Surgical management of ambiguous genitalia in the infant and child

Proper gender assignment to a neonate born with ambiguous genitalia is a social emergency of the newborn period. Once an appropriate sex assignment has been made, the next critical step is performance, if needed, of a reconstructive procedure in a timely fashion. In an attempt to evaluate our experience with this unique group of patients, we have retrospectively reviewed the course of 69 children with ambiguous genitalia managed surgically at this institution between 1974 and 1989. This series consists of 32 genotypic females with congenital adrenal hyperplasia (CAH), 10 children with mixed gonadal dysgenesis (MGD), 10 male pseudohermaphrodites, 3 true hermaphrodites, 8 genotypic females with urogenital sinus anomalies (UGS), and 6 genotypic males with bilateral undescended testes and penoscrotal hypospadius. All newborns initially seen at this institution received proper sex assignment within the first week of life. Prior to 1980, 17 of the children with CAH underwent clitorectomy and vaginoplasty and three underwent clitoral recession and vaginoplasty. After 1980, 10 patients with CAH were managed with clitoral recession and vaginoplasty and 2 with vaginoplasty alone. Eight of 10 cases of MGD were given a female sex assignment and all 8 underwent gonadectomy due to the high risk of gonadoblastoma; the other 2 children were raised as males. There were 3 true hermaphrodites of which 2 were assigned female gender roles and were managed with a clitoral recession and vaginoplasty. All 10 male pseudohermaphrodites were raised as females and all underwent bilateral orchidectomy. The 8 children with UGS were raised as females and underwent vaginal reconstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Redo fundoplication in infants and children with recurrent gastroesophageal reflux

The Nissen fundoplication is well established as the surgical treatment for medically refractory gastroesophageal reflux (GER) in childhood. Recurrent GER following fundoplication is a challenging problem with a reported incidence ranging from 0% to 12%. From January 1974 to January 1989, 286 children have been treated for GER with Nissen fundoplication and gastrostomy tube placement at the University of Michigan C.S. Mott Children's Hospital; 242 of these children have been followed for an average of 30 months, the remaining 44 have been lost to follow-up. Twenty-nine children (12%) have developed recurrent reflux following fundoplication. Medical management with thickened upright feelings, gastrostomy feedings, or gastrojejunostomy tube feedings has been successful for 11 children with control of reflux symptoms. Five additional children who were treated nonoperatively died of coexistant medical problems within 2 months following documentation or recurrent reflux. The remaining 13 children have required redo fundoplication for wrap disruption or herniation, and an additional six children, initially treated at other institutions, have also undergone redo fundoplications. One other child treated at this hospital required redo fundoplication for a postoperative partial gastric volvulus causing gastric outlet obstruction. Of the 20 children who have undergone a second Nissen fundoplication, 16 (80%) are doing well without recurrent GER. Four children have developed recurrent GER with wrap disruption; 1 is doing well following a third fundoplication, 2 have been managed successfully with continuous feedings via gastrojejunostomy feeding tubes, and a fourth child died of complications related to a recurrent tracheoesophageal fistula. Conservative management with gastrojejunal tube feedings should be considered in the initial management of children with recurrent GER following fundoplication.(ABSTRACT TRUNCATED AT 250 WORDS)

Hormonal and metabolic response to operative stress in the neonate

It is evident from this review that newborns, even those born prematurely, are capable of mounting an endocrine and metabolic response to operative stress. Unfortunately, many of the areas for which a relatively well-characterized response exists in adults are poorly documented in neonates. As is the case in adults, the response seems to be primarily catabolic in nature because the combined hormonal changes include an increased release of catabolic hormones such as catecholamines, glucagon, and corticosteroids coupled with a suppression of and peripheral resistance to the effects of the primary anabolic hormone, insulin.

Long-term follow-up of brain-damaged children requiring feeding gastrostomy: should an antireflux procedure always be performed?

