[Tissue adhesives in closing of fistulas after surgery of esophageal atresia]

AIMS

Recurrent tracheoesophageal fistula is a severe postoperative complication after esophageal atresia repair. Endoscopic obliteration with tissue adhesives has been used as an alternative to reoperation. The aim of this study is to review our experience with such procedure.

MATERIAL AND METHODS

The medical records of 415 esophageal atresia patients were retrospectively reviewed in order to analyze the incidence of complications and the outcome of patients in whom tissue adhesives were used to close a recurrent tracheoesophageal fistula.

RESULTS

334 patients underwent an esophageal anastomosis and fistula closure or fistula division alone, 41 (12.3%) of them had recurrent tracheoesophageal fistula. In eight of these patients and one having an H type tracheoesophageal fistula, endoscopic obliteration using tissue adhesives was attempted. None of these nine children cured after this procedure and all required an open procedure for their recurrent tracheoesophageal fistula.

CONCLUSIONS

Contrary to some published cases, we have not succeeded with endoscopic obliteration of recurrent tracheoesophageal fistula using tissue adhesives; therefore, we do not recommend this treatment.

[Respiratory malformations associated with esophageal atresia]

AIMS

Since trachea, lungs and esophagus develop from foregut and esophageal atresia is a defect of its normal division, we examined the occurrence of respiratory malformations in a large clinical series of esophageal atresia.

MATERIALS AND METHODS

The records of 415 patients born with esophageal atresia between 1965 and 1996 and 129 autopsies of the same patients were retrospectively reviewed. The presence of other associated anomalies was carefully studied and noted.

RESULTS

Of 415 patients with esophageal atresia, 25 (6%) had one or more associated respiratory malformations. Only 8 patients (2.8%) having bronchopulmonary malformations were diagnosed clinically (8/286) while 17 (13.2%) were diagnosed at autopsy (17/129). The most frequent malformations were: lung segmentation defects (n = 14), pulmonary hypoplasia (n = 9) and tracheomalacia (n = 4). Eighty percent of esophageal atresia patients had another associated malformations specially of the cardiovascular system.

CONCLUSIONS

Esophageal atresia patients have a high incidence of associated bronchopulmonary malformations that are frequently not diagnosed.

[Effects of diaphragmatic plication in the antireflux barrier in rats]

INTRODUCTION

There is increasing evidence of frequent occurrence of gastroesophageal reflux (GER) in patients surviving operations for congenital diaphragmatic hernia (CDH) and diaphragmatic eventration (DE). The murine model allows to study the behavior of the components of antireflux barrier.

AIM

To study the changes introduced in esophageal-gastric junction by DE due to cervical transection of the left phrenic nerve and subsequent plication of the paralyzed diaphragm.

MATERIAL AND METHODS

Adult male Wistar rats were divided into two groups: in one we measured the pressure conditions before and after phrenic nerve section (PNS) and in the other we evaluated such conditions in PNS rats before and after diaphragmatic plication (DP).

RESULTS

Phrenic transection significantly lowered inspiratory pressure gradient (IPG), (2.79 +/- 1.05 vs 4.43 +/- 1.03, p < 0.05), without changes in expiratory pressure gradient (EPG) (0.31 +/- 1.03 vs 0.25 +/- 1, p > 0.05), or lower esophageal sphincter pressure (LESP) (20.88 +/- 7.73 vs 15.88 +/- 9.25, p > 0.05). Plication of the diaphragm reestablished normal IPG (4.04 +/- 0.75 vs 2.58 +/- 0.51, p < 0.05) while increased EPG (1 +/- 0.75 vs -0.32 +/- 1.05, p < 0.05) and decreased LESP (10.59 +/- 5.74 vs 17.15 +/- 5.59, p < 0.05).

CONCLUSION

Paralyzed diaphragmatic eventration lowered inspiratory gradient pressure; diaphragmatic plication reestablished this gradient, but decreased LESP and increased expiratory gradient pressure. These modifications may contribute to induce GER.

Histologic classification of undescended testes

On the basis of testicular biopsy study in 203 patients and study of a second biopsy specimen from 27 of these patients, prepubertal undescended testes were classified into four categories according to the mean tubular diameter, the tubular fertility index, and the Sertoli cell index. Type I cases (testes with minimal lesions) were characterized by a normal mean tubular diameter and normal tubular fertility and Sertoli cell indexes or slight tubular hypoplasia. This group represented 26 per cent of the undescended testes. The corresponding lesions can be observed from two years of age onward and are probably acquired. After puberty normal spermatogenesis occurs. Type II cases (24 per cent of the undescended testes) included testes with marked germinal hypoplasia as well as slight or marked tubular hypoplasia and a normal Sertoli cell index. After puberty these testes develop a degree of marked hypospermatogenesis, maturation arrest, or Sertoli cells with only isolated spermatogonia and primary spermatocytes. In type III cases (testes with diffuse tubular hypoplasia) the mean tubular diameter and the tubular fertility and Sertoli cell index values were severely reduced. This group represented 33 per cent of the undescended testes, and after puberty most of them showed seminiferous tubules with exclusively adult Sertoli cells. Type IV testes (diffuse Sertoli cell hyperplasia) were associated with a nearly normal mean tubular diameter and variable tubular fertility index values and represented 17 per cent of all the undescended testes. After puberty Sertoli cells do not mature completely, and therefore in spite of the earlier tubular fertility index, the germinal cell line does not reach adult development. Although early orchiopexy prevents tubular fertility index and mean tubular diameter deterioration due to the noxious effects of temperature in type I testes, we believe that there is no such benefit in the other types. These patients may present only slight modifications in these indexes.

Testicular microlithiasis in 2 children with bilateral cryptorchidism

Testicular microlithiasis, associated with bilateral cryptorchidism, is studied in 2, 6-year-old children. In case 1 autopsy revealed that 60 per cent of the seminiferous tubules contained completely calcified microliths. Similar mineralized concretions also were found in different areas of the cerebrum and cerebellum. In the testicular biopsy obtained from case 2, 30 per cent of the seminiferous tubules contained microliths showing different degrees of calcification. The study of such calcifications supports the hypothesis that the mineralization process occurs according to the following stages: 1) accumulation of cellular debris in the tubular lumen, 2) deposit of concentric rings of glycoprotein material surrounding the central core and 3) calcification of the glycoprotein lamellar material. The presence of similar concretion in the nervous system as well as the lung in other reported cases suggests that microlithiasis could be a systemic disease.

[Preduodenal portal vein (author's transl)]

Three cases of preduodenal portal vein (PDPV) observed in newborns and young infants are reported. In two patients the diagnosis was made during operations for duodenal stenosis and in the remaining one while operating for midgut volvulus and necrosis. In no case was the PDPV responsible for the clinical picture but in all three patients it was accompanied by other causes of obstruction: annular pancreas, extrinsic adhesive bands and malrotation. In one case there was also an asplenia, and polisplenia was present in another one. Both had malrotation and some degree of abnormal visceral asimmetry. The incidence of associated malformations in 52 previously reported cases is analyzed, and the more convincing embriological explanation for this anomaly is commented upon.