Symptomatic Helicobacter pylori infection in young patients with severe neurologic impairment

Helicobacter pylori infection was identified in five patients with profound neurologic impairment who were undergoing evaluation for gastrointestinal symptoms, and it was subsequently identified in 7 of 61 patients with symptoms whose condition was evaluated prospectively. Institutionalized patients were at greater risk of infection. Treatment of H. pylori infection resulted in symptomatic improvement for the majority of patients.

Hypoplastic left heart syndrome: anesthetic care prior to transplantation or surgical palliation

Hypoplastic left heart syndrome is the most common lethal cardiac defect in neonates. Options for treatment include cardiac transplantation and surgical palliation. When cardiac transplantation is chosen as the preferred option, a considerable delay may occur until a suitable donor is available. During this time, anesthetic care may be required for various surgical procedures. Associated anomalies seen in these infants and the anesthetic implications imposed by the abnormal cardiac anatomy are discussed.

Metastatic implantation of an oral squamous-cell carcinoma at a percutaneous endoscopic gastrostomy site

Percutaneous endoscopic gastrostomy (PEG) has become an important adjunct in the care of the head-and-neck cancer patient. When resection will likely affect swallowing, PEG can be performed just prior to cancer resection. However, it is unclear whether PEG should be the procedure of choice for establishing enteral access in head-and-neck cancer patients. In this report we describe a man with advanced oral squamous cell carcinoma who had a One-Step PEG button inserted immediately prior to his cancer resection. Six months later, the patient developed metastatic squamous-cell carcinoma at the PEG site. Although the mechanism of spread cannot be confirmed, direct seeding from passage through the cancer-filled oral cavity seems likely. Methods of establishing enteral access which avoid tumor-contaminated fields, such as use of an overtube during conventional PEG, open gastrostomy, or laparoscopic gastrostomy, may be more appropriate in head-and-neck cancer patients.

Gallbladder emptying after antiulcer gastric surgery

It has been shown that truncal vagotomy with pyloroplasty (TVP), but not highly selective vagotomy (HSV), delays the onset, decreases the extent, and changes the pattern of gallbladder emptying. The aim of the present study was to investigate any alterations in gallbladder emptying after a variety of antiulcer gastric surgery, by milk-technetium 99m (99mTc)-dimethyl iminodiacetic acid (HIDA) scintigraphy. After excluding the cases with spontaneous gallbladder evacuation before milk ingestion, there were 26 controls, 41 duodenal ulcer (DU) patients, 22 after HSV (15 prospective cases), 50 after TVP (23 prospective cases), 8 after TV with gastrojejunostomy (TV-GJ), 10 after Billroth I gastrectomy, and 29 after Billroth II gastrectomy. None of the patients with gastrectomy had additional vagotomy. TVP significantly delayed the onset and decreased the rate of gallbladder emptying as compared with the control, DU, HSV, and Billroth I groups. TVP also changed the pattern of emptying in 20% of the cases (sequential emptying and refilling events). Antiulcer operations excluding the duodenum (TV-GJ and Billroth II) further reduced the rate of gallbladder emptying as compared with (1) control, DU, HSV, and Billroth I groups (P < 0.0001) and (2) TVP (P < 0.001). Onset of gallbladder emptying was not affected by Billroth II gastrectomy, but was significantly delayed by TV-GJ (P < 0.001). The latter two operations also significantly changed the pattern of gallbladder emptying, exhibiting sequential emptying and refilling events, in most cases (P < 0.01 versus TVP). In conclusion, all antiulcer procedures, except HSV, greatly disturb the pattern, the onset, and the rate of gallbladder emptying. Truncal vagotomy seems to disrupt vagally mediated preduodenal mechanism, resulting in delayed onset and reduced rate, whereas duodenal exclusion by gastrojejunostomy results in severely decreased rate of gallbladder emptying.

The successful application of jejunal interposition for severe dumping syndrome: report of a case

We report herein the case of a 76-year-old man with intractable dumping syndrome which had manifested itself 3 years after he underwent a gastric resection and Billroth I reconstruction for a gastric ulcer. Despite aggressive medical therapy by the time of admission, he had suffered from disabling dumping symptoms for 9 years. In an attempt to relieve these symptoms, a 15-cm segment of the jejunum was placed isoperistaltically between the lesser curvature of the remnant stomach and the duodenum, and a selective vagotomy was performed. The dumping symptoms that he had experienced preoperatively completely disappeared after the revisory surgery. Postoperatively, an upper gastrointestinal series demonstrated a larger gastric pouch and slower gastric passage into the small intestine than what was seen preoperatively, while gastric emptying studies using the acetaminophen method also showed normal patterns in both the early and late postoperative phases. Thus, we consider that this surgical procedure is a simple and effective way to inhibit rapid gastric emptying and to slow intestinal transit in the treatment of dumping syndrome.