Due to the frequent presence of latent gastroesophageal reflux (GER) in mentally impaired children, it is now standard to perform upper gastrointestinal contrast (UGI) and pH probe studies in all children referred for feeding gastrostomy, even if they are without clinical evidence for GER. For patients with documented GER, an antireflux operation performed in conjunction with gastrostomy is usually considered mandatory. Some authors have suggested that a "protective" antireflux operation be performed at the time of gastrostomy placement in all brain-damaged children, citing a high incidence of postoperative GER in this group of patients following gastrostomy, even with a negative preoperative evaluation for GER. To evaluate this theory, we prospectively studied, over the past 6 years, all mentally retarded children referred for feeding gastrostomy with UGI contrast and esophageal pH probe studies. In total, 148 children were studied; 105 had a positive evaluation for GER and underwent gastrostomy and antireflux surgery. Of the 43 children with a negative preoperative evaluation for GER, 37 are doing well following gastrostomy alone without clinical reflux at an average follow-up of 21 months. Six of the 43 (14%) developed symptomatic GER occurring at an average of 10 months following gastrostomy placement. Five of these children have been successfully treated with an antireflux operation and the sixth patient has been successfully managed nonoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal aneurysms in childhood: report of a case and review of the literature

Abdominal aneurysms are rare in children and are usually found in association with congenital cardiac or aortic malformations, connective tissue disorders, trauma, or previous arterial catheter placement. A 4-year-old girl who had a common iliac artery aneurysm, who had no history of arterial catheter placement or trauma, and who had no evidence of Marfan's or Ehlers-Danlos syndrome, arteritis, coarctation of the aorta, or other diseases associated with childhood aneurysms is presented. Resection of the aneurysm and arterial reconstruction were performed without the use of prosthetic material or vein graft. Pathologic examination showed no evidence of inflammation or medial degeneration in any of the layers of the arterial wall. This is the fourth report found in the literature of documented idiopathic abdominal aneurysm in a child. The conditions associated with abdominal aneurysms in childhood are discussed, and the literature is reviewed.

Arterial aneurysms in children: clinicopathologic classification

Thirty-one arterial macroaneurysms in 23 pediatric-aged patients (16 boys and 7 girls) were treated at the University of Michigan. The average age at time of diagnosis was 10.2 years (range 6 months to 18 years). Vessels involved the aorta (4), as well as hepatic (1), splenic (2), gastroepiploic (1), renal (12), iliac (1), superficial femoral (4), popliteal (1), brachial (1), radial (2), and ulnar (2) arteries. Twelve children exhibited overt clinical manifestations including presence of a mass (7), local pain (3), hematemesis (1), and painless obstructive jaundice (1). Eleven children had asymptomatic lesions. Aneurysm existence was confirmed by arteriography or operation. All but one child underwent surgical therapy, with 20 long-term survivors (mean follow-up 3.5 years). One operative death occurred and one death occurred 6 years after surgery. This experience and a review of previously reported cases served as a basis for categorization of childhood aneurysmal disease as true aneurysms associated with (I) arterial infection, (II) giant-cell aortoarteritis, (III) autoimmune connective tissue disease, (IV) Kawasaki's disease, (V) Ehlers-Danlos syndrome or Marfan's syndrome, (VI) other forms of noninflammatory medial degeneration, (VII) arterial dysplasias, (VIII) congenital-idiopathic factors, as well as (IX) false aneurysms associated with extravascular events causing vessel wall injury or disruption. Knowledge of the varied clinicopathologic characteristics of arterial aneurysms in children is important in treating these patients.

Contribution of demographic and environmental factors to the etiology of gastroschisis: a hypothesis

We examined the clinical literature on congenital abdominal wall defects to confirm our impression that gastroschisis had become more common than omphalocele. We then examined the teratology literature and noted that congenital abdominal wall defects were frequently induced by teratogens. This lead us to review the antenatal history of 19 infants with gastroschisis and 54 control infants born with a congenital anomaly unrelated to gastroschisis. When compared to controls, mothers of infants with gastroschisis were more likely to have used aspirin during pregnancy and to have been taking oral contraceptives at the time of conception. Additionally, an increased incidence of illegal drug use (particularly cocaine) was noted among the study mothers. We conclude that gastroschisis is becoming the more common congenital abdominal wall defect, and that it could be related to exposure to an environmental teratogen.

