Laparoscopic Roux-en-Y feeding jejunostomy as a long-term solution for severe feeding problems in children

Enteral feeding is a common problem in children with gastric emptying disorders. Traditional feeding methods in these patients often show a high rate of complications and maintenance issues. Laparoscopic Roux-en-Y feeding jejunostomy (LRFJ) has been described in a few patients as a minimal invasive option for enteral access in these children. The aim of this study is to evaluate the outcomes of the LRFJ procedure in our tertiary referral center. We conducted a retrospective case-series including all patients, aged 0-18 years old, that underwent a LFRJ procedure between August 2011 and December 2020 for the indication of oral feeding intolerance due to delayed gastric emptying. Outcomes evaluated were complications (short and long term) and parenteral satisfaction. In total, 12 children were identified that underwent LRFJ for the indication of oral feeding intolerance due to delayed gastric emptying. A total of 16 complications were noted in 8/12 patients (67%). Severity classified by Clavien-Dindo were grade I (n = 13), grade II (n = 1), and grade IIIB (n = 2). In 11/12 patients, parents were satisfied with the results.

CONCLUSIONS

Although minor complications after LRFJ are common in our patients, this technique is a safe solution in patients with gastric emptying disorders leading to a definitive method of enteral feeding and high parenteral satisfaction.

WHAT IS KNOWN

• Traditional tube feeding in children (duodenal, PEG-J-tubes) with severe delayed gastric emptying can be challenging with a high rate of complications and maintenance issues. • Open loop jejunostomy and Roux-en-Y jejunostomy are alternative, permanent methods of feeding but either invasive or are accompanied by severe complications. Little is known in the literature about laparoscopic Roux-en-Y feeding jejunostomy.

WHAT IS NEW

• Laparoscopic Roux-en-Y feeding jejunostomy is a permanent, safe and minimal invasive alternative option for enteral feeding in children with severe delayed gastric emptying..

[A black wound on the lower arm]

A 19-year-old man presented on the Emergency Room on New Year's Eve with a 2 cm-wide black burn located on his lower arm. Earlier that evening he was hit by a piece of firework. Even though he immediately felt a sharp burning pain, he did not realize the severity of the injury. He presented with numbness in the digiti 4 and 5 and the Wartenberg sign, which are signs of an ulnar nerve injury. An exploration of the ulnar nerve was performed. Extensive burns and gunpowder were seen on the flexor carpi radialis and ulnaris muscle, the fascia and the epineurium of the ulnar nerve. However, the ulnar nerve was intact. A week later a babysitting procedure was performed because of absent intrinsic muscle activity, with an end-to-side anastomosis of the anterior interosseous nerve to the motor branch of the ulnar nerve. Hand physiotherapy was started after the operation.

If it ain't broke don't fix it? Ethics of splinting deformed newborn ears

Neonatal ear splinting is a proven and safe method to mold deformed ears into a more common shape. Based on our earlier studies, splinting is recommended only before the age of six weeks and preferably within the first week after birth. This can be done by initiating a system in which this intervention is actively proposed to parents. In this paper, we ethically evaluate such a system. By molding perfectly healthy newborn ears, we reach the boundary between treatment and enhancement. A key question is, therefore, whether we could classify neonatal ear splinting as a therapy. On the level of the individual, the advantages outweigh the drawbacks, but on the level of society, it is more complicated. Making ear deformities a part of official national screening programs fails to meet WHO criteria. Moreover, by systematically offering ear molding, professionals may be promoting guilt or fear of missing the opportunity. Additionally, it could affect societal attitudes toward cosmetic deformities. However, if we argue that on the individual level infants may benefit from ear splinting, then active detection of ear deformities allows parents to choose in a timely way from the full range of options, including splinting and a wait-and-see approach. We are inclined to optimally inform parents without setting up a full-blown public health program. The extent to which it is possible to timely offer splints to parents of newborns depends on the infrastructure of health care systems. The key will be for everyone involved, public or commercial, to responsibly educate and facilitate.

Intra- and interrater reliability of the Chicago Classification of achalasia subtypes in pediatric high-resolution esophageal manometry (HRM) recordings

BACKGROUND

Subtyping achalasia by high-resolution manometry (HRM) is clinically relevant as response to therapy and prognosis have shown to vary accordingly. The aim of this study was to assess inter- and intrarater reliability of diagnosing achalasia and achalasia subtyping in children using the Chicago Classification (CC) V3.0.