The inclusion of an omental flap in pancreatoduodenectomy

A technique for reducing the morbidity and mortality of pancreatoduodenectomy by using an omental flap to protect the anastomoses and splanchnic vessels exposed during dissection is described herein.

Enteral access

The enteral route is the preferred method of nutrition support in patients with functional gastrointestinal tracts. Many techniques for obtaining enteral access are available, and the decision regarding which one to use depends on several issues, including anticipated duration of support, aspiration risk, and local expertise. Using laparotomy, laparoscopy, fluoroscopy, or endoscopy, tubes can be placed into the stomach, the duodenum, and the jejunum. Nasogastric and nasoenteric tubes are useful for short-term supplementation; however, patients needing support for more than 6 weeks may be better served with a more permanent tube. In this review, specific methods for obtaining enteral access are discussed along with their advantages and disadvantages.

Undernutrition in children with a neurodevelopmental disability. Nutrition Committee, Canadian Paediatric Society

OBJECTIVE

To offer guidelines for optimal nutritional care in children with a neurodevelopmental disability and an associated impairment in their ability to eat and drink.

OPTIONS

Assessment of nutritional status by skinfold thickness measurement, high-energy nutrition supplementation given orally and feeding by nasogastric tubes, gastrostomy tubes or gastrojejunal tubes.

OUTCOMES

Children receiving adequate nourishment are generally calmer and appear more normal than those who are undernourished. Patients with less severe disabilities have an increased functional status with improved nutrition. In patients with gastroesophageal reflux and aspiration of food, the use of gastrojejunal tubes prevents pneumonia and reduces the need for surgery to correct the reflux. Economic benefits of various options were not considered.

EVIDENCE

Members of the Nutrition Committee of the Canadian Paediatric Society, most of whom are involved in caring for children with a neurodevelopmental disability, reviewed the literature. Members interpreted the literature and developed the guidelines on the basis of their experience and research activities.

VALUES

Improved psychologic, nutritional and functional status were all given a high value.

BENEFITS, HARMS AND COSTS

Supplemental tube feeding allows caregivers to devote less time to feeding and more time to stimulating and educating children with this type of disability. The need for surgery to correct reflux, along with the associated risks and costs, has been greatly reduced with the development of percutaneous placement of the gastrostomy and gastrojejunal tubes.

RECOMMENDATIONS

It is unacceptable not to treat undernutrition associated with a neurodevelopmental disability. Management of nutrition in patients who require tube feeding is greatly simplified by the use of percutaneous enterostomy. Energy needs in children with this type of disability are lower than in other children, ranging from 2900 to 4600 kJ per day. Because they require less energy, such children should be given a formula designed for children less than 6 years of age that has a high ratio of nutrients to energy. Every effort should be made to improve the oral-motor skills of children with a mild disability.

VALIDATION

The guidelines were reviewed and approved by the board of the Canadian Paediatric Society. There are no equivalent guidelines from the Committee on Nutrition of the American Academy of Pediatrics.

The role of pancreatogastrostomy following pancreatoduodenectomy for trauma

The records of all patients undergoing pancreatogastrostomy after pancreatoduodenal resection at the University of Kansas Medical Center were reviewed. Five patients with a mean age of 26 years (range, 20-32 years) and severe penetrating (n = 3) or blunt (n = 2) traumatic injuries have required pancreatoduodenectomy followed by pancreatogastrostomy (n = 4) or pancreatogastrostomy alone (n = 1) since 1975. Their mean Trauma Score was 12 (range, 9-16). All five patients had soft, previously normal pancreatic glands without induration or ductal dilatation. The mean duration of surgery was 6 hours (range, 5-7 hours), mean blood loss was 7200 mL (range, 1,000-17,500 mL), mean transfusion requirements were 14 units of blood (range, 2-32 units), and mean hospital stay was 37 days (range, 11-90 days). Two patients developed right upper quadrant abscesses that required a second procedure. There were no pancreatic anastomotic leaks, fistulas, or other complications related to the pancreatogastrostomy. At last examination, all five patients were alive and well and had not developed endocrine or exocrine pancreatic insufficiency after a mean follow-up of 4 years (range, 1-9 months). Pancreatogastrostomy following pancreatoduodenectomy for trauma has not been previously reported. Our experience demonstrates that pancreatogastrostomy is a safe and expeditious method for handling the pancreatic remnant following pancreatoduodenectomy. Furthermore, the results of this study suggest that pancreatogastrostomy has several advantages over pancreatojejunostomy for restoring pancreato-intestinal continuity in trauma patients.