Use of high-frequency jet ventilation in the management of congenital tracheoesophageal fistula associated with respiratory distress syndrome

Two preterm infants (28 weeks, 960 g; 32 weeks, 1,870 g) with very large tracheoesophageal fistulas suffered from respiratory distress syndrome and failed to respond to conventional mechanical ventilation despite placement of a decompressive gastrostomy. Pulmonary air leaks developed in both, resulting in transdiaphragmatic pneumoperitoneum, and significant gas flow occurred through the gastrostomy tube despite placement under water-seal. High-frequency jet ventilation was instituted in each case and resulted in improved pulmonary gas exchange at lower mean airway pressure (12.0 to 6.7 cm H2O; 11.0 to 8.0 cm H2O) and in prompt resolution of air leaks. Both patients remained refractory to reinstitution of conventional ventilation until division of the fistula in the first patient and complete resolution of the respiratory distress syndrome in the second.

Current diagnosis and treatment of pheochromocytoma in children. Experience with 22 consecutive tumors in 14 patients

Pheochromocytoma is a rare tumor of childhood. In comparison with adults with pheochromocytomas, children have a higher incidence of bilaterality, familial association, and extra-adrenal location. Fourteen children with 22 tumors were treated during the period 1970 through 1988. Children presented at a mean age of 13 years. Most children (10 of 14) presented with sustained hypertension. The majority of tumors were located with a combination of computed tomography and iodine 131 metaiodobenzylguanidine scanning. Eight adrenal and six extra-adrenal tumors were resected. Four children underwent bilateral adrenalectomy. Follow-up data are available on 9 of the 14 children. All of these patients remain normotensive without medication. Preoperative examination of children with pheochromocytoma using the iodine 131 metaiodobenzylguanidine scan provides an accurate diagnosis of adrenal and extra-adrenal tumors, thus making feasible resection of this rare tumor with complete cure.

Hirschsprung's disease in adolescents and adults

Hirschsprung's disease in the adolescent and adult is a rare and often misdiagnosed cause of lifelong refractory constipation. Two adolescent and three adult patients with Hirschsprung's disease treated between 1973 and 1987 at the University of Michigan Medical Center are reported. Each patient presented with chronic constipation requiring enemas, cathartics, and multiple hospital admissions for management. Diagnosis in each case was made with barium enema and full-thickness rectal biopsy. Four patients underwent endorectal pull-through procedures, all with good long-term results. The fifth patient, initially treated with a Duhamel retrorectal pull-through procedure, required reoperation for constipation secondary to a retained rectal septum. Review of 199 cases of adult Hirschsprung's disease enables comparison of the various operative procedures for this disorder with respect to postoperative complications and functional outcomes. Anorectal myectomy with low anterior resection, the Duhamel-Martin procedure, and the Soave endorectal pull-through procedure are the most acceptable methods for surgical management.

The value of intestinal myotomy and myectomy in improving the reservoir capacity of the endorectal pull-through

In laboratory models of massive small bowel resection and colectomy, intestinal myotomy has been shown to decrease stool frequency and malabsorption. Using physiologic and anatomic parameters of gastrointestinal function, we assessed the ability of three types of ileal myotomies to improve outcome after total abdominal colectomy, mucosal proctectomy, and endorectal pull-through (ERPT) without an enteric reservoir. Twenty puppies underwent ERPT. These dogs were randomly assigned to three experimental groups or a control group consisting of animals without a myotomy. The myotomies were performed by excising the serosa and muscularis propria of the ileal wall in three different patterns. There was no difference between any of the groups with respect to general health, postoperative weight gain, stool frequency, intestinal transit time, water absorption, electrolyte absorption, barium enemas, neorectal capacity and dimensions, and histology.

An analysis of factors contributing to the development of total parenteral nutrition-induced cholestasis

