Learning together: Using simulations to develop nursing and medical student collaboration

Collaborative interdisciplinary learning is a core educational requirement cited by the Institute of Medicine Health Professions Education Report (2003). This descriptive study supports the Nursing Education Simulation Framework for designing simulations used as an interdisciplinary teaching strategy in health professions curricula. The purpose of this study was to investigate the use of the framework for the collaborative medical and nursing management of a surgical patient with complications. Simulation design features, student satisfaction, and self-confidence were measured. Results indicate both medical and nursing student groups'perceptions of the design features of the collaborative simulation were positive. Feedback and guided reflection were identified by both student groups as important simulation design features. Data analyzed from the Collaboration Scale suggest that designing simulations that place medical and nursing students together is beneficial for both the medical students and the nursing students.

An evaluation of medication errors-the pediatric surgical service experience

BACKGROUND

Medication errors in pediatric patients are well recognized. The need for weight-adjusted dosing and changes in pharmacokinetic parameters make this patient population susceptible. Surgical literature discussing this topic is limited. The purpose of this study was to review the medication errors (variances) on surgical services at a major children's teaching hospital.

METHODS

Medication variances occurring from January 2004 to June 2006 were reviewed. Data included service, physician, medication, type of variance, severity, explanation of variance, and time of occurrence.

RESULTS

There were 757 patients affected hospital-wide by a medication variance (n = 1340) for which 180 patients were on a surgical service (n = 308 variances). Residents accounted for 82% of all variances. Medication variances occurred most frequently on the general (36%) and neurosurgery services (20.5%). Seventy-one percent of the variances were classified as potential to cause harm but were corrected before reaching the patient. Five percent of variances reached the patient and caused temporary harm. Incorrect dose accounted for 72% of variances, followed by incorrect dosage form or omission in 5%, and missed allergies in 4%. Antibiotics were implicated in 31% of variances. Most errors occurred during daytime work hours.

CONCLUSION

Our data show that most of prescribing medication variances never reached the patient and were recognized by pharmacy or nursing. There is a continued need to enhance local education (resident) using a service-specific clinical pharmacist to focus on appropriate dosing especially in regard to antibiotics. Computerized physician order entry when implemented will help to minimize some of these errors. However, in the interim, a service-specific medication dosing card is being implemented. Quarterly service-specific data will be incorporated into the resident/fellow clinical conferences to minimize future variance occurrences.

Laparoscopic Splenic Procedures in Children

OBJECTIVES

The purpose of this report is to evaluate the efficacy of and complications observed after laparoscopic splenic procedures in children.

METHODS

Review of a prospective database at a single institution (1995-2006) identified 231 children (129 boys; 102 girls; average age 7.69 years) undergoing laparoscopic splenic procedures.

RESULTS

Two hundred twenty-three children underwent laparoscopic splenectomy (211 total; 12 partial) by the lateral approach. Indication for splenectomy was hereditary spherocytosis (111), immune thrombocytopenic purpura (36), sickle cell disease (SCD) (51), and other (25). Four (2%) required conversion to an open procedure. Eight additional laparoscopic splenic procedures were performed: splenic cystectomy for epithelial (4) or traumatic (2) cyst, and splenopexy for wandering spleen (2). Average length of stay was 1.5 days. Complications (11% overall, 22% in SCD patients) included ileus (5), bleeding (4), acute chest syndrome (5), pneumonia (2), portal vein thrombosis (1), priapism (1), hemolytic uremic syndrome (1), diaphragm perforation (2), colonic injury (1), missed accessory spleen (1), trocar site hernia (1), subsequent total splenectomy after an initial partial (1), and recurrent cyst (1). Subsequent operations were open in 3 (colon repair, hernia, and missed accessory spleen) and laparoscopic in 2 (completion splenectomy, and cyst excision). There were no deaths, wound infections, or instances of pancreatitis.

CONCLUSIONS

Laparoscopic splenic procedures are safe and effective in children and are associated with low morbidity, higher complication rate in SCD, low conversion rate, zero mortality, and short length of stay. Laparoscopic splenectomy has become the procedure of choice for most children requiring a splenic procedure.

Minimal access thoracic surgery in the pediatric population

Thoracoscopy was initially described for use in children to obtain pulmonary biopsy samples in the immunocompromised patient. With refinements in technique, development of better instrumentation, and advances in pediatric anesthesia, there are now many diagnostic and therapeutic indications for the use of thoracoscopy in children. One of the most common indications includes pleural debridement for empyema. Many centers consider this the optimal approach for biopsy of mediastinal lesions and excision of bronchogenic or duplication cysts. The technique is useful for pleural disorders, such as spontaneous pneumothorax and chylothorax. Thoracoscopy has been used to achieve exposure for spinal diskectomy in children with thoracic scoliosis, and newer techniques are being developed in performing anatomic lobectomies, repair of esophageal atesias, and closure of diaphragmatic hernias. The role of the robot in pediatric thoracoscopy is still in the early stages of definition.

The whole truth: comparative analysis of diaphragmatic hernia repair using 4-ply vs 8-ply small intestinal submucosa in a growing animal model

BACKGROUND

Diaphragmatic reconstruction remains a challenging problem. There is limited information concerning the use of small intestinal submucosa (SIS) in congenital diaphragmatic hernia repair. A canine model was used to evaluate the use of a SIS patch in diaphragmatic reconstruction.

METHODS

Eleven beagle puppies (1.6-4.2 kg, 8 weeks old) underwent left subcostal laparotomy, central left hemidiaphragm excision (2 x 7 cm, 50% loss), and reconstruction with a 4-ply group I (n = 5) or 8-ply group II (n = 6) SIS patch. Chest radiographs were taken at time of operation and 3 and 6 months postoperatively. Animals were killed at 6 months. Adhesion formation (both pleural and abdominal), gross visual evaluation of the patch, and histology were compared.

RESULTS

In group I (4-ply), 1 animal died at 3 months from patch deterioration accompanied by stomach herniation that resulted in respiratory failure. In the 4 remaining animals, chest radiographs showed no evidence of herniation or eventration. On physical examination, there was no evidence of chest wall deformity. During gross surgical examination, the 4-ply patches showed thinning, multiple defects, and liver herniation in 3 animals. In 1 pup, the patch was thickened, intact, well incorporated at the repair site, and adherent to the liver and spleen. In group II (8-ply), 1 animal died of cardiopulmonary failure in the early postoperative period. In the other 5 animals, chest radiographs showed evidence of eventration in 1. On gross examination the patch adhered to the liver in all 5 surviving animals. In 4, the patches were thickened, viable, but had some shrinkage. One patch pulled away from the native diaphragm laterally; however, no visceral herniation was present. In the 1 animal with eventration, there was no evidence of a patch. Adhesion scores (AS) were graded and determined by the sum of extent (0-4), type (0-4), and tenacity (0-3). Average abdominal AS in group I was 5.6 +/- 0.8 vs 10.2 +/- 0.2 (P = .079) for group II. Average lung AS was 0.6 +/- 0.6 in group I vs 3.8 +/- 1.1 (P = .0476) for group II. Histological examination showed group II patches had greater collagen deposition with central calcification and mild inflammation within the residual graft, whereas group I patches were much thinner and were composed of granulation tissue without evidence of residual graft.

CONCLUSIONS

These data indicate that 8-ply SIS repair of diaphragmatic defects was superior (80%; 4/5 to 4-ply, 20%; 1/5, success). Organ adherence appears to be necessary for neovascularization of the SIS composite. Eight-ply grafts appear to be more durable and persist for a longer period, which may improve neovascularization. Long-term follow-up to evaluate remodeling characteristics of the patch material is required.

Surgical considerations in cystic fibrosis: a 32-year evaluation of outcomes

BACKGROUND

Information concerning long-term operative outcomes in patients with cystic fibrosis (CF) is relatively sparse in the operative literature.

METHODS

A retrospective review of CF patients with operative conditions was performed (1972-2004) at a tertiary children's hospital to analyze outcomes including long-term morbidity and survival.