Laser therapy for esophageal cancer. Results and additional endoscopic treatments

Between 1/1/1988 and 5/31/1991, we treated 96 patients with laser therapy to the esophagus. In 61 inoperable patients, laser therapy has been performed initially. In 64% of these 61 patients, laser therapy alone gave sufficient relief of symptoms until death. However, in 36% of the patients, additional endoscopical interventions had to be performed. In 14 patients (23%), a prosthesis became necessary; 13 patients (21%) needed a percutaneous endoscopical gastrostomy. We conclude that laser therapy has an important role in the treatment of esophageal cancer, but in a significant number of patients, it might not be sufficient alone.

Pure esophageal atresia: a 50-year review

This review encompasses 50 years (1942 through 1991) and 69 newborns (43 boys, 26 girls). Half the babies were premature (weighing less than 2.5 kg), and about one third had other anomalies. The procedures used in this series were late primary anastomosis (17), gastric tube reconstruction (16), staging esophagostomy and gastrostomy (13), gastric pull-up (13), early primary anastomosis (4), and colon replacement (3). Four neonates received no treatment. The most common repair in the 1940s and 1950s was the gastric pull-up; the gastric tube was the most popular in the 1960s and 1970s. Delayed primary anastomosis has been the operation of choice since the 1980s. Over the last decade, it has become apparent that primary repair is successful in three quarters of such infants if the wait is 3 months and/or the newborn weight has at least doubled. This repair appears to provide the best functional result, unless there is an anastomotic stricture. Before the 1970s, the survival rate was below 40%, but since the 1980s the rate has more than doubled, to 90% in our series, regardless of the type of repair used.

Minimal access gastroduodenal surgery

Considerable advances are occurring in the application of laparoscopic techniques to gastrointestinal and hepatobiliary disorders. Following studies in experimental animals, surgeons with an interest in gastroduodenal disease have now introduced laparoscopic techniques into current surgical practice. Elective intervention for peptic ulcer disease is currently being established, particularly in patients with proven negative Helicobacter pylori (HP) status, or when eradication has proved unsuccessful with various drug regimens. In addition, emergency laparoscopic intervention for perforation is gaining acceptance, with or without a definitive anti-ulcer procedure. Therapeutic endoscopy for bleeding peptic ulcer may well be followed by anti-ulcer laparoscopic surgery in selected patients. Laparoscopic techniques have been utilized for the treatment of Mallory Weiss tear, congenital hypertrophic pyloric stenosis, Dieulafoy's lesion, gastric trauma or volvulus and benign gastric tumours. More ergonomic instruments are required before laparoscopic gastric resection becomes more widely acceptable. It is essential that objective evaluation of variations on vagotomy themes be undertaken in prospective clinical trials and that the safety and efficacy of gastric resection procedures be substantiated if this renaissance is to revolutionize gastroduodenal surgical practice.

Results and complications of Toupet partial posterior wrap: 10 years' experience

A 270 degrees posterior wrap, described by Toupet, was performed in 112 patients with medically refractory gastroesophageal reflux (GER) over a 10-year period. The mean age was 39 months (range, 2 months to 19 years). Thirty percent of the patients were neurologically impaired (NI). The approximation of the crura, the posterior fixation of the wrap, and the posterior partial fundoplication were performed with nonabsorbable sutures, over a bougie. Thirty percent of the NI and 15% of the neurologically normal (NN) children underwent a gastrostomy. Early postoperative complications were found in 24% of NI and 18% of NN children; these were treated medically, except for two bowel obstructions. Eight patients died for reasons unrelated to surgery, and nine were lost to follow-up. The mean follow-up period for the 95 remaining patients was 3.5 years for NI and 4.9 years for NN children. The evaluation showed that 6 patients had temporary dysphagia and two had food impaction. Nine wrap herniations (10%) were found; three of them without symptoms were noted by routine upper gastrointestinal series and received no treatment. Six wrap herniations with recurrent reflux were reoperated on successfully. With 90% of patients free of symptoms, the results of the Toupet procedure compare favorably with those of the Nissen fundoplication because of the retained ability to belch or vomit.

Weight gain and triceps skinfolds fat mass after gastrostomy placement in children with developmental disabilities

OBJECTIVE

To determine appropriate outcome indicators of nutritional status that are measurable over time after gastrostomy placement in children with severe neurologic impairments.