The risk of developmental of total parenteral nutrition (TPN)-associated cholestatic jaundice in neonates receiving intravenous hyperalimentation is high. Numerous factors have been cited as contributing to TPN cholestasis; however, the exact etiology remains obscure. This retrospective study was undertaken in order to identify any factors which might contribute to this syndrome. The hospital records of 172 neonates requiring TPN for a minimum of 1 week were reviewed. In addition, a subgroup of 32 infants requiring TPN for a minimum of 7 weeks was also examined. Cholestasis was defined as a direct serum bilirubin greater than 2.0 mg/dl during the course of TPN therapy. Significant factors for the development of cholestasis in both groups (n = 172, n = 32) included: number of operations (2.56 vs. 1.08, p = 0.0000), the number of days the patients received antibiotics (40.3 vs 12.9, p = 0.0000), and delayed start of enteral feedings (33.8 vs 14.1, p = 0.0000). Fifteen of the 32 patients who received TPN for at least 7 weeks did not develop cholestasis. In this subgroup (n = 32), there were no differences in birth weight, gestational age, days from birth to the start of TPN, or respiratory distress between those who developed cholestasis and those who remained anicteric. In contrast, there were significant differences between the cholestasis and noncholestasis groups in number of operations (13 vs 6, p = 0.0407), and days until enteral feedings were started (33.1 vs 18.9, p = 0.0289). This study suggests that the factor(s) contributing to the development of TPN-associated cholestasis are likely multifactorial. There appears to be a direct correlation between increasing severity of cholestatic jaundice and duration of TPN. This review does add a new parameter to the various causative factors suggested, namely the number of operative procedures. This new variable could be related to the stress of surgery itself or to the repeated administration of anesthetic agents.

A comparison between operative and nonoperative management of blunt injuries to the liver and spleen in adult and pediatric patients

Nonoperative management of blunt trauma involving the liver and spleen has been accepted in stable pediatric patients but has been controversial in adult patients. The purpose of this study was to compare nonoperative management of blunt liver and spleen injuries in adult patients with a similar group of adult patients treated operatively and with a group of pediatric patients treated nonoperatively. A 5-year retrospective study was carried out on all hemodynamically stable patients who came to our institution with blunt abdominal trauma. There were 20 adults treated operatively (group I), 25 adults treated nonoperatively (group II), and 34 pediatric patients treated nonoperatively (group III). The mean acute physiology and chronic health evaluation score for group I was 5.1; group II, 3.1; and group III, 7.9. Delayed splenectomy was required in four adult patients in group I and in one patient in group III. There were no deaths. The mean total blood requirement was 6.0 units for group I, 2.8 units for group II, and 1.7 units for group III. The average hospital stay was 19.1 days for group I, 12.6 days for group II, and 9.2 days for group III. These data suggest that the outcome of adult patients whose blunt liver and spleen injuries are managed nonoperatively is comparable with that of pediatric patients treated nonoperatively and is as good as that of adults undergoing early laparotomy.

Body fluid compartment changes following neonatal surgery

The neonate is born with an excess of total body water (TBW) in the range of 75% to 85% of body weight (v 60% in the adult), which is due to a large extracellular fluid volume (ECF) of 40% to 50% of body weight (v 20% in the adult). In an attempt to define the changes that occur in TBW and ECF following neonatal surgery, the following prospective study was carried out. Twenty newborns with major congenital anomalies (gastroschisis, 10; esophageal atresia, 4; ileal atresia, 3; omphalocele, 2; and malrotation, 1) were studied weekly for 4 weeks following surgery while being maintained on a standard protocol of total parenteral nutrition (TPN). Total body water was measured using deuterium oxide, and extracellular fluid volume was assayed with sodium bromide; both were expressed as percent body weight (BW). Weight gain or maintenance was observed in all infants. TBW remained unchanged (from 85.4% to 83.0%), and ECF decreased from 51.2% to 36.7% during the observation period. The TBW in the ten gastroschisis infants decreased from 87.3% to 78.0% v the ten other newborns, in whom there was no change (84.0% to 85.0%). The ECF changes were more dramatic, decreasing from 51.6% to 32.3% in the gastroschisis infants, v 50.8% to 45.5% in the other neonates (P = .0156). There were no differences between the two groups in the intake and output of fluids. The following conclusions were drawn: (1) Following major surgery, newborns show a steady decrease in ECF and minimal change in TBW in spite of adequate weight gain while receiving TPN.(ABSTRACT TRUNCATED AT 250 WORDS)

Late results of fundoplication for gastroesophageal reflux in infants and children

