Long-term management of chronic constipation in children

A retrospective clinical study was conducted to determine the success of a strict regimen employing the prolonged use of daily enemas in 203 children with chronic constipation. This study confirmed that the use of long-term daily enemas did eliminate constipation as well as the primary complaint of fecal soiling. The majority of children treated had an excellent to good result (85.8%) over an extended period of time. Patients with a past medical history of imperforate anus or Hirschsprung's disease required longer treatment periods (32.6 and 20.1 months, respectively) than children with other medical problems (rectal prolapse, rectal stricture, malrotation, spina bifida, mental retardation, psychological; 13 months) or patients with functional constipation (5.9 months).

The practice of pediatric surgery in a medical school environment: is there a conflict between private practice and academic pursuits?

An 11-year review of the clinical practice and the academic activity of the Section of Pediatric Surgery at the University of Michigan was carried out. This was done in an attempt to determine whether or not increased clinical practice in a medical school environment would have a detrimental effect on academic productivity. Clinical activity was evaluated by analyzing the number of patients seen, the number of operations, patient days, admissions, and revenue generated. Academic activity was analyzed by measuring the number of hours of formal lectures and conferences, research space and personnel, the number of completed and active projects, grant support, and the number of publications. During this 11-year period, the number of operations performed increased from 525 per year to over 1,350, the number of office visits increased from 11 per week to 60 to 65, and the gross revenue increased six-fold. At the same time, the number of formal lectures and conferences given increased from 50 to 267 hours per year, the research space increased from 200 to 1,612 square feet, the research budget increased from $20,000 to $120,000 per year, grant support increased from 0 to $62,000 per year, and the number of publications increased from five to 17 per full-time equivalent (FTE) per year. In fact, this review indicates that during the time that clinical practice and revenue generation increased, so did academic productivity in the form of manuscript writing, project completion, and grant acquisition.(ABSTRACT TRUNCATED AT 250 WORDS)

Studies on the toxicity and efficacy of a new amino acid solution in pediatric parenteral nutrition

The optimum composition and concentration of crystalline amino acid solutions necessary for growth and brain maturation in critically ill infants requiring total parenteral nutrition (TPN) are unknown. Either an excess or a deficiency of amino acids could theoretically impair normal brain development in the neonate. The purpose of this study was to compare the toxicity and efficacy of two intravenous amino acid solutions, Neopham, modeled after the amino acid pattern found in human breast milk, and Aminosyn, a marketed product, designed for general usage. Sixteen infants and children requiring continuous intravenous nutrition for at least 7 days received the Neopham amino acid solution, and eight infants and children received the Aminosyn amino acid solution as part of a total parenteral nutrition regimen which included glucose, the fat emulsion Intralipid, as well as routine mineral and vitamin additives. There were no significant differences in mean gestational age, body weight, postnatal age, or mean daily nutrient intake between the patients receiving Aminosyn or Neopham. The daily nitrogen intake, excretion, and retention were similar in both groups. In addition, there were no statistically significant differences in either hematological or biochemical parameters between the two study groups. The plasma levels of three essential amino acids, isoleucine, methionine, and valine, rose significantly higher in the Aminosyn-treated patients. The plasma levels of all the essential amino acids increased in both study groups.

Postappendectomy fluid collections in children: incidence, nature, and evolution evaluated using US

At the authors' medical center, most patients with postappendectomy fluid collections are treated conservatively. Thirty-two (15%) of 216 children underwent postoperative sonography following appendectomies. In ten patients (31%), a total of 16 fluid collections were found on the initial postoperative sonogram. In the seven patients (70%) whose fluid collections were confined to the pelvis, the condition was treated conservatively and it resolved in 2-9 weeks. In three patients, fluid collections required surgical drainage and proved to be abscesses. In two of the three patients, abscesses were multiple and widely distributed in the abdomen, and the patients were clinically ill. The authors conclude that clinically symptomatic fluid collections develop postoperatively in approximately 5% of children who have undergone appendectomy for acute appendicitis and that the size and course of the fluid collection can be objectively monitored using sonography. Such fluid collections confined to the pelvis ultimately resolve with conservative, nonoperative therapy, although resolution may take up to 2 months.

Special problems in management of pediatric trauma

Until recently, concern over the care of the trauma victim has largely involved the adult population; although 7% of emergency calls are for the pediatric patient, insufficient attention has been paid to the care of these children. This article concentrates on those unique problems encountered in the management of pediatric trauma in prehospital and hospital settings.

