Involvement of the appendix in pseudomembranous colitis

Pseudomembranous colitis (PMC) is an inflammatory disorder usually limited to the large intestine and is the consequence of antibiotic associated Clostridium difficile overgrowth with production of its toxin. It has a characteristic gross and microscopic appearance. PMC-like changes, usually associated with peri-operative hypotension and with more extensive gastrointestinal tract involvement, have also been described. In neither clinical setting has pseudomembranous appendicitis been recorded. A case of pseudomembranous appendicitis in a 76 year old woman is described.

Increased cis-atracurium requirements during prolonged administration to a child

PURPOSE

To report increase infusion requirements of cis-atracurium during prolonged infusion (six weeks) to provide neuromuscular blockade in a child during prolonged mechanical ventilation. Despite a previous study in adult patients which demonstrated no increase in infusion requirements over five days, we noted a considerable increase over six weeks.

CLINICAL FEATURES

A seven month old infant required prolonged mechanical ventilation and neuromuscular blockade following an episode of multi-system organ failure from pseudomembranous colitis. The infusion of cis-atracurium was adjusted according to the train-of-four response obtained with a peripheral nerve stimulator using standard train-of-four monitoring. Initial infusion requirements which were 2.8 micrograms.kg-1 min-1 on day #1 increased to 22.3 micrograms.kg-1 min-1 on day #40.

CONCLUSION

Increased infusion requirements were necessary during the prolonged administration of cis-atracurium to a critically ill infant. Titration of the dose based on monitoring with a peripheral nerve stimulator is recommended.

Necrotizing enterocolitis: the impact of the establishment of a Department of Pediatric Surgery on the Beilinson Medical Campus

Necrotizing enterocolitis (NEC) is the most commonly acquired gastrointestinal emergency in neonates. We retrospectively surveyed all cases of confirmed NEC treated at the Beilinson Medical Center (BMC) (now Rabin Medical Center, Beilinson Campus) during a 12 year period to determine whether the establishment of a department of pediatric surgery has influenced the treatment and outcome of NEC patients. Of the 48 patients, 23 were patients treated in the "early period", 1982-87, when surgery was performed in the Department of General Surgery by staff trained in pediatric surgery (group I), and 25 were treated in the "later period" 1988-93, in the same neonatal intensive care unit, with surgical supervision by the new Department of Pediatric Surgery (group II). We found that 32% of the group II patients were of extremely low birthweight (<1,000 g) compared with 13% of group I. They also had lower Apgar scores, and a higher percentage needed respiratory assistance (56 vs. 26%, P = 0.02). All those infants of group II who had been born in other hospitals and were transferred to BMC for treatment were in an advanced state of disease and all required surgery. Total mortality decreased from 22% in group I to 8% in group II. This decrease may be attributed to improved supportive treatment in the neonatal intensive care unit, earlier surgery for NEC based on relative rather than absolute indications, higher rates of primary resection, and better postoperative care. Our review indicates that the establishment of a Department of Pediatric Surgery at the BMC has contributed to the considerable improvement in NEC outcome in our center.

[Surgical treatment of pseudomembranous colitis. Considerations on a clinical case]

Pseudomembranous colitis is an uncommon pathology although the number of cases recorded has risen steadily over the past decades. It is closely correlated with antibiotic treatment and above all affects immunodepressed subjects. It is manifested by a wide variety of clinical symptoms, ranging from simple diarrhea to acute abdomen. The latter, although fortunately extremely rare, often requires surgical therapy.

[Acute necrotizing enterocolitis in an adult--a clinical study]

The authors retrospectively reviewed 24 cases of necrotizing enterocolitis, in which the diagnosis was made or confirmed intraoperatively. This article points to the complex pathophysiology and preoperative diagnostic difficulties of necrotizing enterocolitis due to its clinical heterogeneity and lack of specificity of the laboratory findings. Given all these preoperative problems quite too often the best operatory moment is los and despite the somehow simple intraoperative diagnosis and the modern, well established surgical principles: resection of the necrotic segment with secondary reanastomosis (whenever possible), the post-therapeutic mortality rate remains disappointingly high (70.8%).

Liver hemorrhage during laparotomy in patients with necrotizing enterocolitis

Major liver hemorrhage (LH) without obvious iatrogenic injury was recently observed in several patients during operation for necrotizing enterocolitis (NEC). The purpose of this study was to determine the incidence and risk factors associated with the development of LH in patients with NEC.