The Nissen fundoplication (NFP) for the management of severe gastroesophageal reflux (GER) in infants and children has become one of the most frequently performed operations in pediatric surgical centers in the United States. Short-term outcome, morbidity, and mortality are consistently favorable in several large series. The long-term success of this procedure is presumed but has not been established objectively. To examine the late results of this operation, 46 infants and children were carefully evaluated more than 5 years after NFP (mean, 6.7 years). Evaluation included parental interview, physical examination, upper gastrointestinal series, and esophageal pH monitoring. The mean age at the time of operation was 4.13 years. Fifty-seven percent of the patients had significant neurologic impairment, and 80% had at least one serious additional medical problem. Twenty-four percent of the children died during the period of follow-up--all but one death related to serious underlying medical problems. Of the 35 survivors, 26 (74.3%) have no symptoms; five (14.3%) have mild symptoms potentially referable to GER that necessitate little if any treatment; four (11.5%) have had symptomatic recurrence of GER necessitating repeat fundoplication. Three of these patients now have no symptoms. Forty-five percent of the patients had at least one postoperative complication. NFP provides efficacious, long-term treatment of GER in infants and children, with acceptable morbidity. Mortality in this group of children is related primarily to associated diseases rather than to GER.

Postoperative bleeding in cardiovascular surgery. Does heparin rebound really exist?

Postoperative bleeding following cardiovascular procedures is troublesome and often life-threatening. The effect of heparin (H) is usually reversed with protamine sulfate (P) at the end of vascular procedures; subsequent bleeding or abnormal coagulation times are ascribed to so-called heparin rebound and are treated with extra empiric doses of P. H rebound has heretofore been described only by using biologic clotting tests, which are often abnormal postoperatively. Thus, many instances of postoperative bleeding are treated with inappropriate and dangerous doses of P in the mistaken impression that more H needs to be reversed. Using the new test for plasma H, the azure A Assay, which measures H chemically rather than biologically, 27 patients were tested after cardiac bypass surgery to determine whether H rebound truly exists. Azure A levels of H were measured before the bypass procedure and every half hour from 0-8 hours after bypass in routine coronary artery bypass patients. Tests for prothrombin time (PT) and partial thromboplastin time (PTT) were performed simultaneously. The azure A test was performed on 252 samples of blood in the 27 patients; only one sample drawn anytime except immediately after bypass contained measurable H (0.4%). This sample became negative for H in the ensuing 30 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)

Reversal of mortality for congenital diaphragmatic hernia with ECMO

Extracorporeal Membrane Oxygenation (ECMO) has been available to neonates with respiratory failure at the University of Michigan School of Medicine since June 1981. In order to evaluate the impact of this type of pulmonary support, a retrospective analysis of 50 neonates with posterolateral congenital diaphragmatic hernia (CDH) who were symptomatic during the first hour of life and were treated between June 1974 and December 1987 was carried out. The patients were divided into two groups, those treated before June 1981 (16 patients) and those treated after June 1981 (34 patients). Overall survival improved from 50% (eight of 16 patients) during the pre-ECMO era to 76% (26 of 34 patients) during the post-ECMO period (p = 0.06). During the period after June 1981, 21 neonates were unresponsive to conventional therapy and were therefore considered for ECMO. Failure of conventional therapy was defined as acute clinical deterioration with an expected mortality of greater than 80% based on an objective formula previously reported. Six patients were excluded on the basis of specific contraindications to ECMO. Thirteen of 15 infants (87%) supported with ECMO survived. Three patients treated before 1981 met criteria for ECMO; all three died while receiving treatment using conventional therapy. These survival differences are significant (p less than 0.01). In addition, the survival of 87% for the infants treated with ECMO versus the expected mortality of greater than 80% for these same patients when treated with conventional therapy is highly significant (p less than 0.005). Based on this data, ECMO appears to be a successful, reliable, and safe method of respiratory support for selected, critically ill infants with CDH.

Long-term radiographic follow-up of the Nissen fundoplication in children

This study examined 46 children 5-9 years (mean 6.7) after Nissen fundoplication surgery for gastroesophageal reflux (GER). Eleven were deceased and ten of the 35 families declined objective evaluation. The remaining 25 children (71%) had a barium swallow examination. In 16 of the 25 patients the fundoplication was intact. In 2 patients a small portion of the fundoplication was displaced above the diaphragm. In 5 patients there was residual esophageal disease. In 3 patients (one with esophageal disease), with a hiatus hernia prior to surgery, despite immediate postoperative reduction, the barium swallow examination done for this study revealed recurrent hiatus hernia but no GER. Long-term results of the Nissen fundoplication reveal success in eliminating clinically significant gastroesophageal reflux. Those patients with esophageal disease prior to the surgery need close interval follow-up to monitor continuing problems.