Splenic trauma in the pediatric patient: the integrated roles of ultrasound and computed tomography

Seven children who sustained splenic trauma were scanned by ultrasound and computed tomography (CT) or ultrasound and nuclear liver/spleen scan. All patients were managed conservatively and did not need abdominal surgery. On the initial sonogram, the majority of children had multiple areas of both increased and decreased echogenicity. Hematomas were followed to resolution in five of seven children and were usually multiple and hypoechoic prior to complete disappearance. On contrast-enhanced CT scans, areas of splenic hemorrhage appeared as low attenuation. Our small patient population demonstrates that, following an initial CT scan, sonography is helpful for sequential splenic imaging to show when the appearance of the spleen returns to normal. When correlated with the clinical information, such data are helpful to the clinician in determining when a child who has sustained splenic trauma may resume normal activity.

Fifty years' experience with esophageal atresia and tracheoesophageal fistula. Beginning with Cameron Haight's first operation in 1935

Four hundred twenty-six patients with esophageal atresia with or without tracheoesophageal fistula have been primarily cared for at the University of Michigan Medical Center since Cameron Haight's initial experience with this entity. Over the period of observation, the incidence of new cases as well as the number of associated anomalies has remained constant. The long-term survival of these patients has steadily improved over the past half-century from 36% in the pre-1950 era to 84% during the most recent 20 years. Conversely, operative mortality has shown a progressive decline from 56% early in the authors' series to 6.9% more recently, despite a steady increase in the proportion of high-risk neonates seen at the University of Michigan Medical Center during this time span. In the last 9 years, there have been no postoperative deaths in group A or B risk infants (36 patients), while the rate has been 18.2% in group C risk babies (27 patients); almost all of these deaths were due to severe associated anomalies. During the last 10 years, the authors have changed their technique of anastomosis from a two- to a one-layer method while still advocating a primary repair via an extrapleural approach. Although this change has resulted in a modest increase in the rate of anastomotic leak (17% vs. 6.2%, p less than 0.03), the leaks have been small and asymptomatic because of the extrapleural approach and, as a result, have been managed conservatively without any untoward sequelae. Conversely, there has been a significant decrease in the rate of stricture formation with the one-layer anastomosis (4.3% vs. 23.3%, p less than 0.002). While this may in part be explained by the change in anastomotic technique, it is felt that the more aggressive diagnosis and surgical management of gastroesophageal reflux (seen in 37.9% of our recent group) have contributed greatly to this decrease. The steady improvement in survival over this 50-year period, in spite of the increasing number of high-risk infants, is attributable to major improvements in neonatal care before, during, and after operation.

Extracorporeal membrane oxygenation (ECMO) in neonatal respiratory failure. 100 cases

Extracorporeal membrane oxygenation (ECMO) was used in the treatment of 100 newborn infants with respiratory failure in three phases: Phase I (50 moribund patients to determine safety, efficacy, and risks); Phase II (30 high risk patients to compare ECMO to conventional ventilation); and Phase III (20 moderate to high risk patients, the current protocol). Seventy-two patients survived including 54% in Phase I, 90% in Phase II, and 90% in Phase III. The major complication was intracranial bleeding, which occurred in 89% of premature infants (less than 35 weeks) and 15% of full-term infants. Best survival results were in persistent fetal circulation (10, 10 survived), followed by congenital diaphragmatic hernia (9, 7 survived), meconium aspiration (44, 37 survived), respiratory distress syndrome (26, 13 survived), and sepsis (8, 3 survived). There were seven late deaths; in follow-up, 63% are normal or near normal, 17% had moderate to severe central nervous system dysfunction, and 8% had severe pulmonary dysfunction. ECMO is now used in several neonatal centers as the treatment of choice for full-term infants with respiratory failure that is unresponsive to conventional management. The success of this technique establishes prolonged extracorporeal circulation as a definitive means of treatment in reversible vital organ failure.