METHODS

Six observers analyzed 40 pediatric HRM recordings (22 achalasia and 18 non-achalasia) twice by using dedicated analysis software (ManoView 3.0, Given Imaging, Los Angeles, CA, USA). Integrated relaxation pressure (IRP4s), distal contractile integral (DCI), intrabolus pressurization pattern (IBP), and distal latency (DL) were extracted and analyzed hierarchically. Cohen's κ (2 raters) and Fleiss' κ (>2 raters) and the intraclass correlation coefficient (ICC) were used for categorical and ordinal data, respectively.

RESULTS

Based on the results of dedicated analysis software only, intra- and interrater reliability was excellent and moderate (κ=0.89 and κ=0.52, respectively) for differentiating achalasia from non-achalasia. For subtyping achalasia, reliability decreased to substantial and fair (κ=0.72 and κ=0.28, respectively). When observers were allowed to change the software-driven diagnosis according to their own interpretation of the manometric patterns, intra- and interrater reliability increased for diagnosing achalasia (κ=0.98 and κ=0.92, respectively) and for subtyping achalasia (κ=0.79 and κ=0.58, respectively).

CONCLUSIONS

Intra- and interrater agreement for diagnosing achalasia when using HRM and the CC was very good to excellent when results of automated analysis software were interpreted by experienced observers. More variability was seen when relying solely on the software-driven diagnosis and for subtyping achalasia. Therefore, diagnosing and subtyping achalasia should be performed in pediatric motility centers with significant expertise.

Objectively diagnosing rumination syndrome in children using esophageal pH-impedance and manometry

BACKGROUND

Rumination syndrome is characterized by recurrent regurgitation of recently ingested food into the mouth. Differentiation with other diagnoses and gastroesophageal reflux disease (GERD) in particular, is difficult. Recently, objective pH-impedance (pH-MII) and manometry criteria were proposed for adults. The aim of this study was to determine diagnostic ambulatory pH-MII and manometry criteria for rumination syndrome in children.

METHODS

Clinical data and 24-hour pH-MII and manometry recordings of children with a clinical suspicion of rumination syndrome were reviewed. Recordings were analyzed for retrograde bolus flow extending into the proximal esophagus. Peak gastric and intraesophageal pressures closely related to these events were recorded and checked for a pattern compatible with rumination. Events were classified into primary, secondary, and supragastric belch-associated rumination.

KEY RESULTS

Twenty-five consecutive patients (11 males, median age 13.3 years [IQR 5.9-15.8]) were included; recordings of 18 patients were suitable for analysis. Rumination events were identified in 16/18 patients, with 50% of events occurring <30 minutes postprandially. Fifteen of 16 patients showed ≥1 gastric pressure peak >30 mmHg, while only 50% of all events was characterized by peaks >30 mmHg and an additional 20% by peaks >25 mmHg. Four patients had evidence of acid GERD, all showing secondary rumination.

CONCLUSIONS AND INFERENCES

Combined 24-hour pH-MII and manometry can be used to diagnose rumination syndrome in children and to distinguish it from GERD. Rumination patterns in children are similar compared with adults, albeit with lower gastric pressure increase. We propose a diagnostic cutoff for gastric pressure increase >25 mmHg associated with retrograde bolus flow into the proximal esophagus.

Reflux monitoring in children

Recently, multichannel intraluminal impedance (MII) monitoring was added to the repertoire of tests to evaluate the (patho)physiology of gastroesophageal reflux (GER) in children. Its advantage above the sole monitoring of the esophageal pH lies in the ability of the detection of both acid and nonacid GER and to discern between liquid and gas GER. Currently, combined 24 h pH-MII monitoring is recommended for evaluation of gastro-esophageal reflux disease (GERD) and its relation to symptoms in infants and children, despite the lack of reference values in these age groups. There is new evidence in the current issue of this Journal supporting the role of pH-MII monitoring for the evaluation of children presenting with gastrointestinal symptoms suggestive of GERD and the prediction of the presence of reflux esophagitis. However, several issues should be taken into account when performing pH-MII clinically.

An expert panel-based study on recognition of gastro-esophageal reflux in difficult esophageal pH-impedance tracings

BACKGROUND

Despite existing criteria for scoring gastro-esophageal reflux (GER) in esophageal multichannel pH-impedance measurement (pH-I) tracings, inter- and intra-rater variability is large and agreement with automated analysis is poor. To identify parameters of difficult to analyze pH-I patterns and combine these into a statistical model that can identify GER episodes with an international consensus as gold standard.

METHODS

Twenty-one experts from 10 countries were asked to mark GER presence for adult and pediatric pH-I patterns in an online pre-assessment. During a consensus meeting, experts voted on patterns not reaching majority consensus (>70% agreement). Agreement was calculated between raters, between consensus and individual raters, and between consensus and software generated automated analysis. With eight selected parameters, multiple logistic regression analysis was performed to describe an algorithm sensitive and specific for detection of GER.