RESULTS

A total of 226 patients with CF presented with an operative diagnosis (113 men, 113 women). A total of 422 operations were performed in 213 patients (94%). The mean age at operation was 4.1 +/- 6.2 years (range, 1 d to 26 y) and 109 were neonates. Fifteen of 42 (36%) babies with simple meconium ileus (MI) were treated nonoperatively with hypertonic enemas, 27 of 42 and all 45 patients with complicated MI required operation, including 15 with jejunoileal atresia (17%). Seventeen of 27 (63%) patients with meconium ileus equivalent had MI as neonates; 7 of 27 (26%) required operation. Eight of 9 (89%) with fibrosing colonopathy required operation. Organ transplantation was required in 21 patients. Follow-up evaluation was possible in 204 of 213 (96%) patients. The duration of follow-up evaluation was 14.9 +/- 8.5 years (range, 2 mo to 35 y). Operative morbidity was 11% at 1 year, 2% at 2 to 4 years, 1% at 5 to 10 years, and less than 1% at more than 10 years. There were 24 deaths (11%); 22 followed CF-related pulmonary complications and included 8 of 16 (50%) children with pneumothorax.

CONCLUSIONS

Long-term survival in CF patients has improved significantly (89%), with many surviving into the fourth decade. MI may predispose to late complications including meconium ileus equivalent and fibrosing colonopathy. Pneumothorax in CF patients is an ominous predictor of mortality. Children with CF are living longer and are good candidates for operation, but require long-term follow-up evaluation because of ongoing exocrine dysfunction.

Long-term outcomes in total colonic aganglionosis: a 32-year experience

BACKGROUND/METHODS

A 32-year retrospective review from 1972 to 2004 analyzed complications and long-term outcomes in children with total colonic aganglionosis (TCA) as they relate to the procedure performed.

RESULTS

Thirty-six patients (27 boys, 9 girls) had TCA. The level of aganglionosis was distal ileum (26), mid-small bowel (8), midjejunum (1), and entire bowel (1). Enterostomy was performed in 35 of 36. Eight developed short bowel syndrome. Twenty-nine (81%) had a pull-through at 15 +/- 6 months (modified Duhamel 20, Martin long Duhamel 4, and Soave 5). Six had a Kimura patch. Postoperative complications (including enterocolitis) were more common after long Duhamel and Soave procedures. Seven (19%; 2 with Down's syndrome) died (3 early, 4 late) from pulmonary emboli (1), sepsis (1), fluid overload (1), viral illness (1), liver failure (1), arrhythmia (1), and total bowel aganglionosis (1). Mean follow-up was 11 +/- 9 years (range, 6 months-29 years). Twenty-four (83%) of 29 patients exhibited growth by weight of 25% or more, 21 (91%) of 23 older than toddler age had 4 to 6 bowel movements per day, and 17 (81%) of 21 were continent. In 5 of 6, the Kimura patch provided functional benefit with proximal disease.

CONCLUSION

Long-term survival was 81%. The highest morbidity occurred with long Duhamel or Soave procedures. The modified Duhamel is our procedure of choice in TCA. Bowel transplantation is an option for TCA with unadapted short bowel syndrome.

Supraumbilical pyloromyotomy: a unique indication for antimicrobial prophylaxis

BACKGROUND

The umbilical fold incision for infantile hypertrophic pyloric stenosis provides a convenient exposure and cosmetically appealing scar. This study investigates the possible difference in infection rates between traditional and supraumbilical approaches for pyloromyotomy.

METHODS

All patients who underwent pyloromyotomy for infantile hypertrophic pyloric stenosis at a tertiary pediatric hospital were reviewed. Baseline wound infection rate was determined through review of patients with right upper quadrant incisions (group 1). A nonrandomized comparison was performed between patients with a supraumbilical approach (group 2) and those undergoing supraumbilical incisions after prophylactic antibiotic administration (group 3).

RESULTS

Complete records were reviewed on 384 patients over a 6-year period. Demographics and preoperative factors were similar among groups. The rate of infection in group 1 (n = 258) was 2.3%. With introduction of the supraumbilical approach, there was a statistically significant increase in wound infection rate to 7.0% (chi 2 ; group 1 vs group 2, P < .05). The use of prophylactic antibiotics with a supraumbilical approach reduced this rate of infection back to 2.3% (chi 2 ; group 1 vs group 3, P < 1.0 and group 2 [n = 85] vs group 3 [n = 42], P < .3).

CONCLUSIONS

The risk of wound infection by classic pyloromyotomy of 2.3% is significantly increased with an open supraumbilical approach. The use of prophylactic antibiotics reduces this risk of wound infection.

Long-term results of treatment of Hirschsprung's disease

Many children with Hirschsprung's disease (HD) have a good outcome following surgical treatment, but long-term follow-up studies have identified a number of concerns. Analysis of long-term function in children after surgical management is difficult. The most commonly encountered problems include constipation, incontinence, enterocolitis and the overall impact of the disease on lifestyle (quality of life). Other complications are less frequent. Each of these problems will be discussed.

Predictors of successful outcome after cholecystectomy for biliary dyskinesia

PURPOSE

Laparoscopic cholecystectomy is accepted therapy for children with ill-defined abdominal pain and impaired gallbladder emptying (biliary dyskinesia). Follow-up shows poor clinical response in many of these patients. The purpose of this report is to identify clinical and radiographic predictors of successful outcome after cholecystectomy for biliary dyskinesia.

METHODS

The authors retrospectively reviewed records of 51 children after laparoscopic cholecystectomy for biliary dyskinesia (1990 to 2003). Clinical symptoms, radiographic findings, and pathology were evaluated. Subjective clinical improvement is stratified using an established patient satisfaction score. Logistic regression analysis determines statistically independent predictors of successful outcome.

RESULTS

Thirty-eight of 51 (75%) patients were available for follow-up. Twenty-seven of 38 (71%) patients reported complete resolution of symptoms. Nausea was the only symptom predictive of successful outcome by univariate analysis (odds ratio, 5.00). A cholecystokinin-stimulated, gallbladder ejection fraction less than 15% also predicts successful outcome (odds ratio, 8.00). Children with an ejection fraction greater than 15% did not have predictable resolution of symptoms. When present with pain and nausea, gallbladder emptying less than 15% has a positive predictive value of 93% and a negative predictive value of 81%.

CONCLUSIONS

Together, nausea, pain, and decreased gallbladder emptying (<15%) most reliably predict which children will benefit from cholecystectomy for biliary dyskinesia.

Duodenal atresia and stenosis: long-term follow-up over 30 years

BACKGROUND

Duodenal atresia and stenosis is a frequent cause of congenital, intestinal obstruction. Current operative techniques and contemporary neonatal critical care result in a 5% morbidity and mortality rate, with late complications not uncommon, but unknown to short-term follow-up.

METHODS

A retrospective review of patients with duodenal anomalies was performed from 1972 to 2001 at a tertiary, children's hospital to identify late morbidity and mortality.

RESULTS

Duodenal atresia or stenosis was identified in 169 patients. Twenty children required additional abdominal operations after their initial repair with average follow-up of 6 years (range, 1 month to 18 years) including fundoplication (13), operation for complicated peptic ulcer disease (4), and adhesiolysis (4). Sixteen children underwent revision of their initial repair: tapering duodenoplasty or duodenal plication (7), conversion of duodenojejunostomy to duodenoduodenostomy (3), redo duodenojejunostomy (3), redo duodenoduodenostomy (2), and conversion of gastrojejunostomy to duodenoduodenostomy (1). There were 10 late deaths (range, 3 months to 14 years) attributable to complex cardiac malformations (5), central nervous system bleeding (1), pneumonia (1), anastomotic leak (1), and multisystem organ failure (2).

CONCLUSIONS

Late complications occur in 12% of patients with congenital duodenal anomalies, and the associated late mortality rate is 6%, which is low but not negligible. Follow-up of these patients into adulthood is recommended to identify and address these late occurrences.

Do you know your students' basic clinical skills exposure?

BACKGROUND

Undergraduate medical education in the United States is changing. Many medical schools have developed a set of basic clinical skills (BCS) that all students are required to have mastered; however, very few have acquired objective information regarding specific student experiences. The purpose of this study was to determine the BCS encounters for junior medical students at a large midwestern university utilizing a handheld personal digital assistant (PDA).

METHODS

A core curriculum of BCS was proposed and involved 52 procedures/skills. An electronic BCS database was developed utilizing HanDBase software and then placed on a PDA (Palm) and distributed to 25 third-year medical students randomly as they entered their clinical year. Students logged their skill encounters for 9 months and then electronically transferred the database by e-mail.