METHODS

The hospital charts of patients with NEC who underwent surgical exploration during a 5-year period (1989-1994) were reviewed. The patients in whom LH developed without obvious significant iatrogenic liver injury were compared with those who did not have LH.

RESULTS

Eight of the 68 patients reviewed had LH. The survival rate for those with LH was 13%, compared with 88% for those without LH (P < .001). The patients with LH had a younger gestational age (28 +/- 3 weeks v 32 +/- 5 weeks) and a lower birth weight (1,262 +/- 489 g v 1,649 +/- 666 g); however, the differences were not significant. The patients with LH had significantly lower preoperative mean arterial blood pressure (35 +/- 1 mm Hg v 46 +/- 3 mm Hg; P < .001) and required greater fluid intake (272 +/- 28 mL/kg/d v 186 +/- 9 mL/kg/d; P < .01) for the 24 hours preceding surgery.

CONCLUSION

LH is as an important and lethal complication associated with laparotomy in very small infants with NEC. The presence of hypotension and the administration of large amounts of volume in the preoperative period appear to be risk factors. Earlier surgical intervention and restoration of blood pressure using inotropic agents, once a particular level of fluid administration has been achieved, my be preventive.

Neonatal lipid utilization increases with injury severity: recombinant human growth hormone versus placebo

Increased lipid oxidation has been observed in injured adult and pediatric patients who receive growth hormone (GH). In infants, whose bodies make fat more readily (de novo lipogenesis), this effect has not been tested. After surgery for necrotizing enterocolitis or gastroschisis, 22 neonates (average gestational age, 35 weeks; average postnatal age, 7 days) were provided basal protein-calorie parenteral repletion, and were prospectively randomized to receive either recombinant human GH (rhGH, 0.2 mg/kg/d) or placebo for 6 days. Injury severity was established by serial serum C-reactive protein (CRP) levels (high v low stress: CRP > or = 6.0 mg/dL v < 6.0 mg/dL). Indirect calorimetry was used to measure energy expenditure (MEE), respiratory quotient (RQ), net lipid oxidation (Fe), and lipid oxidative O2 consumption (VO2f). Among the GH+ group, MEE, Fe, and VO2f were significantly higher for the high-stress patients (MEE: 52.87 +/- 13.35 v 42.57 +/- 9.47 kcal/kg/d; P < .03: Fe; 18.32 +/- 27.74 v 0.81 +/- 13.47 kcal/kg/d; P < .02; VO2f: 7.21 +/- 9.86 v 0.01 +/- 7.42 L/d, P < .02), and RQnp was significantly lower in the high-stress patients (RQnp: 0.93 +/- 0.14 v 1.05 +/- 0.11; P < .02). In addition, Fe and RQnp were directly proportional to carbohydrate intake (CHO) in the high-stress patients (CHO to Fe: Pearson r = -.701; CHO to RQnp: Pearson r = .714; P < .05). Lipid oxidation was directly proportional to stress severity, was higher in the GH group (18.32 v 11.91 kcal/kg/d for the placebo group), and was depressed in response to increased CHO intake in all groups. Lipid is an important energy source in acutely injured, especially severely stressed neonates. Lipid substrate utilization is improved with GH supplementation during acute metabolic stress. In addition, excess carbohydrate delivery reduces the amount of lipid utilized for energy metabolism. An appropriately balanced, mixed-fuel formula should be used for caloric repletion in this infant population.

Impact of intestinal lengthening on the nutritional outcome for children with short bowel syndrome