Follow-up imaging of benign pediatric liver tumors

Though surgery has been recommended in the past for the management of benign hepatic tumors, the current emphasis is on medical management. This report of 4 cases with long-term (8-28 months) follow-up emphasizes the natural history of these tumors which serves to indicate the advantages and disadvantages of CT and ultrasound. The lesions typically involute with some calcification. Calcification can technically be a problem in follow-up with sonography.

Obstructive jaundice secondary to chronic pancreatitis in children: report of two cases and review of the literature

Chronic pancreatitis is a rare childhood illness, most often presenting with nausea, vomiting, and recurrent abdominal pain. Obstructive jaundice secondary to biliary stricture is an uncommon manifestation of childhood pancreatitis, with only 11 patients previously described in the surgical literature. We report our experience with two additional children with jaundice secondary to pancreatitis and review the literature on this problem. Laboratory tests are often of little diagnostic value, and a high index of suspicion is essential for correct diagnosis. Endoscopic retrograde cholangiopancreatography is emerging as an extremely useful diagnostic study in these patients. The surgical management of this uncommon pediatric illness remains controversial.

The development of necrotizing enterocolitis following repair of gastroschisis: a surprisingly high incidence

We recently observed the development of necrotizing enterocolitis (NEC) in two consecutive newborn infants after gastroschisis repair. Because this association was unexpected, a retrospective review of our 11-year experience was performed using a multivariant computer analysis. The cohort consisted of 54 newborns with gastroschisis. All infants with omphalocele were excluded. Ten of 54 infants (18.5%) developed NEC as defined by classical clinical findings and pneumatosis intestinalis. Twenty-one distinct episodes of NEC occurred with up to three episodes (mean, 2.1) per patient. Twenty of the 21 episodes were successfully treated nonoperatively. Two infants developed pneumoperitoneum, one of whom underwent laparotomy upon which no perforation or intestinal infarction was found. Eight of the ten patients survived--a survival rate no different than for the remainder of the study group. Neither of the two deaths was attributable to NEC. The NEC was atypical in that no significant relationship was established with known predisposing conditions such as prematurity or low Apgar scores. Suspected risk factors such as time of feeding, type of closure, type of formula, total parenteral nutrition (TPN), and composition of TPN were not statistically related. Significant associations included concurrent TPN associated cholestatic liver disease in nine of the ten infants, antecedent intestinal surgery other than abdominal wall closure in five of the ten infants, and delay in initiation of enteral feedings (greater than 30 days) in eight of ten infants. In addition, the NEC occurred significantly later (range, 32 to 79 days; mean, 52 days) in the clinical course than usual; in fact, three of ten infants were rehospitalized with NEC following discharge. We conclude that a relationship exists between NEC and gastroschisis.(ABSTRACT TRUNCATED AT 250 WORDS)

Oxygen free radical activity during live E. coli septic shock in the dog

Free radicals generated during purine catabolism or by activated granulocytes cause tissue injury by peroxidation of lipid membranes. In a canine model of sepsis initiated by intravenous live Escherichia coli, fluorescent products of lipid peroxidation (FP) were measured in serum. Four groups of five dogs infused with 10(9)E. coli/kg were analyzed--I: no further treatment; II: prior depletion of granulocytes with a cytotoxic antibody; III: pre-treatment with superoxide dismutase and catalase; and IV: resuscitation after bacterial infusion to maintain cardiac output greater than 80% of pre-bacteremic levels. In Groups I, II, and III, cardiac output fell to less than 50% of baseline within 1 hr and remained there throughout the study. FP in Groups I and II rose to greater than 200% of baseline (P less than .02 and less than .03). In Groups III and IV, FP did not rise significantly from baseline. The rise in serum FP and the prevention of this rise by-treatment with antioxidants indicate generation of oxygen radicals. Their presence had no effect on hemodynamic parameters. Granulocyte depletion did not alter appearance of FP; however, prevention of low cardiac output blocked FP formation. These data suggest that oxygen free radicals were generated by tissue ischemia, rather than by granulocytes, in this model of septic shock.