RESULTS

Students participated in 1,115 procedural/skill encounters (range 17 to 90; median 41; average 44.6). Of the 52 core BCS, all students performed 10. Fewer than 50% of students had any exposure to very common skills. Thirty-four percent of skill encounters occurred at a county hospital, 19% at a clinic, 10% at a university hospital, 10% at a private hospital, 7% at a VA hospital, 4% at a children's hospital, and 16% at miscellaneous locations.

CONCLUSIONS

The PDA devices were simple and convenient to use, while allowing for easy transfer and tabulation of database information by electronic mail. Significant gaps in BCS exposure were noted across the curriculum. Mentor sign-off on the PDA permitted early feedback opportunities. We can now begin to reward educators for skills mentoring and perform formal assessment of BCS within specific clerkships to enhance future educational objectives.

Intravenous catheter training system: computer-based education versus traditional learning methods

BACKGROUND

Virtual reality simulators allow trainees to practice techniques without consequences, reduce potential risk associated with training, minimize animal use, and help to develop standards and optimize procedures. Current intravenous (IV) catheter placement training methods utilize plastic arms, however, the lack of variability can diminish the educational stimulus for the student. This study compares the effectiveness of an interactive, multimedia, virtual reality computer IV catheter simulator with a traditional laboratory experience of teaching IV venipuncture skills to both nursing and medical students.

METHODS

A randomized, pretest-posttest experimental design was employed. A total of 163 participants, 70 baccalaureate nursing students and 93 third-year medical students beginning their fundamental skills training were recruited. The students ranged in age from 20 to 55 years (mean 25). Fifty-eight percent were female and 68% percent perceived themselves as having average computer skills (25% declaring excellence). The methods of IV catheter education compared included a traditional method of instruction involving a scripted self-study module which involved a 10-minute videotape, instructor demonstration, and hands-on-experience using plastic mannequin arms. The second method involved an interactive multimedia, commercially made computer catheter simulator program utilizing virtual reality (CathSim).

RESULTS

The pretest scores were similar between the computer and the traditional laboratory group. There was a significant improvement in cognitive gains, student satisfaction, and documentation of the procedure with the traditional laboratory group compared with the computer catheter simulator group. Both groups were similar in their ability to demonstrate the skill correctly. CONCLUSIONS; This evaluation and assessment was an initial effort to assess new teaching methodologies related to intravenous catheter placement and their effects on student learning outcomes and behaviors. Technology alone is not a solution for stand alone IV catheter placement education. A traditional learning method was preferred by students. The combination of these two methods of education may further enhance the trainee's satisfaction and skill acquisition level.

Long-term analysis of children with esophageal atresia and tracheoesophageal fistula

BACKGROUND/PURPOSE

For children with esophageal atresia (EA) or tracheoesophageal fistula (TEF), the first years of life can be associated with many problems. Little is known about the long-term function of children who underwent repair as neonates. This study evaluates outcome and late sequelae of children with EA/TEF.

METHODS

Medical records of infants with esophageal anomalies (May 1972 through December 1990) were reviewed. Study parameters included demographics, dysphagia, frequent respiratory infections (> 3/yr), gastroesophageal reflux disease (GERD), frequent choking, leak, stricture, and developmental delays (weight, height < 25%, < 5%, respectively).

RESULTS

Over 224 months, 69 infants (37 boys, 32 girls) were identified: type A, 10 infants; type B, 1; type C, 53; type D, 4; type E, 1. Mean follow-up was 125 months. During the first 5 years of follow-up, dysphagia (45%), respiratory infections (29%), and GERD (48%) were common as were growth delays. These problems improved as the children matured.

CONCLUSIONS

Children with esophageal anomalies face many difficulties during initial repair and frequently encounter problems years later. Support groups can foster child development and alleviate parent isolationism. Despite growth retardation, esophageal motility disorders, and frequent respiratory infections, children with EA/TEF continue to have a favorable long-term outcome.

Surgical management of duodenal injuries in children

BACKGROUND

The goal of this study was to review current injury characteristics, severity, intervention, and outcome of duodenal injuries from a single, pediatric trauma facility.

METHODS

A retrospective review was performed of duodenal injuries in children less than 16 years of age from 1990 to 2000.

RESULTS

Twelve children had duodenal injuries as a result of blunt abdominal trauma. Six injuries were the result of motor vehicle crashes. Nonaccidental trauma (2) and contact injury (4) provided the remaining cases. Diagnosis was achieved by abdominal computed tomography. Severity of duodenal injury included grade I (1), II (8), and III (3). Seven patients had associated visceral or neurologic injuries. Average Injury Severity Score was 18. Duodenal repair was required in 9 of the 10 patients explored. Treatment included observation (3); primary repair, alone, (2) or with proximal decompression (4); and pyloric exclusion with gastrojejunostomy (3). Exclusion techniques had fewer complications (0% vs 57%) and fewer hospital days (19 vs 23).

CONCLUSIONS

Blunt abdominal trauma remains the most prevalent mechanism for pediatric duodenal injuries. Patients undergoing pyloric exclusion for severe duodenal trauma had a lesser morbidity and a shorter hospital stay in this small series. Pyloric exclusion remains an alternative for the treatment of severe duodenal injuries in selected children.

Laparoscopic splenectomy has become the gold standard in children

Splenectomy is frequently required in children with various hematologic disorders. The reported advantages of laparoscopic splenectomy (LS) include less pain, shorter hospital stay, and improved cosmesis. This report evaluates the outcome of children undergoing LS at a single children's facility. One hundred twelve children underwent LS by the lateral approach between August 1995 and February 2001. Indications for LS were hereditary spherocytosis in 58, idiopathic thrombocytopenic purpura in 21, sickle cell disease in 19, and other conditions in 14. LS alone was completed in 89 children and LS and cholecystectomy (LSC) in 20. Three required conversion to open splenectomy. Accessory spleens were identified in 19. Complications included ileus (four), acute chest syndrome (four), bleeding (two), pneumonia (one), and diaphragm perforation (one). There was no mortality. An accessory spleen was missed in one child with recurrent anemia. Average operative time for LS was 106 minutes and for LSC 135 minutes. Operative time for LS decreased with experience but the difference was not significant. Average length of stay was 1.51 days (range 1-11) and was longer in sickle cell disease (2.47 days) versus hereditary spherocytosis (1.29 days) and idiopathic thrombocytopenic purpura (1.16 days). We conclude that LS is safe and effective in children with hematologic disorders and is associated with minimal morbidity, zero mortality, and a short length of stay.

Laparoscopic Splenectomy Has Become the Gold Standard in Children

Splenectomy is frequently required in children with various hematologic disorders. The reported advantages of laparoscopic splenectomy (LS) include less pain, shorter hospital stay, and improved cosmesis. This report evaluates the outcome of children undergoing LS at a single children's facility. One hundred twelve children underwent LS by the lateral approach between August 1995 and February 2001. Indications for LS were hereditary spherocytosis in 58, idiopathic thrombocytopenic purpura in 21, sickle cell disease in 19, and other conditions in 14. LS alone was completed in 89 children and LS and cholecystectomy (LSC) in 20. Three required conversion to open splenectomy. Accessory spleens were identified in 19. Complications included ileus (four), acute chest syndrome (four), bleeding (two), pneumonia (one), and diaphragm perforation (one). There was no mortality. An accessory spleen was missed in one child with recurrent anemia. Average operative time for LS was 106 minutes and for LSC 135 minutes. Operative time for LS decreased with experience but the difference was not significant. Average length of stay was 1.51 days (range 1–11) and was longer in sickle cell disease (2.47 days) versus hereditary spherocytosis (1.29 days) and idiopathic thrombocytopenic purpura (1.16 days). We conclude that LS is safe and effective in children with hematologic disorders and is associated with minimal morbidity, zero mortality, and a short length of stay.

Gastric tonometry and direct intraabdominal pressure monitoring in abdominal compartment syndrome

BACKGROUND/PURPOSE

Abdominal compartment syndrome (ACS) may complicate abdominal closure in patients with abdominal wall defects, abdominal trauma, intraperitoneal bleeding, and infection. Increased intraabdominal pressure (IAP) leads to respiratory compromise, organ hypoperfusion, and a high mortality rate. This study evaluates the efficacy of continuous direct monitoring of IAP and gastric tissue pH in detecting impending ACS.