DESIGN

Twenty-two nonambulatory children met the selection criteria: feeding by gastrostomy of at least 50% of total energy, age between 1 and 12 years, diagnosis of neurologic impairments, and presurgical recommendation for weight gain. Each child served as his or her own control; three assessments were made after gastrostomy placement.

SETTING

Children were seen in specialty outpatient clinics.

STATISTICAL ANALYSES

Scores and Pearson product moment correlations.

RESULTS

Outcomes of gastrostomy placement were (a) increase in actual weight, (b) increase in weight-age equivalent, (c) rate of weight accretion as expected by National Center for Health Statistics growth charts and improved z scores for half of the children, and (d) improvement in triceps skinfolds percentiles for nearly half (n = 10) of the children. The results reflect the heterogeneity of children with severe disabilities. Pearson correlations showed a significant relationship between chronologic age and weight-age equivalent (r = .96), but not for weight for age and weight-age equivalent, or triceps skinfolds fat mass and weight-age equivalent.

CONCLUSIONS/APPLICATIONS

Weight and triceps skinfolds fat mass were appropriate outcome indicators of nutritional status measurable over time. Weight-age equivalent and z scores were more helpful than standard growth plots for interpreting weight gain over time. Our data also support findings that undernutrition limits growth before gastrostomy placement in patients with disabilities. Nutritionists are encouraged to track improvement in nutritional status after gastrostomy placement with measurements of triceps skinfolds fat mass and to use the information to support families facing decisions about the need for this surgery.

[Duodenal atresia]

The article deals with 5-year (1986-1992) experience in the diagnosis and treatment of duodenal atresia in 26 infants. Timely diagnosis of this developmental anomaly, the variants of operative treatment, and the principles of postoperative management are discussed. The necessity of antenatal ultrasonic examination and the high diagnostic value of radiological and endoscopic methods of diagnosis are emphasized. Operations were conducted on 25 children for total high intestinal obstruction, on 23 infants in the neonatal period. The continuity of the intestinal tube was restored by duodenoduodenostomy (12), duodenojejunostomy (3), gastroduodenostomy (1), excision of the membrane (4), and dissection of the membrane (5). The latter is technically the simplest and is the operation of choice. Preliminary jejunostomy for adequate preparation for the radical operation is recommended in profoundly preterm infants with as serious premorbid background. Of high importance is postoperative enteral catheteral feeding which is begun from the first day after the operation. Seven out of the 26 patients died from severe combined developmental anomalies and infection. The mortality was 26.9%.

Early identification and treatment necessary to prevent malnutrition in children and adolescents with severe disabilities

Children with severe developmental disabilities frequently have nutrition and growth problems that range from moderate to severe. Because of notable continuing medical concerns and lowered growth expectations, parents and physicians may fail to recognize gradual deterioration in nutritional status before severe medical complications occur. The two cases reported in this article illustrate the need for early identification and treatment to prevent the development of notable morbidity secondary to malnutrition. Children and adolescents who have growth parameters consistently below age norms require assessment and monitoring by a registered dietitian to detect feeding problems and intake changes and to provide early intervention to help prevent negative consequences (eg, dehydration, protein-energy malnutrition, decubitus ulcers, increased rate and duration of infections, and altered bowel motility). An initial assessment should consist of measurement of length or height, weight, triceps, and subcapsular skinfolds; dietary and feeding history and a review of medical history; and biochemical testing as indicated by the medical and dietary histories. Monitoring frequency, which is determined by age, severity of condition, and response to treatment, may vary from weekly to bimonthly.

Gastrostomy tubes after gynecologic oncologic surgery

In order to prevent the complications of long-term nasogastric suctioning and increase patient comfort, we have been using gastrostomy tubes (G-tubes) in gynecologic oncology patients who are deemed to be at risk for protracted postoperative bowel dysfunction. This study describes our patient selection criteria and evaluates the results with 35 MIC (Medical Innovation Corporation, Milpitas, CA) gastrostomy tubes inserted between September 1, 1992 and April 30, 1993. The procedure is technically easy and adds approximately 10 min to operating time. The tubes were well tolerated by the patients over periods ranging from 5 to 135 days. All tubes were used for postoperative gastric drainage and in addition, eight tubes were used for short-term enteral feeding. One patient with short bowel syndrome continued enteral nutritional supplementation at home. Twenty patients were discharged with their G-tubes in situ. Five of these patients required continuous gastric drainage because of obstruction of gastric emptying or small bowel by advanced tumor, and four of them were taking full liquids orally prior to discharge from the hospital. Gastrostomy tubes are convenient adjuncts to postoperative care of the gynecologic oncology patient and afford palliation with few complications to patients dying with bowel obstruction.