Survival among children with short bowel syndrome has increased with the use of supportive nutritional techniques including parenteral and enteral nutrition. Further improvement in outcome has been sought by using intestinal lengthening procedures to lengthen the bowel, improve intestinal motility, initiate a progressive increase in intestinal mucosal mass, and thereby improve tolerance to enteral nutrition. The authors examine the growth parameters and the tolerance to enteral nutrition in children with refractory short bowel syndrome before and after intestinal lengthening procedures. For seven children, the percentage of calories from enteral nutrition, the medical and surgical complications, and the number of days in the hospital (1 year before and 2 years after the lengthening procedure) were evaluated. The mean birth weight was 1,991 g (range, 1,198 to 3,096 g). The initial diagnoses requiring bowel resection included necrotizing enterocolitis, multiple small bowel atresias, gastroschisis with midgut volvulus, cloacal exstrophy, and long-segment Hirschsprung's disease. The mean length of the residual small bowel was 49 cm (range, 6 to 92 cm). All but one child had surgical resection of the ileocecal valve. The percentage of enteral nutrition calories significantly increased by 9 months after the procedure (P < .008, analysis of variance). Only one child has been completely weaned from parenteral nutrition. All children's growth parameters have been maintained or improved (weight/age, height/age, and weight/height). Few major medical and surgical complications have been observed. Central venous catheter infection has been the most common medical complication. The mean number of hospitalization days decreased during the second year after the lengthening procedure. The authors conclude that the intestinal lengthening procedure enhances the tolerance for enteral nutrition, improves the nutritional status, and decreases the need for hospitalization. The procedure should be considered for children with refractory short bowel syndrome who require prolonged parenteral nutrition.

[Our experience in neonatal surgery in a 15-year period. Follow-up of 1,003 cases]

From 1982 to 1994, 1.003 cases of surgical newborns have been retrospectively studied. Frequency and epidemiology have been evaluated, so as associated malformations. Prenatal diagnosis was made in 72 cases (7.1%). The most frequent entity was intestinal atresia, with 122 cases (12.1%), followed by necrotizing enterocolitis in 80 cases (7.9%), nevertheless this last one was the most frequent finding in preterm newborns. Esophageal atresia was found in 57 cases (5.6%). Association with other malformations was found in 127 cases (12.6%), and 32 cases of them (3.1%) constituted congenital malformations syndromes. The number of surgical newborns has increased in the last years, mainly due to ambulatory surgery. Global mortality of operated patients was 62 cases (5.9%); the highest mortality index was for congenital diaphragmatic hernia (33.5%), followed by necrotizing enterocolitis (28%). Mortality rate has decreased in recent years, due to improving in management and treatment of these patients, and the consolidation of surgical newborn units. Future efforts should be aimed for decreasing in mortality and improving the standard of life of these patients.

Choledocholithiasis in a premature neonate

Choledocholithiasis in neonates and infants has been reported only rarely. Infants with complications of prematurity are more predisposed to development of biliary calculi. With the current widespread use of diagnostic ultrasonography, more neonates may be found to have gallstones and common bile duct stones. We describe a case of choledocholithiasis and cholelithiasis in a premature neonate successfully treated by surgical placement of a cholecystotomy tube and irrigation of the biliary system.

Surgical conditions of the neonatal intestinal tract

Many different pathophysiologic conditions can affect the neonatal intestinal tract and ultimately require surgical intervention. The symptomatology is primarily that of bowel dysfunction and obstruction. A thorough understanding of these disease processes is necessary of the managing physician. With this knowledge, a systematic course of resuscitation, evaluation, and treatment can be instituted, usually with predictably gratifying results for patient, family, and physician alike.

Perinatal intussusception in premature infants

Intussusception is common in infants aged 5 to 18 months, but there have been only 12 reports of its occurrence among premature infants. Nine of these previously reported cases with adequate data and one new case are reviewed. Many of the infants were believed to have necrotizing enterocolitis, leading to an average 12-day interval between the onset of signs and the operation. Bilious emesis or nasogastric contents, bloody stool, and intestinal dilation without pneumatosis intestinalis were common. A contrast enema showed the intussusception in only 1 of 7 cases. Most cases were diagnosed in the operating room and underwent successful primary anastomosis, with no recurrences. A pathological lead point was identified in 2 of the 10 cases. The overall mortality rate was 23%; the one death since 1970 was secondary to attempted hydrostatic reduction. These cases may represent what, in the absence of premature delivery, would have been the intrauterine development of intussusception likely leading to small bowel atresia.

The necessity for T-cryptantigen activation screening in babies with necrotising enterocolitis

OBJECTIVE

To determine the prevalence of T-cryptantigen activation (TCA) and its predictive value for severity of necrotising enterocolitis (NEC) in babies.

STUDY DESIGN

Prospective descriptive.