Diagnosis and management of congenital cystic disease of the lung in children

Pulmonary sequestration, congenital adenomatoid malformation (CAM), congenital lobar overinflation (CLO), and bronchogenic cysts are four congenital lesions that may present as abnormal cystic areas within the pleural cavity in early life. They share similar clinical and embryologic characteristics, are frequently difficult to diagnose, and all require surgical treatment. From December 1974 to January 1985, 22 patients were operated upon on the Pediatric Surgical Service for congenital cystic disease of the lung. There were eight females and 14 males, ranging in age from 1 day to 18 years; 12 were under 6 months of age, and 14 were under one year. There were 7 CAMs, 5 extralobar pulmonary sequestrations, 5 intralobar pulmonary sequestrations, 3 bronchogenic cysts, and 3 cystic lobes caused by CLO. One patient had bilateral pulmonary sequestrations, intralobar on one side and extralobar on the other, with both sharing a common systemic artery arising from the infradiaphragmatic aorta. All except two asymptomatic patients presented with either progressive respiratory distress or recurrent pulmonary infections, and had cystic changes noted on chest roentgenograms. The differentiation of these congenital lesions from resolvable inflammatory cysts is important. Diagnosis was aided by selective utilization of barium contrast studies, ultrasonography, computed tomography, and arteriography. Operation consisted of resection alone of the extralobar pulmonary sequestrations and bronchogenic cysts, and total lobectomy in CAM, intralobar sequestration, and CLO. One infant with CAM died 1 day postoperatively from bilateral hypoplastic lungs. The other 21 patients are alive and well with follow-up ranging from 1 month to 9 years, with a mean of 3.5 years.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of pericardium for the management of recurrent tracheoesophageal fistula

Correction of congenital esophageal atresia and tracheoesophageal fistula (TEF) with either a primary or staged repair may result in recurrence of the TEF, most often at the site of esophageal anastomosis. Definitive operative repair of a recurrent TEF involves isolation and resection of the fistula with closure of the tracheal and esophageal defects. A technique is described, whereby mobilization of a vascularized pedicle of pericardium allows further enhancement of the standard repair of a recurrent TEF. The vascularized pedicle of pericardium serves to isolate the tracheal and esophageal suture lines from each other, as well as aid in sealing leaks at either or both suture lines. This may dramatically reduce the incidence of second recurrences and lower the overall operative mortality, reportedly as high as 59%.

Gastroesophageal reflux in children: is there a place for the upper gastrointestinal study?

Objective tests for gastroesophageal reflux in children have shown only fair correlation with clinical symptoms. Thirty-four children referred to the pediatric surgery service for evaluation of gastroesophageal reflux had both 24-hour pH probe monitoring and standardized upper gastrointestinal examinations. A total of 16 children (47%) had documented significant or pathologic gastroesophageal reflux, 11 on pH monitors and 9 on contrast examinations. There were 4 in whom both tests were positive. None of the pH monitoring criteria correlated with the radiographic studies. The patient population documented by contrast study did not differ from the general test-positive population by age or associated clinical findings. The 2 studies probably measure different aspects of significant gastroesophageal reflux, are confirmatory and complementary, and must be correlated with the clinical symptoms.

The radiographic appearance of the endorectal pull-through

Children and young adults with ulcerative colitis and polyposis syndromes requiring colectomy are increasingly undergoing the endorectal pull-through procedure. We reviewed the contrast studies of the neorectum of 27 patients and the abdominal radiographs in 26 patients after the endorectal pull-through operation. Normal features included smooth mucosa with loss of the small bowel features, dilatation of the neo-rectum on consecutive examinations, and an enlarged presacral space. The normal appearance before closure of the ileostomy varied depending upon the amount of distension of the pull-through segment; redundant ileum within the rectal muscle sleeve was seen in the two patients. Abnormalities included rectovaginal fistulas, sinus tracts, focal strictures requiring dilatation, complete obstruction, mucosal irregularities, and generalized narrowing with lack of distensibility. These abnormalities are attributable to inflammation and were associated with a poor clinical outcome. A contrast examination of the pull-through segment is useful to exclude the presence of serious inflammatory change before ileostomy closure or in the patient with excessive diarrhea or obstruction.

Sonography of ruptured appendicitis

Three girls and 4 boys with the final diagnosis of ruptured appendicitis underwent 19 sonographic studies, 5 before any therapy was instituted and 14 follow-up studies. Four abscesses identified before treatment and 2 seen postoperatively were ovoid, irregularly marginated, and contained low-amplitude echoes. Gastrointestinal ileus with gas-and fluid-filled loops of bowel made the studies technically difficult. Follow-up studies also showed fluid collections distant from the original abscesses. The complete resolution of the abscess was followed sonographically in 1 patient treated with antibiotics. Ultrasound can be useful in confirming or suggesting the diagnosis of ruptured appendicitis in the child with abdominal pain, but careful attention to detail is necessary in these technically difficult studies.