KEY RESULTS

Majority consensus was reached for 35/79 episodes in the online pre-assessment (interrater κ = 0.332). Mean agreement between pre-assessment scores and final consensus was moderate (κ = 0.466). Combining eight pH-I parameters did not result in a statistically significant model able to identify presence of GER. Recognizing a pattern as retrograde is the best indicator of GER, with 100% sensitivity and 81% specificity with expert consensus as gold standard.

CONCLUSIONS & INFERENCES

Agreement between experts scoring difficult impedance patterns for presence or absence of GER is poor. Combining several characteristics into a statistical model did not improve diagnostic accuracy. Only the parameter 'retrograde propagation pattern' is an indicator of GER in difficult pH-I patterns.

Inter- and intrarater reliability of the Chicago Classification in pediatric high-resolution esophageal manometry recordings

BACKGROUND

The Chicago Classification (CC) facilitates interpretation of high-resolution manometry (HRM) recordings. Application of this adult based algorithm to the pediatric population is unknown. We therefore assessed intra and interrater reliability of software-based CC diagnosis in a pediatric cohort.

METHODS

Thirty pediatric solid state HRM recordings (13M; mean age 12.1 ± 5.1 years) assessing 10 liquid swallows per patient were analyzed twice by 11 raters (six experts, five non-experts). Software-placed anatomical landmarks required manual adjustment or removal. Integrated relaxation pressure (IRP4s), distal contractile integral (DCI), contractile front velocity (CFV), distal latency (DL) and break size (BS), and an overall CC diagnosis were software-generated. In addition, raters provided their subjective CC diagnosis. Reliability was calculated with Cohen's and Fleiss' kappa (κ) and intraclass correlation coefficient (ICC).

KEY RESULTS

Intra- and interrater reliability of software-generated CC diagnosis after manual adjustment of landmarks was substantial (mean κ = 0.69 and 0.77 respectively) and moderate-substantial for subjective CC diagnosis (mean κ = 0.70 and 0.58 respectively). Reliability of both software-generated and subjective diagnosis of normal motility was high (κ = 0.81 and κ = 0.79). Intra- and interrater reliability were excellent for IRP4s, DCI, and BS. Experts had higher interrater reliability than non-experts for DL (ICC = 0.65 vs ICC = 0.36 respectively) and the software-generated diagnosis diffuse esophageal spasm (DES, κ = 0.64 vs κ = 0.30). Among experts, the reliability for the subjective diagnosis of achalasia and esophageal gastric junction outflow obstruction was moderate-substantial (κ = 0.45-0.82).

CONCLUSIONS & INFERENCES

Inter- and intrarater reliability of software-based CC diagnosis of pediatric HRM recordings was high overall. However, experience was a factor influencing the diagnosis of some motility disorders, particularly DES and achalasia.

Applying the Chicago Classification criteria of esophageal motility to a pediatric cohort: effects of patient age and size

BACKGROUND

Applying the 2012 Chicago Classification (CC) of esophageal motility disorders to pediatric patients is problematic as it relies upon adult-derived criteria. As shorter esophageal length and smaller esophago-gastric junction (EGJ) diameter may influence CC metrics, we explored the potential for age- and size-adjustment of diagnostic criteria.

METHODS

We evaluated 76 high-resolution solid state impedance-manometry recordings in children referred for manometry (32M; mean age 9 ± 1 years) and 25 recordings from healthy adult subjects (7M; mean age 36 ± 2 years). CC metrics; integrated relaxation pressure (IRP4s, mmHg), contractile front velocity (CFV, cm/s), distal contractile integral (DCI, mmHg cm/s), distal latency (DL, s), and peristaltic break size (BS, cm) were derived for 10 liquid swallows using CC analysis software. Effects of age and size were examined using regression analysis.

KEY RESULTS

Younger patient age and shorter size correlated significantly with greater IRP4s (p < 0.05), shorter DL (p < 0.001) and smaller BS (p < 0.05). Standard diagnostic CC criteria were adjusted using the slope of the linear regression equation to define the age/size-related trend. Sixty-six percent of the pediatric cohort showed abnormal motility when applying standard CC criteria. Adjustment for age and size reduced this to 50% and 53% respectively, with the largest reduction being in the IRP4s- and DL-dependent disorders EGJ outflow obstruction and diffuse esophageal spasm (13% to 7% and 5% and 14% to 1 and 5%, respectively).