STUDY POPULATION

Thirty-four babies with NEC were prospectively screened for TCA at Tygerberg Hospital over a 6-month period. TCA screening was done by testing for red blood cell agglutination by the common peanut lectin, Arachis hypogea. Once TCA was confirmed, only washed red cells were administered to the babies and plasma-containing blood products were avoided. NEC was divided into suspected NEC (stage 1), classic NEC (stage 2) and fulminant NEC (stage 3).

MAIN OUTCOME MEASURES

Prevalence of TCA in babies with various stages of NEC; the association between TCA and bowel necrosis, need for surgery and mortality.

RESULTS

TCA was positive in 8 (24%) of the babies in this study. Six babies (18%) had stage 1 NEC, 10 (29%) had stage 2 NEC and 18 (53%) had fulminating or stage 3 NEC. All 18 babies with stage 3 NEC required surgery and TCA was present in 8 (47%) of them. Twelve babies (35%) died, 3 with TCA and 9 with no TCA. Babies with TCA had portal venous gas on abdominal radiographs (P = 0.037) and stage 3 NEC (P = 0.003) more often than babies with no TCA.

CONCLUSIONS

A strong association was noted between TCA and the fulminant form of NEC with bowel necrosis. TCA is a baby with NEC should alert the surgeon to the possibility of severe disease and the need to avoid plasma-containing blood products. Blood banks are urged to introduce routine screening for TCA in all babies with NEC.

Avoidance of stomas and delayed anastomosis for bowel necrosis: the 'clip and drop-back' technique

Necrotizing enterocolitis (NEC) and midgut volvulus (MGV) often are associated with extensive bowel necrosis. These cases may require extensive enterectomy and the formation of high or multiple stomas, and frequently are complicated by short bowel syndrome, excessive fluid losses, fistulas, stenosis, and skin breakdown. This report describes a "clip and drop-back" technique, followed by delayed anastomosis performed 48 to 72 hours later. The technique was successful in five severely ill infants (3 NEC, 2 MGV) with extensive necrosis, bowel perforation(s), and peritonitis, who required either a high stoma near the ligament of Treitz or multiple resections and enterostomies. This method removes obvious necrotic perforated bowel, controls contamination, avoids stomas (and their inherent complications in this age group), and preserves bowel length. All five babies survived. The technique is a useful addition to the pediatric surgeon's operative armamentarium in selective cases.

Necrotizing enterocolitis: late surgical results after enterostomy without resection

Between January 1985 and December 1992, 36 neonates were treated for necrotizing enterocolitis (NEC). 13/36 were treated conservatively and 2 (18%) died. 23/36 required surgical treatment at birth and 6/23 (26%) died; 14, out of 17 surviving initial surgery, underwent reintervention to restore intestinal continuity, 3 to 26 months later. In these 14 infants the acute necrotizing process involved the whole colon and ileum in 3 cases, the whole colon in 5, part of the colon in 3, part of the colon and ileum in 2 and was confined to the ileum in 1. 11 cases were perforated. During their first laparotomy all 14 cases had a decompressive enterostomy without resection. 21 reoperations were later needed in these 14 patients: simple enterostomy closure was performed in only 1 case, while resection of delayed strictures was required in 13. 12 cases underwent partial colectomy, 3 of these had multiple segmental resections for skip lesions and only 1 child had a total colectomy. The only postoperative complication was one anastomotic leak. Two children had short-gut syndrome but later outgrew their need for parenteral nutrition. Our experience does not support the need of resecting the gangrenous bowel in the acute phase. A simple diverting enterostomy seems to be effective treatment. Delaying the intestinal resection up to the time of recanalisation allows spontaneous healing and results in the sparing of a significant length of bowel.

Necrotizing bowel lesions complicated by Pseudomonas septicaemia in previously healthy infants

Two previously healthy infants with Pseudomonas septicaemia presented with necrotizing bowel lesions. Necrotizing bowel lesions should be suspected when infants presenting with a history of diarrhoea, develop abdominal distension and toxic signs. Pseudomonas aeruginosa should be regarded as one of the important aetiologies in such disorders, especially if there is associated neutropenia and ecthyma gangrenosum-like lesions. Antibiotics must be able to cover this pathogen to avert a catastrophic outcome.

CONCLUSION

The intestine should be considered a possible site of involvement in Pseudomonas sepsis and special attention should be paid to examination of the abdomen.