[A case of free jejunal graft for anastomotic recurrence after subtotal esophagectomy]

A case of anastomotic recurrence after a radical operation for thoracic esophageal carcinoma is presented. A 68-year-old male was treated by subtotal esophagectomy and esophagogastrostomy through retrosternal route. One year after the operation he experienced dysphagia and anastomotic recurrence was detected by an upper gastrointestinal series and fiberscopy. He was admitted to our hospital for radiation therapy. The response was poor and dysphagia wasn't disappeared after radiation therapy at a dose of 10,200 rad. He was consulted to our surgical department for operative therapy. Cervical esophagectomy, partial resection of gastric tube and free jejunal transplantation for the reconstruction were performed. He had been eating anything of food after the operation.

Vagovagal inhibition of motilin-induced phase III contractions by antral acidification in dog stomach

Gastric acidification at pH 1.0 strongly inhibits the spontaneously occurring and motilin-induced phase III contractions in canine and human stomach. In this study, we examined inhibition by gastric acidification in dogs following gastrojejunostomy, truncal vagotomy, and antrectomy. As a result, gastric acidification with 0.1 N HCl solution at pH 1.0 for 30 min at a rate of 1.0 ml/min significantly inhibited motilin-induced phase III activity to 23.5 +/- 5.9% of the control in the normal intact dogs and to 17.2 +/- 3.4% in the gastrojejunostomized dogs. In the antrectomized dogs, gastric acidification did not significantly inhibit the action of motilin (81.7 +/- 10%), but, in the vagotomized dogs, gastric acidification inhibited the action of motilin to 72.0 +/- 4.9%; the inhibition was much weaker than in the intact and gastrojejunostomized dogs but was significant. The duodenal acidification had no effect at all on the action of motilin (94.6 +/- 12.5%) in the gastrojejunostomized dogs. These findings strongly suggest the existence of a vagovagal reflex in the inhibition of motilin-induced phase III contractions by gastric antral acidification, although the involvement of sympathetic regulation cannot be completely ruled out.

The clinical challenge of multiple pancreatic pseudocysts

To evaluate the frequency of multiple pancreatic cysts, the likelihood of preoperative diagnosis, and therapeutic outcome, we retrospectively reviewed the records of 157 patients who underwent operation for pancreatic pseudocysts at 2 institutions between 1970 and 1992. Multiple pseudocysts were found in 29 (18.5%). The 8 women and 21 men ranged in age from 21 to 79 years. The etiology was alcohol abuse in 15 (52%), biliary tract disease in 6 (21%), alcohol abuse and biliary tract disease in 3 (10%), and a variety of other causes in the remaining 5 (17%). There was no difference in age, sex, race, etiology, or presenting signs and symptoms between patients with single pseudocysts and those with multiple cysts. Serum amylase levels were significantly higher in patients with multiple cysts compared to those with single cysts (P < 0.05). Computed tomography accurately demonstrated the extent of disease in 20 of 25 patients (80%), while 1 or more cysts were missed in 5 (20%). The mean number of cysts per patient was 2.7, with a range of 2 to 5. Average pseudocyst diameter was 7.8 cm, with a range from 3 to 20 cm. Multiple internal drainage procedures were performed in 19 patients, a combination of internal and external drainage in 6, external drainage in 1, and resection of multiple cysts in the tail in 2. There was no operative mortality. With a mean follow up of 38.5 months, only 1 recurrent pseudocyst has been found. There were six attempts at percutaneous drainage in six patients. Two of these patients were referred to our institution following failure of percutaneous drainage at other hospitals. Three other patients had residual symptomatic pseudocysts following percutaneous drainage at our hospitals and then underwent multiple internal drainage. The sixth patient refused operative drainage despite the persistence of residual symptomatic pseudocysts after attempted percutaneous drainage. The incidence of multiple pseudocysts (18.5%) is higher than previously reported. There is no difference in the clinical features of patients with single versus multiple pseudocysts. Patients with multiple cysts have higher serum amylase levels. Preoperative computed tomography underestimated the number of cysts in 20% of patients. Careful intraoperative exploration is still needed to avoid missing multiple pseudocysts. Internal drainage is the preferred therapy. A thorough search for multiple cysts at the initial operation should eliminate one potential cause for pseudocyst recurrence.