CONCLUSIONS & INFERENCES

CC metrics, particularly IRP4s and DL, are age and size dependent, and therefore, require adjustment to improve accuracy of diagnosis of esophageal motility disorders in children.

T-bar reconstruction of constricted ears and a new classification

For the correction of constricted ears, many techniques are described in the literature, the majority based on Tanzer's classification of 1975. The improvements in ear reconstruction published by Brent, Nagata, Firmin and Park make better outcomes possible. It is therefore that a new classification for constricted ears is proposed, together with an alternative technique for correction of group IIA and IIB deformities, using a T-strut of costal cartilage to reconstruct the underdeveloped or missing superior crus of the antihelix.

Esophageal impedance baselines in infants before and after placebo and proton pump inhibitor therapy

BACKGROUND

Esophageal impedance monitoring records changes in conductivity. During esophageal rest, impedance baseline values may represent mucosal integrity. The aim of this study was to assess the influence of acid suppression on impedance baselines in a placebo-controlled setting.

METHODS

Impedance recordings from 40 infants (0-6 months) enrolled in randomized placebo-controlled trials of proton pump inhibitor (PPI) were retrospectively analyzed. Infants underwent 24 h pH-impedance monitoring prior to and after 2 weeks of double blind therapy with placebo or a PPI. Typical clinical signs of gastro-esophageal reflux (GER) were recorded and I-GERQ-R questionnaire was completed.

KEY RESULTS

Median (IQR) impedance baseline increased on PPI treatment (from 1217 (826-1514) to 1903 (1560-2194) Ω, P < 0.001) but not with placebo (from 1445 (1033-1791) to 1650 (1292-1983) Ω, P = 0.13). Baselines before treatment inversely correlate with the number of GER, acid GER, weakly acid GER, acid exposure, and symptoms. The change in baseline on treatment inversely correlates with acid exposure and acid GER. Patients with initial low baselines have no improved symptomatic response to treatment.

CONCLUSIONS & INFERENCES

Impedance baselines are influenced by GER and increase significantly more with PPI therapy than with placebo. Clinical impact of this observation remains undefined as targeting therapy at infants with low baselines does not improve symptomatic response to treatment.

A prospective study on non-surgical correction of protruding ears: the importance of early treatment

OBJECTIVES

Splinting is an elegant method to correct ear deformities in the newborn. However evidence is lacking on the relation between age and efficacy and duration of the treatment. We prospectively studied these questions on protruding ears in 132 babies.

METHODS

A splint in the scaphal hollow was used in combination with tape (Earbuddies(®)). Treatment continued until the desired shape persisted. Results were judged from photographs and mastoid-helical distance was measured.

RESULTS

In 132 babies 209 ears were treated. Twenty-four patients had no follow-up, 27 stopped therapy for skin irritation and fixation problems. In the remaining patients results were good in 28%, fair in 36%, poor in 36%. Efficacy deteriorates with age; with fair or good results in 66.7% if therapy started before the sixth week. Older children needed to be splinted longer. The anti-helical fold was easier corrected than a deep concha (correction in 69.8% versus 26.8%).

CONCLUSIONS

Considering splinting therapy for protruding ears, a reasonable chance of success can only be offered to parents of children up to six weeks of age. It is favorable if the deformity is mainly due to a flat antihelix.

Review article: reflux and its consequences--the laryngeal, pulmonary and oesophageal manifestations. Conference held in conjunction with the 9th International Symposium on Human Pepsin (ISHP) Kingston-upon-Hull, UK, 21-23 April 2010

BACKGROUND

Gastro-oesophageal reflux disease (GERD) is one of the commonest diseases of Western populations, affecting 20 to 30% of adults. GERD is multifaceted and the classical oesophageal symptoms such as heartburn and regurgitation often overlap with atypical symptoms that impact upon the respiratory system and airways. This is referred to as extra-oesophageal reflux disease (EERD), or laryngopharyngeal reflux (LPR), which manifests as chronic cough, laryngitis, hoarseness, voice disorders and asthma.

AIM

The 'Reflux and its consequences' conference was held in Hull in 2010 and brought together a multidisciplinary group of experts all with a common interest in the many manifestations of reflux disease to present recent research and clinical progress in GERD and EERD. In particular new techniques for diagnosing reflux were showcased at the conference.

METHODS

Both clinical and non-clinical key opinion leaders were invited to write a review on key areas presented at the `Reflux and its consequences' conference for inclusion in this supplement.