The anastomotic stoma: a useful procedure in emergency bowel surgery

In emergency surgery of the bowel a primary anastomosis may be risky. Discontinuing colostomies have the disadvantage that a secondary laparotomy is necessary to restore continuity. If sufficient bowel loop mobilization is possible, we prefer to perform an anastomotic stoma. After resection of the diseased bowel segment, we bring the proximal and distal loop together and proceed to the anastomosis of the posterior wall. The anterior wall of the anastomosis remains open and is then fixed to the abdominal wall as a stoma. So far, we have used this method in 91 patients. In 73 cases this technique was performed during emergency operations. No patient died as a result of complications of the method: 21 patients, however, died as a consequence of their primary disease. Bowel continuity could be restored in 78 cases. The anastomotic stoma protects the posterior wall from elevated pressure and allows daily control of the anastomosis. In the case of extraperitoneal closure, a secondary laparotomy for reconstruction of the continuity is not necessary. The anastomotic stoma can be performed in most regions of the small and large bowel.

Trends in pediatric ostomy surgery: intestinal diversion for necrotizing enterocolitis and biliary diversion for biliary hypoplasia syndromes

Ostomies are placed in children for different indications than in the older population. Many ostomies of childhood are placed because of congenital or neonatal problems that require temporary or long-term diversion to stabilize the neonatal patient. Necrotizing enterocolitis, the most common reason for placement of neonatal colostomies and ileostomies, is increasing in frequency as more prematurely born infants survive. Recently, there has been an increase in treatment of various biliary hypoplasia syndromes with biliary cutaneous diversion. Children with biliary hypoplasia syndromes are a challenging group of patients who frequently can be helped by ostomies. This article reviews current information on biliary cutaneous diversion for the biliary hypoplasia syndromes and intestinal diversion for necrotizing enterocolitis.

[Retrospective analysis of 80 cases of neonatal necrotizing enterocolitis]

We present the cases of necrotizing enterocolitis (NEC) treated in our hospital between 1980 and 1994, in order to analyze the risk factors that appear in the disease. We elaborate treatment and follow-up protocols. Prematurity, low birth weight and perinatal stress have a significant influence in NEC. Hemodinamic inestability, bloody stools, abdominal distension with decrease gastric outlet, along with significant radiological evidence in 90 percent of the cases, should rise suspition of NEC. We find fundamental the prevention of the disease in premature newborns with risk factors. Mean gestational age was 33 weeks. Prematurity was found in 87.5 percent of the patients, with a mean birth weight of 1683 g. Symptoms appeared at the age of 14 days. 32 percent of the cases were operated, 13 cases (16%) presenting with pneumoperitoneum, and a Mortality rate 15 percent. We treated 15 patients with colonic stenosis by resection and end-to-end anastomosis, with 6 percent mortality global mortality rate for NEC has been 28 percent.

Neonatal necrotizing enterocolitis. A 12-year review at a county hospital

PURPOSE

A retrospective, 12-year review of neonatal necrotizing enterocolitis was undertaken at a county hospital, with emphasis on presentation signs and symptoms.

METHODS

Eight-two patients with presence of intramural air were included in the study. The following signs and symptoms were studied: evidence of respiratory distress, use of umbilical catheters, white blood cell count and temperature at presentation, time interval from birth to diagnosis and time interval from diagnosis to operative intervention, presence of intramural air, air in biliary tree or free air, changes in abdominal girth, and presence of occult or gross blood in stools. Comparison was done among infants who had surgical or medical treatment, premature and full-term infants, and infants who had neonatal necrotizing enterocolitis less than or more than 20 days after birth.

RESULTS

Eleven patients had a fatal outcome, with an overall survival of 87 percent. Sixty-four patients were treated medically and 18 had operative treatment. Mortality of the surgically treated group was 44 percent. Neonates who had surgical intervention had a left shift of the white blood cell count more commonly present, and all had documented abdominal distention. There were 62 premature and 20 full-term neonates in the group. Full-term neonates developed neonatal necrotizing enterocolitis earlier after birth (5.3 days compared with 15.3 days in the premature neonate group). Full-term neonates had a better prognosis in our series. Presentation of symptoms more than 20 days after birth did not change outcome.

CONCLUSION

Our results reflect the experience of a community-based hospital. Clinical acumen remains the cornerstone of diagnosis and management.