The metabolic effects of oral L-carnitine administration in infants receiving total parenteral nutrition with fat

beta-Oxidation, an important pathway in the metabolism of free fatty acids, occurs within the mitochondria in mammals. L-Carnitine is an essential cofactor in the transfer of long-chain fatty acids across the inner mitochondrial membrane. Maintenance of normal carnitine concentrations in whole blood and tissues, either through diet or biosynthesis, would appear necessary for adequate utilization of fat as an energy source. Infants, especially premature ones, without an exogenous dietary source of carnitine, have decreased plasma carnitine levels compared with infants receiving carnitine-supplemented feedings. To determine the importance of carnitine supplementation in a total parenteral nutrition program in infants in which a fat emulsion serves as a major calorie source, the following study was undertaken. Twelve infants receiving total parenteral nutrition (TPN) with fat for seven days were divided into two treatment groups. Group 1 was orally supplemented for seven days with carnitine (70 mumol/l/kg/24 h in 24 mL of 5% dextrose), while the second group received seven days of placebo supplementation (dextrose 5%, 24 cc/24 h). Plasma carnitine levels in the carnitine-supplemented group were significantly higher (29 +/- 8 nmol/mL) than in the control group (12.4 +/- 3.5 nmol/mL) after seven days of treatment. However, clearance of serum triglycerides and free fatty acids was not significantly different between the two groups. Baseline triglyceride levels in the carnitine-supplemented group were 96 +/- 42 mg/dL, increased to 242 +/- 101 mg/dL after the lipid challenge and decreased to 121 +/- 47 mg/dL two hours after the lipid infusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term survival of dogs maintained solely on intraperitoneal nutrition

Total intraperitoneal nutrition (IPN) for patients in whom enteral nutrition is impossible would utilize the access techniques of peritoneal dialysis and avoid long-term central venous cannulation. We previously demonstrated that a lipid emulsion was quantitatively absorbed from the dog's peritoneal cavity over four hours. We have now investigated the efficacy of total IPN in dogs over periods up to four weeks. A solution of 1.25% amino acids, 1% glucose, 77 mEq/L Na, 4 mEq/L K, and 81 mEq/L Cl (AGE) was administered IP at 65 mL/kg every 12 hours in combination with 25 mL/kg of 20% lipid emulsion to five dogs allowed free access to food and water for ten days. Sixty percent of administered fluid was absorbed. When AGE and lipid were administered separately every 12 hours to six dogs, 90% was absorbed. In five dogs kept strictly NPO for two weeks while receiving alternating AGE and lipid, absorption averaged 60%. Removing the amino acids allowed absorption to remain at 70% for two weeks, although it dropped to 40% by four weeks. Nine dogs were maintained for a mean of 3.5 weeks while strictly NPO using a solution of 1% glucose and electrolytes at 120 mL/kg every 12 hours with 50 mL/kg of 20% lipid given at a third separate infusion. During the fourth week, they absorbed 118 mL/kg/24 hours of fluid and 26 calories/kg/24 hours. Body weight decreased to 75% of control over four weeks. Complete blood cell count (CBC), Na, K, Cl, total protein (TP), SGOT, and alkaline phosphatase (AP) remained unchanged during this time.(ABSTRACT TRUNCATED AT 250 WORDS)

The endorectal pull-through for the management of familial polyposis

The standard surgical approach to multiple polyposis has been a total proctocolectomy and an end ileostomy because of the premalignant nature of the disease. This operation has been successful, but has resulted in a significant amount of psychological trauma due to the presence of an abdominal stoma. For that reason, we have utilized the sphincter-saving operation, namely, the endorectal pull-through for the definitive management of patients with familial polyposis since 1979. During the years 1979 to 1984, seven patients (4 female and 3 male), ranging in age from 10 to 30 years, have undergone an endorectal pull-through at our institution. Four of these patients had previously undergone a subtotal colectomy and ileoproctostomy and were seen because of persistent polyps in the remaining rectum. The operation consisted of a total colectomy, a mucosal proctectomy, an ileoanostomy and a loop ileostomy (1 patient did not undergo a loop ileostomy). The loop ileostomy was closed about two months after the pull-through procedure. There was no mortality and only one complication was seen postoperatively. This complication consisted of a bowel obstruction one week after ileostomy closure which was successfully treated with an enterolysis. Patient satisfaction has been excellent. All patients have either returned to full-time work or full-time school activity. All were completely continent immediately after ileostomy closure, both during the day and at night. The median stool frequency one year after the operation is five stools per 24 hours. Our results with this operation have encouraged us to recommend the endorectal pull-through to all patients with multiple polyposis.

Hematochezia and the false negative Meckel's scan: a continued need for barium studies

A patient with hematochezia and a false negative Meckel's scan is presented. A Meckel's diverticulum was subsequently diagnosed on barium small bowel follow-through. Meckel's diverticulum is discussed with emphasis on the relationship of barium and radionuclide studies.

