Experience with the Nissen fundoplication for correction of gastroesophageal reflux in infants

In the past 15 years at Children's Hospital in Washington, D.C., approximately 500 infants under 1 year of age have been evaluated because of symptomatic gastroesophageal reflux. A contrast esophagogram will demonstrate reflux in the majority of affected infants. However, this diagnostic method is not always reliable. Timed monitoring of esophageal pH, and extended radionuclide scan even in infants can document accurately the frequency and character of episodic reflux. Following diagnosis, most infants are treated by conservative therapy, which includes the upright position. Of the 500 patients, 72 infants (14%) were selected for operative correction using the Nissen fundoplication. The indications for surgery in these infants with gastroesophageal reflux were: (A) failure to thrive, (35); (B) chronic respiratory infection, (24); (C) apnea spells, (8); and (D) esophagitis. One infant was found to have a stricture. In these symptomatic patients, three had previous operative correction of esophageal atresia, and two had congenital gastric dislocation in the chest.

RESULTS

61 excellent; six recurrences, of whom five are satisfactory after a second operation; two lost to follow-up but doing well when last seen; three deaths from causes unrelated to reflux. The selection of infants with gastroesophageal reflux for surgical correlation is primarily based on life-threatening clinical effects. The Nissen fundoplication has worked well in this group of infants.

Reconstruction of the renal artery after unsuccessful percutaneous transluminal angioplasty in children

The use of percutaneous transluminal angioplasty as the primary treatment of renovascular stenosis in adults has recently been described. Previously, only three children have been reported to have undergone transluminal angioplasty for stenosis of the renal artery and hypertension. At our hospital, transluminal angioplasty was attempted in four children with renal artery stenosis; one attempt was successful and three were unsuccessful. The three patients who required surgical repair of the renal artery after unsuccessful transluminal angioplasty have been described in detail. The histopathology of the stenotic vessels is also discussed. Based on the analysis of the three children, certain criteria have been derived to select pediatric patients with renovascular hypertension either for attempted transluminal angioplasty or for primary surgical revascularization.

Omphalocele and gastroschisis: different entities, similar therapeutic goals

Omphaloceles, varying widely in size and content, result from incomplete central fusion of the four somatic plates that come to form the abdominal wall. Gastroschisis, which permits the midgut to spill freely out of an otherwise properly formed abdominal wall, comes about from rupture of the cord membrane at its site of attachment to the umbilical skin. The advent of parenteral nutrition was a signal advance for babies born with both of these anomalies, allowing for their support while various surgical maneuvers are used to reconstruct the abdominal wall.

Abdominal wall reconstruction in the prune belly syndrome

In our institution, 12 patients have been encountered with prune belly syndrome. Eight children have undergone evaluation of their abdominal musculature by electromyography. Results of their studies show that major functioning or recoverable muscle exists in the lateral and upper sector of the abdomen, but that little or no muscle exists in the lower central abdomen. Based in part on these findings, an operation has been devised which spares all potentially functioning musculature and corresponding motor nerves, and disposes of nonfunctioning and nonrecoverable muscle. In terms of cosmetic appearance and gross motor testing, these growing boys show significant improvement.

Surgical correction and rehabilitation for children with "Prune-belly" syndrome

Until the recent past, patients born with congenital absence of the abdominal musculature, and associated deformity of the urinary collecting system, have often had an unhappy life and an early death. Twelve years ago, a treatment protocol was devised in our institution which included the following major steps: 1) bilateral tubeless pyelostomy immediately after birth; 2) serial evaluation of renal status during the first year of life; 3) laparotomy at one year of age with orchiopexy, reconstruction of the urinary collecting system and reconstruction of the abdominal wall; 4) serial electromyographic evaluation of the growth and development of the lateral abdominal musculature; 5) serial studies of renal function; 6) secondary revision of the abdominal wall and of the urinary drainage system as needed. Nine patients so treated have been followed from the third through the twelfth years of life. All are alive and growing well. Four patients had chronic urinary infection treated with long-term antibiotics; three of these have required a second surgical correction of some aspect of the urinary drainage system. Three patients have required additional surgery on the abdominal wall, but have recaptured enough function so that corsets and other devices have not been necessary. Electromyographic studies show good growth and development of some aspects of the lateral abdominal musculature which has been used in the repair. The outcome in these patients is highly encouraging for this constellation of anomalies. The cause remains controversial.

Surgical correction of familial diaphragmatic hernia of Morgagni in the Golden Lion Tamarin

The Golden Lion Tamarin (Leontopithecus rosalia) is an endangered species of primate indigenous to the coastal rain forest of Brazil. Since 1971 a propagation and behavioral research program has been carried out on a colony of these monkeys at the Zoological Park. Several related animals have died and at necropsy have shown absence of the anterior portion of the diaphragm with a variety of abdominal viscera in the thorax. Diagnostic studies undertaken on the living members of the colony include plain chest radiographs and gastrointestinal series. Four of the animals have been found to have major diaphragmatic defects with the liver, stomach, spleen, colon, and portions of the intestine in the chest. In three of the animals so affected clinical signs of failure-to-thrive were clearly manifest, although one female born in 1968 has reproduced successfully for 8 yr with no deleterious clinical effects from the hernia. Surgical repair of the diaphragm with relocation of the abdominal viscera has been carried out in three of the animals under a combination of intravenous and intra-tracheal anesthesia. The monkeys weighed 550, 685, and 710 g, respectively. All three Tamarins have survived the operative procedure, and subsequently have shown improved clinical status. These cases have been instructive from the genetic point of view, the major anatomical defect, the type of repair necessary, and the postoperative care in small vigorous mammals. Additionally this study documents a familial factor in diaphragmatic defects in higher mammals.

Diagnosis and repair of familial diaphragmatic defects in golden lion tamarins

Diaphragmatic defects were identified in 11 of 130 golden lion tamarins. Seven of the cases were found at necropsy (52 tamarins) and 4 were diagnosed by radiography (78 tamarins). When screening radiography revealed a thoracic mass, a barium series was indicated and either demonstrated loops of bowel within the thorax or suggested liver displacement by the cranial location of the intestine. In 1 case, pneumoperitoneum aided in the diagnosis, by showing liver displacement cranially in an eventration of the diaphragm. The 4 defects diagnosed clinically were successfully corrected surgically. The defects mainly involved the ventromedial to lateral aspect of the costal and sternal muscular portions of the diaphragms. Either a thin pleuroperitoneal sac remained or wide gaps were associated with herniation of abdominal contents into the thorax. Of the 11 affected tamarins, 10 were closely related and the other had no direct consanguinity. An autosomal recessive mode of inheritance was suggested, but other genetic factors may have been involved.

Modulation transfer characteristics of an acoustooptic deflector

The modulation transfer function of an acoustooptic deflector is described in terms of device parameters. The transfer function is calculated with the autocorrelation theorem assuming a truncated gaussian pupil function.