A water-sealed indirect calorimeter for measurement of oxygen consumption (VO2), carbon dioxide production (VCO2), and energy expenditure in infants

We have developed a water-sealed infant calorimeter (IC) system which uses the techniques of closed-circuit spirometry to measure oxygen consumption (VO2) in premature and full-term infants. Carbon dioxide production (VCO2) is simultaneously calculated from the effluent mixed expired CO2 and the circulating flowrate. Respiratory Quotient (RQ) and Energy Expenditure (EE) are then calculated from the primary data. Measurement of VO2, VCO2, and calculation of RQ were +/- 5.0% of predicted values determined by burning ethyl alcohol or volume extraction and CO2 infusion in our bench model. Measurement in 11 premature infants produced mean values for VO2 and VCO2 of 8.5 +/- 2.5 ml/min/kg and 8.5 +/- 2.4 ml/min/kg, respectively. This system is noninvasive, does not interfere with infant tube feedings or iv infusions, and permits safe, long-term monitoring of the infant's metabolic activity. It allows a more exact matching or oral or intravenous feedings to the actual energy expenditure of the infants, and offers potential advantages for the nutritional management of sick infants.

Physiologic assessment of the four commonly performed endorectal pullthroughs

The popularity of the endorectal pullthrough for the treatment of benign mucosal diseases of the rectum has created a controversy regarding the need for a reservoir. The four currently advocated procedures, the straight endorectal anastomosis, the J pouch, the S pouch, and the lateral isoperistaltic ileal reservoir were evaluated in a puppy model with four animals in each experimental group. Measurement of rectal capacitance showed that all groups achieved 80-85% of control values at 6 months after surgery. Intestinal transit time decreased by one-half in all groups. Stool consistency, stool culture, water, and electrolyte absorption did not show any statistical superiority of one group over another. Stool frequency varied widely at 6 months; 10 stools per 8-hour period were counted in the lateral reservoir group versus 25 with the J pouches, and 16 with the straight and S groups. Stool frequency did not correlate with transit time, stool consistency, or rectal capacitance. Barium enemas showed that straight pullthroughs more closely resembled the measurements of the normal animal's endorectal canal. Based on these studies, there appears to be no advantage to adding a reservoir to the endorectal pullthrough.

Experience with the straight endorectal pullthrough for the management of ulcerative colitis and familial polyposis in children and adults

The first significant experience with the straight endorectal pullthrough for the management of ulcerative colitis was presented before the American Surgical Association in 1977 by Lester Martin. Since then the operation with or without modification has been used extensively. High stool frequencies in some series led to disenchantment with the straight anastomosis and to the development of various reservoir procedures to increase rectal capacity and thereby reduce frequency. As a result, no large series of straight pullthroughs is available for comparison with the reservoir modifications. Between September 1977 and September 1986, 72 children and adults, 61 with ulcerative colitis and 11 with familial polyposis, underwent endorectal pullthrough (ERPT) and straight ileoanal anastomosis under the overall direction of a single surgeon (AGC). Sixty patients have undergone ileostomy closure and form the basis of this study. Mean age at operation was 22.7 years (range 4-48 yr), and duration of active disease averaged 6 years. One-half of the patients underwent total abdominal colectomy with ERPT as a primary procedure. There were 11 cases of adhesive bowel obstruction following ERPT, and in six patients in the series permanent revision to a Brooke ileostomy was required. One patient died of hepatic failure in the late postoperative period. Follow-up has ranged from 3 months to 9 years. Mean stool frequency for the group as a whole at 3, 6, 12, 24, and 36 months was 11.8, 11.2, 9.6, 9.0, and 8.3 per 24 hours, respectively. Daytime continence was achieved in all patients. Occasional nocturnal soiling occurred in 11.1% of patients at 1 year. Stool frequency and continence were also analyzed by age group above and below 18 years and above and below 30 years. There were no statistically significant differences between these groups. The authors conclude from this study that ERPT with straight ileoanal anastomosis remains an appropriate alternative for children and adults with ulcerative colitis or familial polyposis and compares favorably with the more complicated ERPT involving a reservoir.