuries in pediatric patients. However, the resolution of the splenic injury has not been previously evaluated. The records of 50 pediatric patients with splenic injuries from blunt trauma treated nonoperatively between 1984 to 1992 were reviewed retrospectively. Abdominal computed tomography (CT) was performed at the time of injury and 6 weeks postinjury in 25 patients. These scans were reviewed and categorized by a modification of a previously reported grading system for parenchymal injury. All patients had healing of the splenic injuries, with complete resolution of the healing process observed at 6 weeks postinjury in 44%. Even those with shattered spleens (n = 6) had consistent improvement in splenic architecture, with resolution of fractures and/or contusions and return of splenic perfusion. Ten (77%) of 13 grade 1 and 2 injuries were completely resolved by the 6-week follow-up examination, whereas only one (8%) of 12 grade 3 to 5 injuries showed radiological resolution of splenic injuries. None of the 25 follow-up CT scans affected clinical decision-making or led to a deviation from the established protocol, which included a 3-month period of reduced activity. All 50 patients did well, without evidence of morbidity, mortality, or complications after return to full activity 3 months postinjury.(ABSTRACT TRUNCATED AT 250 WORDS)

Extracorporeal life support for neonatal respiratory failure. A 20-year experience

OBJECTIVE

The authors reviewed their experience with extracorporeal life support (ECLS) in neonatal respiratory failure; they define changes in patient population, technique, and outcomes.

SUMMARY BACKGROUND DATA

Extracorporeal life support has progressed from laboratory research to initial clinical trials in 1972. Following a decade of clinical research, ECLS is now standard treatment for neonatal respiratory failure refractory to conventional pulmonary support techniques. Our group has the longest and largest experience with this technique.

METHODS

Between 1973 and 1993, 460 neonates with severe respiratory failure were treated using ECLS. The records of all patients were reviewed.

RESULTS

Overall survival was 87%. Primary diagnoses were meconium aspiration syndrome (MAS; 169 cases [96% survival]), respiratory distress syndrome/hyaline membrane disease (91 cases [88% survival]), persistent pulmonary hypertension of the newborn (37 cases [92%]), pneumonia/sepsis (75 cases [84% survival]), congenital diaphragmatic hernia (CDH; 67 cases [67% survival]), and other diagnoses (21 cases [71% survival]). Common mechanical complications included clots in the circuit (136; 85% survival); air in the circuit (67; 82% survival); cannula problems (65; 83% survival) and oxygenator failure (34; 65% survival). Patient-related complications included intracranial infarct or bleed (54 cases; 61% survival), major bleeding (48 cases; 81% survival), seizures (88 cases; 76% survival), metabolic abnormalities (158 cases; 71% survival) and infection (21 cases; 48% survival). Since 1989, treatment groups have been expanded to include premature infants (13 cases; 62% survival), infants with grade I intracranial hemorrhage (28 cases; 54% survival) and "non-honeymoon" CDH patients (15 cases; 27% survival). Since 1990, single-catheter venovenous access has been used in 131 patients (97% survival) and currently is the preferred mode of access. Follow-up ranges from 1 to 19 years; 80% of patients are growing and developing normally.

CONCLUSIONS

Extracorporeal life support has become standard treatment for severe neonatal respiratory failure in our center (460 cases; 87% survival), and worldwide (8913 cases; 81% survival). The availability of ECLS makes the evaluation of other innovative methods of treatment, such as late elective repair of diaphragmatic hernia and new pulmonary vasodilators, possible. The application of ECLS is now being extended to premature and low-birth weight infants as well as older children and adults.

Effect of extracorporeal life support on survival when applied to all patients with congenital diaphragmatic hernia

Extracorporeal life support (ECLS) has been used for neonates with congenital diaphragmatic hernia (CDH) and respiratory failure at the authors' hospital since June 1981. In 1988, criteria for inclusion in ECLS were broadened to include "nonhoneymoon" infants (honeymoon: best postductal PaO2 of > 50 mm Hg). To evaluate the impact of this approach on the treatment of CDH, the authors reviewed the records of all newborns managed at their institution, since the availability of ECLS in 1981, who were symptomatic with CDH in the first 24 hours of life (n = 111). The patients were divided chronologically into two groups: 1981 to 1987 (early ECLS, n = 36) and 1988 to 1993 (expanded ECLS, n = 75). The data demonstrate that the number of CDH patients managed at our institution each year has increased (1981 to 1987 = 6, 1988 to 1993 = 14) as has the severity of associated respiratory insufficiency (% of patients with best PaO2 of < or = 50 mm Hg: 1981 to 1987 = 6%, 1988 to 1993 = 28%). Overall, the survival rate was lower for patients in the expanded ECLS group (59% v 75%; P = .121). When the survival rates for patients supported with ECLS postoperatively were compared for the expanded and early groups, a significant difference (59% v 80%; P < .05) was noted.(ABSTRACT TRUNCATED AT 250 WORDS)