METHODS

Ten mongrel puppies weighing 2.8 to 6.4 kg underwent general endotracheal anesthesia, placement of an intraabdominal inflatable balloon to simulate ACS and a Swan-Ganz catheter to measure direct IAP. A gastric tonometer, nasogastric tube, foley catheter, and arterial catheter also were inserted. Half-hourly inflation's of the intraabdominal balloon were used to simulate the development of ACS. Direct intraabdominal (IAP), gastric (GP), bladder (BP), and peak airway pressures (PAP) were measured. Gastric tonometry fluid and arterial blood gas levels were obtained during inflation, and the gastric tissue pH level was calculated. Data were statistically analyzed using Pearson's correlation coefficients.

RESULTS

Baseline pressures were 2 to 5 cm H(2)O in the stomach and bladder catheters, 1 to 3 mm Hg in the intraabdominal catheter, and correlated with a gastric tissue pH level of 7.4. Significantly high correlation coefficients (cc) were observed between IAP versus BP (cc, 0.77; P <.002). IAP versus GP (cc, 0.79; P <.002) and IAP versus PAP (c, 0.83; P <.0004). A high negative correlation coefficient was noted between gastric pH and IAP (cc, 0.61; P <.026). The pH level dropped to 7.0 with BP and GP of 20 cm H(2)O and IAP of 10 mm Hg, to 6.8 at 30 cm H(2)O and 20 mm Hg, and 6.5 at 40 cm H(2)O and 30 mm Hg, respectively. However, correlation coefficients between gastric tissue pH and BP, GP, or PAP were not significant.

CONCLUSIONS

These data suggest that continuous direct intraabdominal pressure monitoring is a simple and effective method that correlates well with indirect bladder or gastric pressure measurement. Changes in gastric tissue pH in association with increased intraabdominal pressure may be an early indicator of impending abdominal compartment syndrome. These observations indicate that these techniques may be more sensitive than current methods of indirect measurement, which may be associated with delayed recognition of ACS.

Portal venous air: the poor prognosis persists

BACKGROUND/PURPOSE

The prognostic importance of portal vein air (PVA) in babies with necrotizing enterocolitis (NEC) has been controversial. This study compares the outcome in babies with NEC and PVA treated surgically versus those with medical management.

METHODS

Forty neonates in the neonatal intensive care unit (NICU; 1995 through 1999) had (PVA) during their hospitalization. Babies were analyzed for gestational age (GA), birth weight (BW), and survival after operative versus medical management.

RESULTS

The average GA was 26 weeks, average BW was 1,173 g. Twenty-three patients (57.5%) tolerated full feedings and 8 (20%) partial feedings at diagnosis. All 40 babies required intubation at birth with 23 (57.5%) requiring reintubation with onset of PVA. In all cases, PVA was present within 24 hours of onset of abdominal distension, feeding intolerance, or heme-positive stools. Two cases of PVA "resolved" only to recur later in the patients' courses. Thirty-two patients (80%) manifested pneumatosis intestinalis on abdominal radiographs, and 8 (20%) had perforations. Acidosis was present in 25 (63%) patients, and vasopressor support (dopamine) was required in 15 (38%), with 2 patients requiring support only preoperatively. Initial management consisted of bowel rest, fluid resuscitation, orogastric decompression, and broad-spectrum antibiotics. Operation was performed in 31 (78%). Seventeen underwent resection with ostomy formation with 6 deaths and 11 survivors. Four underwent resection using the clip and drop back method, with one death and 3 requiring an ostomy at second look laparotomy. Ten had NEC totalis and closure of the abdomen only. Overall operative mortality rate was 17 of 31 (54%). Nine seemingly stable patients were treated nonoperatively. Six had progressed disease and died before salvage laparotomy could be performed, whereas 3 (33%) survived without further therapy.

CONCLUSIONS

PVA has been a relative indication for operation. This view has been challenged by the survival of some patients without laparotomy. Although nonoperative therapy seems appealing in hemodynamically stable patients without acidosis, our data confirm the poor prognosis of infants with PVA and NEC.

The utility of lung biopsy in recipients of stem cell transplantation

BACKGROUND/PURPOSE

Pulmonary infiltrates in recipients of stem cell transplantation often present as diagnostic dilemmas. Although lung biopsy may establish the diagnosis of parenchymal disease, it remains unclear whether such a procedure results in a significant change in the patient's treatment and outcome. This study evaluates the efficacy of lung biopsy in recipients of stem cell transplantation.

METHODS

The medical records of 15 stem cell transplant recipients who underwent 18 lung biopsies were reviewed. The indications for stem cell transplantation were leukemia in 10 patients, lymphoma in 2, histiocytosis in 1, neuroblastoma in 1, and Ewing's sarcoma in 1. The results of the lung biopsies were correlated to the clinical management and outcomes.

RESULTS

The overall mortality rate was 67% (10 patients). Eight of the 9 patients who required mechanical ventilatory support at the time of lung biopsy died. The pathologic diagnoses were pneumonitis in 6 biopsies, fibrosis in 6, brochiolitis obliterans organizing pneumonia in 3, hemorrhage in 2, and infarction in 1. Therapy was changed in 1 patient who improved after a course of steroids for bronchiolitis obliterans organizing pneumonia. Lung biopsy cultures were positive in 6 patients but rarely resulted in changes in antibiotic therapy.

CONCLUSIONS

Results of very few lung biopsies performed in stem cell transplant recipients redirected therapy. Furthermore, the ultimate outcome of these patients were not improved by the results of lung biopsies.

Pectus excavatum repair: experience with standard and minimal invasive techniques

BACKGROUND/PURPOSE

The Nuss procedure is a minimally invasive pectus repair that helps avoid cartilage resection and osteotomy. This report compares outcomes in patients undergoing a standard pectus repair to patients with the Nuss procedure.

METHODS

One hundred three children (ages 5 to 20 years) with severe pectus excavatum underwent repair. Patients were evaluated for type of repair performed, associated anomalies, cardiopulmonary function, operating time, analgesia requirements, complications, length of hospital stay, hospital and operative charges, and cosmetic result. Statistical analysis was performed using the Mann-Whitney rank sum test.

RESULTS

There were 68 patients (average age, 12.6 years) in the standard group and 35, (average age, 9.5 years) in the Nuss group. Associated anomalies were found in 6 standard group and 2 Nuss group patients. Average operating time in Nuss was 3.3 hours and in open procedures, 4.7 hours. Postoperative complications occurred in 13 (20%) standard repair patients and 15 (43%) after the Nuss. In the standard group, 14 patients received intrathecal and 3 received epidural analgesia, while 35 (52%) required an intravenous patient-controlled anesthetic device (PCA; average, 1.8 days). In the Nuss group, 25 patients (71%) received epidural anesthesia (average, 3 days), and 31 (89%) utilized PCA (average 3.8 days). Four (6%) standard patients and 8 Nuss patients (29%) required reoperation. Length of stay averaged 4.0 days (range 2 to 30) in the standard group and 4.8 days (range, 2 to 11) in the Nuss group. Average operating room charge was $8,325 in the standard group and $9,480 in the Nuss group. Average hospital charge was $4,137 for the standard patient and $4,044 for the Nuss group. Analgesic requirements and length of hospital stay were increased (P <.05). The complication rate and operative and hospital charges were similar between groups.

CONCLUSIONS

Although the Nuss repair is associated with shorter operating time, smaller incisions, and less dissection, early results indicate few other advantages. Drawbacks of the Nuss procedure include high complication and reoperation rates and lack of efficacy in older teenagers and those with connective tissue disorders. Long-term follow-up will be necessary to determine final cosmetic and functional outcomes and define the overall risks and benefits of this procedure as compared with the standard technique.

Patch esophagoplasty using AlloDerm as a tissue scaffold

BACKGROUND/PURPOSE

Anastomotic leak and stricture are common causes of morbidity after esophageal repair. The authors describe a technique of patch esophagoplasty using decellularized human skin.

METHODS

Twelve conditioned dogs underwent a cervical 2.0- x 1.0-cm esophagoplasty with AlloDerm. A gastrostomy tube was used for feedings until an esophagram was performed on the 10th to 14th postoperative day. Dogs were then given oral chow and followed up for leak and dysphagia. Animals were killed at 1-, 2-, and 3-month intervals and evaluated for stricture, diverticula formation, and patch histology.