A ten-year experience with ninety-two cases of Hirschsprung's disease. Including sixty-seven consecutive endorectal pull-through procedures

From July 1974 through November 1984, 92 patients with Hirschsprung's disease (congenital aganglionosis) have been treated at the University of Michigan-Mott Children's Hospital. This series includes 67 consecutive modified endorectal pull-through (ERPT) procedures in children. Fifty-one of these 67 patients had standard rectosigmoid disease and underwent a successful ERPT with only two major complications. One of these 51 children underwent a successful ERPT but died in the late postoperative period from severe congenital heart disease. Eighteen of the 92 patients suffered from total aganglionosis or long-segment disease. Sixteen of these have undergone an ERPT with no mortality or operative morbidity. The follow-up ranges from 6 months to 10 years. All of the children who have reached 3 years of age are continent. Of the remaining 23 patients, 12 were referred following an unsuccessful pull-through at another hospital. The 12 operations included five Swenson pull-throughs, five Duhamel procedures, one ERPT, and one subtotal colectomy. It was possible to redo or revise the pull-through procedures successfully in all but one patient, who required a permanent colostomy. Finally, 11 children were referred for management of a variety of complications following pull-through procedures performed at other institutions. None of these 11 patients required a reperformance of their pull-through, and all were successfully treated with lesser surgical procedures or with medical management. The excellent functional results and the low morbidity and zero operative mortality are attributed to the technical ease of performing the modified ERPT.

Hepatic artery aneurysm associated with the mucocutaneous lymph node syndrome

A case of a 4-year old child with a hepatic artery aneurysm after the mucocutaneous lymph node syndrome is reported. The child had obstructive jaundice and preoperative evaluation did not lead to the correct diagnosis. The aneurysm was resected and the postoperative course was unremarkable. The literature on this entity is reviewed.

Achalasia in children: treatment by anterior esophageal myotomy (modified Heller operation)

Although rare in children, achalasia can be the cause of debilitating symptoms and growth retardation. During a 4-year period, six patients (mean age 9.9 years) underwent a modified Heller operation (anterior esophageal myotomy) without complication. A concomitant modified Belsey fundoplication was performed in three patients who were judged at the time of operation to be at high risk for postoperative gastroesophageal reflux. Preoperative symptoms of dysphagia, postprandial vomiting, retrosternal pain, and pulmonary complications were eliminated in all patients. Follow-up interviews seven to 48 months (mean 23 months) following operation revealed normal diet and normal growth in all six children, with no recurrence of preoperative symptoms or evidence of gastroesophageal reflux. Technical details which we believe contribute to success in the operative management of pediatric achalasia include the transthoracic approach and the selective performance of complementary anti-reflux procedures.

A technique for tunneling central venous catheters

Tunneling the central venous catheter from the venous insertion site in the subclavicular or cervical area to the exit site on the chest wall can be difficult, especially in small children with a very convex chest wall. We present a technique which avoids many of the problems encountered with previously described methods.

Gastrointestinal complications of gastroschisis

The mortality of infants with gastroschisis has been reduced markedly in the last decade with the application of new surgical techniques, improved metabolic monitoring, and total parenteral nutrition. The late complications of repaired gastroschisis are now emerging. In this series of 30 infants with gastroschisis (20% mortality) significant gastroesophageal reflux was identified in seven of 10 infants with the appropriate barium study. The clinical symptom complexes of dysmotility, a recognized problem in gastroschisis, and gastroesophageal reflux can be easily confused. In addition, 11 episodes of necrotizing enterocolitis were identified in seven infants, four with perforations. The children with necrotizing enterocolitis had a deceptively benign clinical presentation, which was easily misinterpreted in these ill infants. Awareness of these two significant gastrointestinal complications and close cooperation of clinicians and radiologists to detect them should insure better survival in the infant with gastroschisis.

Familial extra-adrenal pheochromocytoma. A new syndrome

Pheochromocytomas in the same anatomic site, the right renal hilum, occurred in a family over three successive generations. For two patients in the latter two generations, scintigraphy with iodine 131-tagged metaiodobenzylguanidine (MIBG) showed tumors only in the region of the right renal hilum, thus indicating that they were primary lesions. At surgery, except for lymph node metastases noted microscopically in one patient, tumors were found only near the right renal hilum. The adrenal glands seemed normal on inspection, palpation, and computed tomography. In another family, a mother and son had primary pheochromocytomas arising from the urinary bladder. We suggest that primary extra-adrenal pheochromocytoma is a syndrome in which specific genetic abnormalities determine sites of tumor development.