Predictors of postoperative outcome after general surgical procedures in patients with congenital heart disease

This study was undertaken to evaluate factors predictive of postoperative outcome after general surgical (GS) procedures in patients with congenital heart disease (CHD). All patients with a diagnosis of CHD who underwent a GS procedure under general anesthesia during a consecutive 10-year period were considered eligible for the study The congenital heart defect was classified as either simple (ASD, VSD, PDA) or complex (endocardial cushion defects, transposition of the great vessels, tetralogy of Fallot), and the GS procedure as either major (intraperitoneal, intrathoracic, or vascular reconstructive) or minor (inguinal herniorrhaphy, vascular access). The overall mortality rate for the patient population was 12% (27 deaths among 226 procedures), minor procedures being associated with a 3% mortality rate (2 of 70 procedures), and major procedures with a 16% mortality rate (25 of 156 procedures). Incremental risk factors for mortality included a preoperative American Society of Anesthesiologists' (ASA) physical status class of IV or higher (P = .0003), a preoperative in-hospital stay of 10 or more days (P = .004), birth at a tertiary care center (P = .04), and emergency operations (P = .05). In the subgroup of patients less than 6 months old, weight of less than 2.4 kg at the time of surgery and a 1-minute Apgar score of less than 4 were additional independent risk factors (P = .04 and .01, respectively). By logistic analysis, previous corrective cardiac procedures, whether complete or palliative, did not significantly alter the postoperative outcome. The authors conclude that physiologically well-compensated patients with CHD can undergo elective operations at a low operative risk; however, poorly compensated patients undergoing urgent or emergent operations are at high risk.(ABSTRACT TRUNCATED AT 250 WORDS)

Bacterial translocation in the neonate

Bacterial translocation has been a major topic of investigation for the past two decades. Despite recent evidence that bacterial translocation may play a significant role in the morbidity and mortality of adults faced with multiple types of stress, very little is known about the effect of bacterial translocation on the neonate. Recently more and more evidence has suggested that normal as well as premature or ill neonates experience spontaneous bacterial translocation quite commonly. This article reviews the recent literature on bacterial translocation in stressed adults, the development of an intact intestinal mucosal barrier in the newborn as a protection against bacterial translocation, and the role of spontaneous bacterial translocation in the development of systemic sepsis and its accompanying morbidity and mortality.

Definitive treatment of Hirschsprung's disease in the newborn with a one-stage procedure

BACKGROUND

The purpose of this study was to review our experience and early follow-up with 15 one-stage pull-through procedures performed at the time of diagnosis in neonates and infants with Hirschsprung's disease.

METHODS

Historic chart review of all patients with the new diagnosis of Hirschsprung's disease seen at the C.S. Mott Children's Hospital at the University of Michigan, Ann Arbor, between June 1989 and June 1992 was performed. Progress notes, operative and anesthetic records, pathology reports, and outpatient follow-up notes were used for data collection.

RESULTS

Operative technique included a modified endorectal pull-through after determining the presence of ganglion cells by frozen section. No colostomies were performed before or after operation. Three patients had affected family members. All infants were born at term. Operation was performed within 24 hours of diagnosis and as early as 48 hours of age. Twelve patients had standard rectosigmoid disease, two had total colonic disease, and another had long-segment disease. Bowel function returned within 4 days of operation, and feeding was instituted by postoperative day 6 in all patients. All of the patients with rectosigmoid disease are doing well. Patients with long-segment or total colonic disease had more problems but are currently at home and doing well. Morbidity included two postoperative bowel obstructions and three patients with postoperative enterocolitis.

CONCLUSIONS

A single definitive operation may be used to treat Hirschsprung's disease diagnosed in the newborn. Long-term follow-up in these patients is required.