RESULTS

All animals survived, and none had sepsis or dysphagia. All esophagrams were without evidence of leak or stricture. At death there were no strictures or diverticula. Histologic examination of 1-month specimens showed partial reepithelialization of the patch with neovascularization. Control staining of AlloDerm was strongly positive for elastin. This was decreased in the region of the patch at 1 month. Two-month specimens showed intact epithelium and an increase in the caliber of new blood vessels. Three-month specimens showed no significant variation from 2-month animals.

CONCLUSION

Decellularized human skin (AlloDerm) provides a temporary collagen framework on which esophageal healing can occur and function can be maintained.

Gastroschisis: a plea for risk categorization

BACKGROUND

The incidence of gastroschisis has increased in the past decade. A differing clinical course between "complex" (those with atresias, perforation, or stenosis) and "simple" cases has prompted a review of risk assessment factors.

METHODS

A retrospective chart review was conducted of 103 infants with gastroschisis over 5 years (1992 to 1997).

RESULTS

Of 103 infants, 52 were girls and 51 were boys. Seventy-one infants (69%) had a simple defect, and 32 (31%) were complex. The simple group had an average estimated gestational age of 37.5 weeks (range, 26 to 40), and a birth weight of 3.0 kg (range, 1.7 to 3.8). A total of 71% underwent primary repair, whereas 29% required a silo. Mechanical ventilation averaged 6.8 days (range, 1 to 19). Enteral feedings were initiated at 15 days (range, 3 to 27) with full enteral intake achieved by 22.4 days (range, 5 to 40). Three infants required home parenteral nutrition. The average length of stay (LOS) was 26.4 days (range, 10 to 57). Complications occurred in 26 infants (36%), including intravenous catheter sepsis (n = 15), pneumatosis (n = 2), pneumonia (n = 1), bowel obstruction (n = 7), wound infection (n = 5), and SVC thrombosis (n = 1). Survival rate was 100%. Thirty-two infants had complex defects; 27 patients had atresias, stenosis, or perforations; and 3 had volvulus. The average estimated gestational age was 34 weeks (range, 26 to 38), and birth weight was 2.0 kg (range, 0.9 to 4.0). Primary repair was performed in 65% and silo placement in 35%. Mechanical ventilation was required for 22.3 days (range, 2 to 14). Enteral feedings were initiated at 22.5 days (range, 6 to 56) with full feedings achieved at 50 days (range, 21 to 113). Fourteen infants required home total parenteral nutrition (TPN). The LOS was 85.4 days (range, 24 to 270). A total of 47 complications occurred in the complex group including catheter sepsis (n = 15), short bowel syndrome (n = 7), pneumatosis (n = 3), bowel obstruction (n = 4), pneumonia (n = 2), superior vena cava thrombosis (n = 1), enterocutaneous fistula (n = 1), and 9 deaths (28% mortality rate).

CONCLUSIONS

These data indicate gastroschisis can be divided into low-risk (simple) and high-risk (complex) categories. These 2 groups have significant differences in clinical behavior, postsurgical complications, LOS, and mortality rate (0 v 28%). Although the overall survival rate was 91% (94 of 103), parents, referring physicians, and insurers must be made aware of the impact of risk categorization on the estimated cost, LOS, and outcomes.

Home bowel preparation for elective colonic procedures in children: cost savings with quality assurance and improvement

BACKGROUND/PURPOSE

The current health care environment pressures providers to lower cost and demands quality care that is measured by outcomes and patient satisfaction. Most insurers will not approve bed days for in-hospital preoperative bowel preparations for elective colorectal procedures. This policy does not take into account that infants and children are unable to tolerate large volumes of enteral preparation, which adversely affects outcome because of an inadequate preparation. This report describes a prospective evaluation of a standard home bowel preparation regimen utilizing local and regional home health care agency support.

METHODS

For an elective colorectal procedure, pediatric patients underwent a home bowel preparation using GoLYTELY (100 mL/kg) via a nasogastric tube infused over 4 hours by a pediatric home health nurse trained in this technique. During the bowel preparation, the nurse educated the family members about the service and performed physiological monitoring to insure safety. At the completion of the preparation, any unusual events were transmitted to the staff surgeon for further instructions. Our initial 30 patients were treated by our hospital home health agency personnel to insure safety. Since then, 41 additional bowel preparations have been performed by statewide agencies.

RESULTS

Seventy-one patients underwent complete home bowel preparation (45 boys; 26 girls). The age range was 3 months to 9 years (average, 5 months). There was one complication caused by incorrect mixing of GoLYTELY causing gastrointestinal cramping. All 71 home bowel preparations were recorded as good at the time of the colorectal procedure by the staff pediatric surgeon. The average cost for home bowel preparation was $300 in network, and $350 out of network. This compares with an inpatient hospital day cost of greater than $800 ($36,000 savings).

CONCLUSIONS

This technique offers the pediatric surgeon an opportunity to maintain a high standard of quality care while using home health agency personnel to minimize cost. This program is safe, effective, and associated with a good outcome and a high degree of family satisfaction.

Efficacy of primary and secondary video-assisted thoracic surgery in children

BACKGROUND/PURPOSE

Video-assisted thoracic surgery (VATS) is used commonly for diagnostic and therapeutic procedures in children. The purpose of this study was to determine the accuracy, efficacy, and complications associated with primary and secondary VATS in children.

METHODS

Eighty-seven infants, children, and adolescents underwent 104 VATS procedures between March 1993 and April 1999. There were 47 boys and 40 girls with an age range of 6 months to 19 years. VATS was performed for excision of pulmonary nodule (n = 51), biopsy of infiltrate (n = 14), excision or biopsy mediastinal mass (n = 12), decortication of empyema (n = 16), pleurodesis and bleb excision for pneumothorax (n = 5), pleurolysis for P32 administration (n = 3), esophageal myotomy (n = 2), and thymectomy (n = 1). In 6 children a contralateral thoracic procedure was performed along with VATS (3 VATS, 3 thoracotomies). Secondary VATS was performed in 20 after prior thoracic procedures.

RESULTS

VATS was efficacious for diagnostic or therapeutic purposes in 93 cases. Overall, 11 (11%) VATS required conversion to open thoracotomy. Average length of thoracostomy tube drainage (CTD) was 2.2 days, and average length of stay (LOS) was 3.7 days. Complications included prolonged air leak (> 7 days) in 3 (2 empyema, 1 nodule). Two children with malignancy and pulmonary infiltrates died within 30 days of progressive respiratory failure. There were no bleeding complications or deaths related to VATS.

CONCLUSIONS

VATS is a safe and effective primary and secondary procedure in children resulting in a short length of CTD and LOS. Duration of CTD and LOS are prolonged if empyema is associated with a bronchopleural fistula, and VATS may not be of value in this setting.

Prehospital triage in the injured pediatric patient

BACKGROUND/PURPOSE

Identifying major trauma patients in the prehospital setting is essential in determining management, destination, and best utilization of emergency department resources. Few methods of trauma triage have been accepted unanimously. This study prospectively evaluates the efficacy of comprehensive field triage using 12 criteria (simplified version of the American College of Surgeon's guidelines) in 1,285 pediatric trauma patients.

METHODS

Major trauma was defined as occurring in those who died in the emergency room, had major surgery (penetrating injury involving surgery of the head, neck, chest, abdomen, or groin), or were admitted directly to the intensive care unit. The correlation between trauma triage criteria, hospital disposition, and triage accuracy were determined prospectively and compared in the pediatric patients (36 months) with an adult cohort of patients (12 months).

RESULTS

A total of 1,285 pediatric trauma patients were evaluated and compared with 1,326 adult trauma patients. The most accurate trauma triage criterion for major injury was a blood pressure < or = 90 mmHg (systolic) with an accuracy of 86%. This was followed by burn greater than 15% total body surface area (79%), Glasgow Coma Scale score < or = 12 (78%), respiratory rate less than 10/min or greater than 29/min (73%), and paralysis (50%). Less accurate criteria included a fall from greater than 20 feet (33%); penetrating injury to head, neck, chest, abdomen, or groin (29%); ejection from vehicle (24%); pedestrian struck at greater than 20 mph (16%); paramedic judgement (12%); rollover (3%); and extrication (0%). The Glasgow Coma Scale score was a more accurate indicator of major injury in children than adults, and paramedic judgement was less accurate in children when compared with adults. Of the 379 major pediatric trauma victims, the Revised Trauma Score and Pediatric Trauma Score missed 36% and 45% of these major trauma victims, respectively. The overtriage rate for children was 71% with a sensitivity of 100% (no missed major trauma patients).