RESULTS AND CONCLUSION

Eleven chapters contained in this supplement reflected the sessions of the conference and included discussion of the nature of the refluxate (acid, pepsin, bile acids and non-acid reflux); mechanisms of tissue damage and protection in the oesophagus, laryngopharynx and airways. Clinical conditions with a reflux aetiology including asthma, chronic cough, airway disease, LPR, and paediatric EERD were reviewed. In addition methods for diagnosis of reflux disease and treatment strategies, especially with reference to non-acid reflux, were considered.

Characterization of intraluminal impedance patterns associated with gas reflux in healthy volunteers

Multichannel intraluminal impedance (MII) recording allows assessment of flow through the oesophagus and differentiation between liquid and gas contents. Existing MII criteria for recognition of gas gastro-oesophageal reflux (GOR) have not been validated during known gas GOR in humans.

AIMS

(i) Characterize MII patterns of known gas GOR and optimize criteria. (ii) Clarify interrelationships between magnitude of maximal impedance change, luminal diameter and electrode-mucosa contact. Ten healthy volunteers (six male, 21-37 years) were studied using an oesophageal MII-manometry catheter. After catheter placement, subjects were asked to drink 600 mL of carbonated soft drink. Recordings were made for 20 min and the protocol repeated. Reported belches confirmed manometrically (triggered by transient lower oesophageal sphincter relaxations) were included for analysis. Those episodes were compared against commonly used criteria. Another five subjects (three male, 26-52 years) underwent simultaneous MII and videofluoroscopy using the same protocol. Videofluoroscopic images were analyzed for luminal diameter and the presence of electrode-mucosa contact. All analyzed gas GOR episodes (n = 88) were associated with a pattern of impedance rise which was either retrograde (62.5%), synchronous (19.3%) or antegrade (18.2%). Depending on the exact criteria used, sensitivity ranged from 33% to 75%. A multivariate regression model including luminal diameter and the presence of electrode-mucosa contact as independent factors accounted for 53% of all variation in impedance changes. In conclusion, a significant number of gas GOR episodes does not meet criteria for their recognition. New criteria are proposed to include specific antegrade patterns of impedance rise. Luminal diameter and the extent of contact between the oesophageal mucosa and MII-electrodes influence the magnitude and patterning of impedance change.

Ear piercing techniques and their effect on cartilage, a histologic study

BACKGROUND

The popularity of high ear piercing has led to an increased incidence of perichondritis. Damage to the relatively avascular cartilage will make the ear prone to infection. The literature suggests that a piercing gun, mainly used by jewellers to pierce the lobule, may give excessive cartilaginous damage. Therefore some authors favour the piercing needle, as used in piercing studios. But until now, no comparative histological studies have been performed.

PURPOSE OF STUDY

To evaluate the extent of damage to ear cartilage using different piercing techniques.

METHODS

Twenty-two fresh human cadaver ears were pierced using two spring loaded piercing guns (Caflon and Blomdahl), one hand force system (Studex) and a piercing needle (16G i.v. catheter). Extent of damage to the perichondrium and cartilage was quantified using a transverse section along the pin tract and compared between the different methods.

RESULTS

The pattern of injury was similar in all techniques, showing perichondrium stripped from the cartilage around the pin tract, with most damage present on the exit site (mean length of 0.43 mm). Cartilage fractures and loose fragments were present over a mean length of 0.21 mm. No significant difference in the amount of injury between the different techniques was observed.

CONCLUSIONS

In contradiction with assumptions in the literature, all piercing methods give the same extent of damage to cartilage and perichondrium. Each method is expected to have the same risk for perichondritis, thus in the prevention of post-piercing perichondritis focus should be on other factors such as hygiene and after-care.

Prognosis of constipation: clinical factors and colonic transit time

BACKGROUND

Measurement of colonic transit time (CTT) is sometimes used in the evaluation of patients with chronic constipation.

AIM

To investigate the relation between symptoms and CTT, and to assess the importance of symptoms and CTT in predicting outcome.

METHODS

Between 1995 and 2000, 169 consecutive patients (median age 8.4 years, 65% boys) fulfilling the criteria for constipation were enrolled. During the intervention and follow up period, all kept a diary to record symptoms. CTT was measured at entry to the study.

RESULTS

At entry, defecation frequency was lower in girls than in boys, while the frequency of encopresis episodes was higher in boys. CTT values were significantly higher in those with a low defecation frequency (< or =1/week) and a high frequency of encopresis (> or =2/day). However, 50% had CTT values within the normal range. Successful outcome occurred more often in those with a rectal impaction. CTT results <100 hours were not predictive of outcome. However, those with CTT >100 hours were less likely to have had a successful outcome.

CONCLUSION

The presence of a rectal impaction at presentation is associated with a better outcome at one year. A CTT >100 hours is associated with a poor outcome at one year.