CONCLUSIONS

Physiological variables, anatomic site, and mechanism of injury provide a sensitive and safe system of triage. Continued education of prehospital personnel regarding pediatric trauma and stratification of the current triage tools are necessary to minimize overtriage in an era of shrinking resources.

The use of pleuroperitoneal shunts in the management of persistent chylothorax in infants

BACKGROUND/PURPOSE

The development of chylothorax is a serious and often life-threatening clinical entity that may cause profound respiratory, nutritional, and immunologic complications and has become increasingly common in recent years. Optimal management of this problem has not been well defined because medical therapy has a significant failure rate. Surgical treatment of complicated chylothorax has become a mainstay of care.

METHODS

Over the last 36 months, seven infants had a pleuroperitoneal shunt placed for the management of refractory chylothorax. Ages ranged from 10 to 66 days with a weight between 1,000 to 4,850 g. Five of the seven infants were ventilator dependent. The etiologies were congenital in four and acquired in three with one related to a cardiothoracic procedure, one related to superior vena caval thrombosis, and one postoperative diaphragmatic hernia repair with superior vena caval thrombosis. Associated conditions included a left congenital diaphragmatic hernia, asplenia, isolated renal agenesis, bronchopulmonary dysplasia, and a patent ductus arteriosus. Each patient was unresponsive to thoracentesis, tube thoracostomy, and dietary manipulation with preoperative volume of chest tube output ranging from 50 to 162 cc/kg/d. The duration of preoperative therapy in congenital occurrences ranged from 10 to 46 days (average, 22 days). A Denver double-valved shunt system was used and catheters were implanted under general anesthesia. Manual pumping was required postoperatively on an hourly basis.

RESULTS

All seven patients had excellent results with the elimination of the chylothorax and resolution of symptoms. There were two complications. Shunt survival rate was six of seven (86%). Shunt removal ranged from 24 to 79 days (average, 44 days). Patient survival rate was five of seven (71%) with one infant dying of progressive pulmonary disease and one infant dying from viral sepsis; both had functioning shunts. One patient remains ventilator dependent secondary to chronic lung disease from prematurity.

CONCLUSIONS

Pleuroperitoneal shunting is safe, simple, and an effective treatment of chylothorax in infants despite their size, age, or degree of prematurity.

A case controlled comparison of open and laparoscopic splenectomy in children

BACKGROUND

This case controlled study compares the efficacy, safety, and cost of laparoscopic splenectomy (LS) and open splenectomy (OS) for hematologic disorders in children.

METHODS

The records of 82 consecutive children and adolescents undergoing splenectomy for hematologic disorders between August 1994 and September 1997 were reviewed retrospectively.

RESULTS

Fifty patients underwent LS by a lateral approach and 32 underwent OS through a left subcostal incision. Mean age was 7.76 years for LS and 6.9 years for OS. Patient weights were similar: (LS, mean 30.5 kg; OS, mean 27.6 kg). Hematologic indications included hereditary spherocytosis in 43 children (LS 26, OS 17), sickle cell anemia with sequestration in 13 (LS 7, OS 6), immune thrombocytopenic purpura in 14 (LS 8, OS 6), and 12 with other disorders (LS 9, OS 3). Concomitant cholecystectomy was performed in 10 of 50 LS and 6 of 32 OS cases. Accessory spleens were identified in 8 of 32 (25%) OS and 9 of 50 (18%) LS cases (P = .578). No LS procedures required conversion to OS. The mean estimated blood loss was 54.4 mL for LS and 49.0 mL for OS (P = .233). LS required a longer operative time (115 vs 83 minutes, P = .002), less need for postoperative intravenous narcotic (51% vs 100%, P < .0001), lower total narcotic doses (0.239 vs 0.480 mg/kg morphine, P = .006), shorter length of hospital stay (1.4 +/- 0.97 vs 2.5 +/- 1.43 days, P = .0001), and lower average total hospital charges ($5713 vs $6564) than OS. There were no deaths or major complications in either group.

CONCLUSIONS

Laparoscopic splenectomy is a safe and effective procedure in children with hematologic disorders resulting in longer operative times, less narcotic administration, shorter length of stay, and lower total hospital charge.

Long-term follow-up after bowel resection for necrotizing enterocolitis: factors affecting outcome

BACKGROUND

Necrotizing enterocolitis (NEC) is the most common surgical emergency among newborns and is associated with a high morbidity and mortality. This study evaluates the long-term survival of infants requiring surgical intervention for NEC and factors affecting outcome.

METHODS

A retrospective review of infants requiring surgery for complications of NEC at a tertiary care, pediatric hospital over a 16-year period was performed. Patients were evaluated for early and late morbidity and mortality, length of intestinal resection, presence of the ileocecal valve (ICV), days of parenteral nutrition (PN), and growth.

RESULTS

Two hundred forty-nine patients were included, with an average gestational age of 30 +/- 5 (+/- SD) weeks and birth weight of 1.50 +/- 0.89 kg. The surgical mortality rate was 45%, with survivors (137) being larger (P < .001) and older (P < .001) at time of birth than nonsurvivors. Mortality rates varied inversely with gestational age and birth weight. Surgical survivors had an average of 21 +/- 26 cm of intestinal length resected. The ileocecal valve was preserved in 45% of infants. Growth was similar between infants with or without an ICV. Stratification of length of intestine resected showed that infants with larger resections had greater requirements for parenteral nutrition, but this had no influence on long-term growth at follow-up.

CONCLUSIONS

Survivors of NEC are characterized by greater gestational age, greater birth weight, and older postgestational age at surgery. Infants who underwent greater intestinal resections required longer periods of PN. The length of intestine resected or presence of the ileocecal valve had no overall bearing on long-term outcome.

Intestinal atresia and stenosis: a 25-year experience with 277 cases

OBJECTIVE

To evaluate the causes, clinical presentation, diagnosis, operative management, postoperative care, and outcome in infants with intestinal atresia.

DESIGN

Retrospective case series.

SETTING

Pediatric tertiary care teaching hospital.

PATIENTS

A population-based sample of 277 neonates with intestinal atresia and stenosis treated from July 1, 1972, through April 30, 1997. The level of obstruction was duodenal in 138 infants, jejunoileal in 128, and colonic in 21. Of the 277 neonates, 10 had obstruction in more than 1 site. Duodenal atresia was associated with prematurity (46%), maternal polyhydramnios (33%), Down syndrome (24%), annular pancreas (33%), and malrotation (28%). Jejunoileal atresia was associated with intrauterine volvulus, (27%), gastroschisis (16%), and meconium ileus (11.7%).

INTERVENTIONS

Patients with duodenal obstruction were treated by duodenoduodenostomy in 119 (86%), of 138 patients duodenotomy with web excision in 9 (7%), and duodenojejunostomy in 7 (5%) A duodenostomy tube was placed in 3 critically ill neonates. Patients with jejunoileal atresia were treated with resection in 97 (76%) of 128 patients (anastomosis, 45 [46%]; tapering enteroplasty, 23 [24%]; or temporary ostomy, 29 [30%]), ostomy alone in 25 (20%), web excision in 5 (4%), and the Bianchi procedure in 1 (0.8%). Patients with colon atresia were managed with initial ostomy and delayed anastomosis in 18 (86%) of 21 patients and resection with primary anastomosis in 3 (14%). Short-bowel syndrome was noted in 32 neonates.

MAIN OUTCOME MEASURES

Morbidity and early and late mortality.

RESULTS

Operative mortality for neonates with duodenal atresia was 4%, with jejunoileal atresia, 0.8%, and with colonic atresia, 0%. The long-term survival rate for children with duodenal atresia was 86%; with jejunoileal atresia, 84%; and with colon atresia, 100%. The Bianchi procedure (1 patient, 0.8%) and growth hormone, glutamine, and modified diet (4 patients, 1%) reduced total parenteral nutrition dependence.

CONCLUSIONS

Cardiac anomalies (with duodenal atresia) and ultrashort-bowel syndrome (<40 cm) requiring long-term total parenteral nutrition, which can be complicated by liver disease (with jejunoileal atresia), are the major causes of morbidity and mortality in these patients. Use of growth factors to enhance adaptation and advances in small bowel transplantation may improve long-term outcomes.

Necrotizing enterocolitis

Necrotizing enterocolitis is a relatively common disorder of unknown etiology that primarily affects premature newborns. The majority of babies with necrotizing enterocolitis respond to nonsurgical management, and, despite an increase in the number of premature infants, the surgical mortality rate has improved. This review provides an overview of the current literature covering new developments in etiology, risk factors, pathogenesis, diagnosis, therapy, outcome, and preventable measures related to necrotizing enterocolitis.

Reoperation after Nissen fundoplication in children with gastroesophageal reflux: experience with 130 patients

OBJECTIVE

The authors evaluate reoperation for recurrent gastroesophageal reflux (GER) after a failed Nissen fundoplication.

SUMMARY BACKGROUND DATA

Nissen fundoplication is an accepted treatment for GER refractory to medical therapy. Wrap failure and recurrence of GER are noted in 8% to 12%.

METHODS

Medical records of 130 children undergoing a second antireflux operation for recurrent GER from January 1985 to June 1996 retrospectively were reviewed.

RESULTS

One hundred one patients (78%) were neurologically impaired (NI), 74 (57%) had chronic pulmonary disease, and 8 had esophageal atresia. Recurrent symptoms included vomiting (78%), growth failure (62%), choking-coughing-gagging (38%), and pneumonia (25%). Gastroesophageal reflux was confirmed by barium swallow, gastric scintigraphy, and endoscopy. Operative findings showed wrap breakdown (42%), wrap-hiatal hernia (30%), or both (21%). A second Nissen fundoplication was performed in 128 children. Complications included bowel obstruction (18), wound infection (10), pneumonia (6) and tight wrap (9). There were two postoperative (<30 days) deaths (1.5%). Of 124 patients observed long term, 89 (72%) remain symptom free. Eight were converted to tube feedings. Twenty-seven required a third fundoplication, and 19 (70%) were successful outcome. Two with repetitive wrap failure due to gastric atony underwent gastric resection and esophagojejunostomy.

CONCLUSION

Nissen fundoplication was successful in 91% of patients. In 9% with wrap failure, a second Nissen fundoplication was successful in 72%. Reoperation is justified in properly selectedpatients. Conversion to jejunostomy feedings is suggested for neurologically impaired after two wrap failures and a partial wrap in those with esophageal atresia and severe esophageal dysmotility. Repeated wrap failure due to gastric atony requires gastric resection and esophagojejunostomy.

The "other side" of pediatric hernias: the role of laparoscopy

The role of contralateral inguinal exploration in neonates, infants, and children presenting with unilateral hernias is controversial. Factors considered by surgeons include the patient's age, sex, and side of the clinically apparent hernia. The purpose of this study was to evaluate the role of diagnostic laparoscopy performed through the clinically apparent hernia sac to identify a contralateral patent processus vaginalis (CPPV) in children and limit contralateral exploration to CPPV-positive patients. One hundred neonates, infants, and children underwent laparoscopic evaluation for a CPPV through the ipsilateral hernia sac. There were 79 boys and 21 girls. Forty-eight of 100 (48%) had a CPPV identified, which was confirmed operatively. Thirty-one of 68 patients (46%) with a right-sided and 18 of 32 (56%) with a left-sided hernias had a CPPV (P = 0.39). Thirty-six of 56 (64%) patients younger than 6 months of age had a CPPV compared to 13 of 44 (30%) older than six months (P = 0.001). Fourteen of 21 (67%) girls had a CPPV compared to 35 of 79 (44%) boys (P = 0.087). Laparoscopy through the hernia sac is a safe and effective means of identifying the presence of a CPPV and avoiding unnecessary contralateral inguinal exploration. Infants (< 6 months) are much more likely to have a CPPV.

Gastrointestinal perforation and peritonitis in infants and children: experience with 179 cases over ten years

BACKGROUND

Premature infants continue to have a high mortality after gastrointestinal perforation. This report describes 179 patients with gastrointestinal perforation and peritonitis and compares etiologic factors, mortality, and causes of death in premature infants and older children in an attempt to predict outcome.

METHODS

The 113 boys (63.1%) and 66 girls (36.9%) had an age range of newborn (n = 139, 77.6%) to 17 years. Site of perforation was gastric in 16, duodenal in 9, small bowel in 105, colon in 37, and undesignated in 12. Eighteen had multiple perforations. Etiologic factors in newborns (younger than 2 months) included necrotizing enterocolitis (NEC) (75, 41.9%), isolated ileal perforations (30, 21.5%), malrotation/volvulus (8), iatrogenic causes (5), and others (6). Gestational age was 29.6 +/- 4.3 weeks for NEC versus 31.4 +/- 5.4 weeks for non-NEC. Birth weight for patients with NEC was 1.45 +/- 0.8 gm and 1.81 +/- 1.0 gm for non-NEC babies. Etiologic factors in 33 older children (older than 2 months to 17 years) were trauma (10), Meckel's diverticulum (4), intussusception (2), pseudomembranous colitis (2), adhesions (2), stomal leak (2), others (4), and nondesignated (7). Gastric perforations (n = 16) were iatrogenic in 7, idiopathic in 5, and caused by an ulcer in 4.

RESULTS

Mortality for NEC was 36 of 75 (48%), 15 of 55 (27.2%) for non-NEC infants (p < 0.05 versus NEC), 15.1% (5 of 33) for older children (p < 0.05 versus NEC), and 4 of 16 (25%) for gastric perforation. Infant deaths were related to overwhelming sepsis, immaturity of systems, and multiorgan failure. Deaths for older children were a result of sepsis, multiorgan failure, and immunodeficiency.

CONCLUSIONS

Gastrointestinal perforation is more common in premature infants with the highest mortality (48%) noted in NEC. Despite surgical intervention and advances in neonatal intensive care unit care, premature low birth weight infants (especially NEC) continue to have a high mortality.

Increased risk of necrotizing enterocolitis in premature infants with patent ductus arteriosus treated with indomethacin

OBJECTIVE

The authors evaluated the risk of necrotizing enterocolitis (NEC) in very low birth weight infants receiving indomethacin (INDO) to close patent ductus arteriosus (PDA).

BACKGROUND DATA

Controversy exists regarding the best method of managing very low birth weight infants with PDA and whether to employ medical management using INDO or surgical ligation of the ductus.

METHODS

Two hundred fifty-two premature infants with symptomatic PDA were given intravenously INDO 0.2 mg/kg every 12 hours x 3 in an attempt to close the ductus. Patients were evaluated for sex, birth weight, gestational age, ductus closure, occurrence of NEC, bowel perforation, and mortality.

RESULTS

There were 135 boys and 117 girls. The PDA closed or became asymptomatic in 224 cases (89%), whereas 28 (11%) required surgical ligation. Ninety infants (35%) developed evidence of NEC after INDO therapy. Fifty-six were managed medically; surgical intervention was required in 34 of 90 cases (37.8%) or 13% of the entire PDA/INDO study group. Bowel perforation was noted in 27 cases (30%). Factors associated with the onset of NEC included gestational age < 28 weeks, birth weight < 1 kg, and prolonged ventilator support. The overall mortality rate was 25.5%, but was higher in infants with NEC versus those without. The highest mortality was noted in perforated NEC cases. The PDA/INDO patients were compared with a control group of 764 infants with similar sex distribution, birth weights, and gestational ages without PDA who did not receive INDO. Necrotizing enterocolitis occurred in 105 of 764 control patients (13.7%), including 13 (12.3%) with perforation. The overall mortality rate of controls was 25%, which was similar to the overall 25.5% mortality rate in the PDA/INDO study group.

CONCLUSION

These data indicate that there is increased risk of NEC and bowel perforation in premature infants with PDA receiving INDO. Mortality was higher in the PDA/INDO group with NEC than those PDA/INDO infants without NEC.

Improved survival in children with esophageal perforation

OBJECTIVE

To analyze the cause, location, signs and symptoms, presence of underlying disease, time interval to diagnosis, treatment, and morbidity and mortality in 24 children (19 boys and 5 girls) with esophageal perforation who were treated from 1975 to 1995.

DESIGN

Data were collected retrospectively from hospital and office records.

SETTING

A tertiary care children's hospital.

RESULTS

The average age at diagnosis was 58 months (range, 1 day to 19 years). Fourteen children had underlying esophageal disease (atresia, n = 7 and gastroesophageal reflux, n = 7). Iatrogenic perforations occurred in 17 children: 8 during dilatation, 5 during an antireflux procedure, 2 during endoscopy, and 2 after passage of a feeding tube. Trauma was the cause of perforation in 6 children. In 2 cases the cause was unknown. Perforation occurred in the thoracic esophagus in 12 cases, abdominal esophagus in 7, cervical esophagus in 5, and involved both the thoracic and abdominal esophagus in 1. Signs and symptoms included dysphagia (15 patients), dyspnea (14), fever (12), cyanosis (8), abdominal pain (6), chest pain (5), and subcutaneous emphysema (3). Management of esophageal perforation included nonoperative management (7 patients), drainage alone (1), primary closure (16), and resection and diversion (1). Two perforations occurred in 1 child. Complications occurred in 11 (44%) of the 25 cases and were more common after delayed diagnosis (73%). The average hospital stay was 20 days. There was 1 death (4%) attributed to esophageal perforation.

CONCLUSIONS

Morbidity and mortality are directly related to delays in diagnosis and therapy. Most cases of esophageal perforation in children can be closed primarily and the esophagus salvaged despite delayed presentation. The mortality rate in children with esophageal perforation (4%) is significantly less than that for adults (25%-50%).

Analysis of morbidity and mortality in 227 cases of esophageal atresia and/or tracheoesophageal fistula over two decades

OBJECTIVE

This report analyzes the morbidity and mortality in 227 infants (127 boys and 100 girls) with variants of esophageal atresia and/or tracheoesophageal fistula who were treated from 1971 to 1993.

DESIGN

Data were collected retrospectively from hospital and office records. Mean follow-up was 76 months, ranging from 1 month to 22 years.

SETTING

Patients were treated at a tertiary care children's hospital.

RESULTS

The mean birth weight was 2557 g (range, 1100 to 4460 g), and the mean gestational age was 38 weeks (range, 28 to 42 weeks). Classification included 29 cases of type A esophageal atresia (13%); two cases of type B (1%), 178 cases of type C (78%), five cases of type D (2%), and 13 cases of type E (6%). Associated anomalies occurred in 146 infants (64%), including cardiac defects in 86 (38%), skeletal defects in 44 (19%), neurological defects in 34 (15%), renal defects in 35 (15%), anorectal defects in 18 (8%), and other abnormalities in 30 (13%). A single-layer anastomosis was performed in 81%, and a two-layer repair, in 17%. Esophagomyotomy was necessary in 9% of the patients. Anastomotic complications included leakage (16%), symptomatic stricture (35%), and recurrent tracheoesophageal fistula (3%). Gastroesophageal reflux was present in 127 cases (58%), with 56 (44%) requiring an antireflux procedure. Tracheomalacia occurred in 32 cases (15%), and 13 required operative treatment. Postoperative esophageal dysmotility was documented in 56 children (30%). The overall survival rate was 95%. The cause of death in 12 patients included severe cardiac anomalies (n = 3), fatal sleep apnea (n = 1), renal failure (n = 1), trisomy 18 (n = 2), accidental decannulation of tracheostomy (n = 1), pulmonary failure (n = 1), and unknown causes (n = 3).

CONCLUSIONS

Early diagnosis, improved surgical technique, neonatal anesthesia, sophisticated ventilatory support, advanced intensive care management, early treatment of associated anomalies, responsiveness of anastomotic strictures to dilatation, and aggressive treatment of gastroesophageal reflux have influenced survival positively. Improved survival rates were noted irrespective of the traditional Waterston criteria, which now seem outdated. With few exceptions, most infants with esophageal atresia and/or tracheoesophageal fistula should survive in the current era.

Does preoperative chemotherapy for hepatic tumors have an adverse effect on hepatic proliferation after delayed liver resection?

The authors evaluate the effect of preoperative cisplatin and Adriamycin on hepatic proliferation after delayed partial hepatectomy. Sprague-Dawley rats were placed into five experimental groups. Group I received 0.9% saline intraperitoneally (IP). Group II received 2 mg/kg of cisplatin IP. Group III received 4 mg/kg of cisplatin IP. Group IV received 6 mg/kg of Adriamycin intravenously. Group V received 0.9% saline IP. Groups I through IV underwent 70% partial hepatectomy 2 and 10 days after chemotherapy. They were killed 24 hours later, and analyses were performed. Group V animals underwent celiotomy and were killed. Hepatic proliferation was evaluated by tritiated thymidine (3H-TdR) incorporation into DNA, quantitative image analysis (QIA), and proliferating cell nuclear antigen immunostained hepatic nuclei (PCNA). 3H-TdR incorporation values in animals treated 2 days before partial hepatectomy in treatment groups II through IV were similar to those of the hepatectomized controls. Although among the animals treated 10 days before partial hepatectomy there was inhibition of 3H-TdR DNA incorporation in the Adriamycin group, no significant differences were noted between all treatment groups. QIA of the S-phase nuclei (an indicator of proliferation) indicated that the animals treated with 2 mg/kg of cisplatin had significantly more nuclei than those treated with Adriamycin. PCNA labeling showed a decrease in proliferating nuclei in all treatment groups compared with the control hepatectomized animals.(ABSTRACT TRUNCATED AT 250 WORDS)

Familial Hirschsprung's disease: 20 cases in 12 kindreds

This report describes 20 infants and children with a family history of Hirschsprung's disease in 12 kindreds. A total of 260 patients were treated for Hirschsprung's disease (1972 to 1991), yielding a familial incidence of 8%. There were no families with consanguineous marriage. Sixteen patients were male and four were female. The mean age at diagnosis was 18 days. Clinical presentation included delayed passage of meconium in 15, abdominal distention in 11, vomiting in 9, feeding abnormalities in 3, and complete bowel obstruction in 1. Associated congenital anomalies occurred in 25% of the patients. The extent of aganglionosis was rectal in 4, sigmoid in 4, left colon in 2, transverse or right colon in 2, and total colonic in 8. Enterocolitis occurred in 7 patients (35%); 2 at diagnosis, 2 after an ostomy, and 3 after a pull-through procedure. There were no deaths associated with enterocolitis. All patients had a proximal diverting colostomy or ileostomy, and 19 of 20 underwent a definitive pull-through procedure. Three patients were lost to follow-up and one patient died of complications of multiple congenital anomalies unassociated with Hirschsprung's disease. Of the remaining 16 patients, all of whom have undergone a pull-through procedure, 11 are fully continent, 2 have nighttime soiling, 2 are too young to evaluate bowel function, and 1 still has an ostomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Early use of cisplatin is safe after partial hepatectomy

Although cisplatin is widely used in the treatment of liver tumors, little information is available concerning its effect on liver regeneration. This report evaluates the effect of cisplatin on liver regeneration after hepatectomy (HPx). One hundred sixty male Sprague-Dawley rats were placed into five experimental groups following 70% hepatectomy. Group I (untreated controls, n = 32) received 0.9% saline intraperitoneally (IP); group II (n = 31), cisplatin 4 mg/kg IP; group III (n = 36), cisplatin 10 mg/kg IP; group IV (n = 34), cisplatin 20 mg/kg IP; and group V (n = 27), doxorubicin 6 mg/kg intravenously (IV). Five additional sham groups underwent celiotomy without hepatectomy (n = 106) followed by the above treatment protocols. Liver regeneration was evaluated by liver weight, DNA incorporation measured by tritiated thymidine (3H-TdR), and quantitative image analysis (QIA) of hepatic nuclei at 18, 24, 36, 48, and 72 hours, and 5 days postoperatively. 3H-TdR incorporation peaked at 36 hours and was similar in hepatectomized controls group I (404 +/- 110 counts per minute [CPM]/mg liver weight) and cisplatin-treated rats (groups II to IV) (P > .05, ANOVA). All sham groups were similar to controls. QIA of feulgen-stained touch preps identified polyploid, stem line, and proliferating nuclei in both controls and treated groups. At 36 hours, QIA showed differences in mitotic status of sham, control, and adriamycin-treated HPx rats, consistent with 3H-TdR incorporation. In contrast, although cisplatin-treated rats receiving 4 mg/kg showed proliferating nuclei, QIA demonstrated decreasing hepatocyte proliferation with higher doses of cisplatin (10 mg/kg, and 20 mg/kg).(ABSTRACT TRUNCATED AT 250 WORDS)