A. J. W. Millar

Long-term clinical, manometric, and histological evaluation of obstructive symptoms in the postoperative Hirschsprung's patient

One hundred seventy-eight of 326 patients had surgery for Hirschsprungs disease at Red Cross Childrens Hospital (1957 to 1990) agreed to participate in a recall follow-up study. Assessment of the postoperative outcome of the Swenson, Duhamel, and Soave procedures included manometric evaluation in 43 patients by perfused-tube and balloon-series techniques. Rectal suction biopsies were performed for patients who had persistent problems with stool evaluation. One hundred fifteen of the 178 patients were more than 4 years of age, and long-term functional outcome could be assessed. Although good results were obtained in 94% overall, 16 had clinical evidence of a degree of persisting obstruction. Results of manometric assessment of anorectal function in these patients were not significantly different from those of 28 patients who had normal stool evacuation. A biopsy was performed in 14 of the 16 patients who had symptoms of obstruction postoperatively, and abnormal histological features were noted. There was aganglionosis in four, features of neuronal intestinal dysplasia in nine, ganglioneuromatosis of the colon in one. The results of two biopsies were entirely normal. Implications of postoperative dysfunction after surgery for Hirschsprungs disease are discussed, and a protocol for investigation and management is proposed.

Iatrogenic esophageal perforation in children: patterns of injury, presentation, management, and outcome.

Iatrogenic esophageal perforations in children are rare. To evaluate patterns of injury, clinical presentation, and treatment options for such patients, the authors reviewed the case records of 11 children who had sustained transmural injury to the esophagus during a dilatation procedure at their institution between 1967 and 1994. Strictures requiring dilatation were attributable to caustic ingestion in eight, esophageal atresia repair in two, and congenital stenosis in one. Eight were penetrating injuries, and three were disruptions. Two involved the cervical esophagus; and nine involved the thoracic esophagus. Pain, pyrexia, and tachycardia were early signs. Proximal thoracic perforations led to signs in the left chest region (effusion/pneumothorax); with distal perforation the signs were on the right side. Treatment along conventional lines (local drainage, gastrostomy, primary repair after early recognition, and antibiotic therapy) was successful, with two major complications, both empyemas. The most recent case, a disruption of a tracheoesophageal fistula stricture, was successfully treated with oral water irrigation and antibiotics only. Six had colonic interposition (all caustic ingestion), one required endoesophageal resection of a distal stricture, and four had resolution of the stricture, three without additional dilatation. The majority of children with iatrogenic injuries of the esophagus can be managed successfully by conservative measures and pleural drainage, with surgical procedures reserved for large disruptions of the esophagus, intraabdominal perforations, and cases that do not respond to appropriate conservative measures. Patients with caustic injury to the esophagus have a greater risk for the development of penetrating injury, and this may be one indicator of the severity of scarring. There are distinct clinical patterns of presentation, which depend on the level at which the esophagus is perforated. Dilatation disruption of a localized stricture has a good long-term prognosis for the esophagus and may even cure the stricture. The role of oral irrigation still must be fully evaluated where disruption has occurred as distinct from a penetrating injury.

Blunt liver trauma in children: nonoperative management.

Since 1978, we have treated 19 of 23 (83%) children with blunt liver trauma nonoperatively. Management consisted of observation in an intensive care unit, repeated physical examination, frequent reevaluation of laboratory values, special investigations, and bed rest. The 19 patients all remained stable, required no surgical intervention, and showed resolution of the hepatic injuries with no early or delayed complications. Ultrasonography, although not as reliable a method as computed tomography or liver isotope scans for identification of hepatic trauma at first presentation, provided a very useful method for documenting subsequent progress and eventual healing of the lesions. The presence of an isolated hepatic injury is insufficient indication for surgery. If there is significant extrahepatic injury requiring surgery, or if the patient with hepatic trauma is deteriorating, operative intervention is mandatory.

Esophageal pH assessment of gastroesophageal reflux in 18 patients and the effect of two prokinetic agents: Cisapride and metoclopramide

Foregut drug receptors permit inotropic manipulation of the dysmotility pattern associated with gastroesophageal reflux (GER). Two prokinetic agents, ie, Metoclopramide and Cisapride were assessed in 18 infants with severe GER (mean age 6.5 months) by means of 18-hour continuous intraesophageal pH monitoring. Six parameters were recorded, and the results compared before and during pharmacologic stimulation. Both agents improved the parameters measured, but Cisapride was found to be more effective in enhancing lower esophageal sphincter competence and esophageal motor function. Long-term assessment of both agents in the management of GER in infants is indicated.

Oesophageal replacement in the management of corrosive strictures : when is surgery indicated ?

Abstract The accidental ingestion of corrosive agents is a major cause of oesophageal strictures in children. The mainstay of treatment is repeated dilatations. Despite this, a significant number of patients eventually require oesophageal bypass. We reviewed the records of all cases managed with this condition at the University of Cape Town teaching hospitals between 1976 and 1994. Dilatation therapy alone was successful in 14 out of 39 patients (41%). Morbidity of failed dilatation therapy included repeated hospital admissions over an average 11.5 months and 17 dilatations each. Oesophageal perforations occurred in 7 cases (18%). Early factors predictive of failure of conservative treatment were: delay in presentation of more than 1 month; severe pharyngo-oesophageal burns requiring a tracheostomy; oesophageal perforation; and a stricture longer than 5u2009cm on radiological assessment. The size of dilators accepted during early bougienage also correlated with eventual outcome. These criteria may be useful in predicting which patients will not respond to repeated dilatations. Early surgical intervention in such cases will prevent fruitless dilatations and related complications.

Colorectal carcinoma in children

An increasing incidence of colorectal carcinoma has been noted at this institution. We report seven children with colorectal carcinoma. The average delay between onset of symptoms and diagnosis was 41/2 months, and in five patients distant metastases were present at the first operation. Initial symptoms were ignored in all cases and in only one was the serious nature of the condition realized at first presentation. In five lesions the histology was mucin secreting adenocarcinoma, a poor prognostic variant. All seven died on average 11 months after diagnosis. These three factors--delay in diagnosis, advanced stage of disease, and poorly differentiated histology--contribute overall to a poor prognosis in the young.

Abdominal complications of Ascaris lumbricoides in children

Human infestation with Ascaris lumbricoides is common in tropical and subtropical areas and is responsible for 20% of acute admissions annually to the surgical wards of the Red Cross Childrens Hospital. Of the 225 children with symptomatic ascariasis seen during the 5-year period 1985–1989, 66% were intestinal, 30% hepato-biliary, and 4% pancreatic. Real-time ultrasound was the method of choice for diagnosis of invasion of the biliary and pancreatic systems. Eighty-four per cent resolved within 3 days after a short transient illness. Endoscopic retrograde cholangio-pancreatography was performed 15 times in 13 children when conservative measures failed and hepato-biliary infestation persisted. Complete removal of common bile duct worms was achieved in 55%. Thirty-seven (16%) were operated upon for deteriorating intestinal obstruction or persistent biliary and complicated hepatic disease. Indications for surgery are suspicion of ischaemic bowel, persistence of common bile duct worms for more than 4–6 weeks, liver disease, and persisting pseudocyst of the pancreas.

Radiation enteritis in children

Six children with intestinal radiation injury following cancer therapy are presented. The radiation dose varied from 3500 rads to 6600 rads. Symptoms of radiation enteritis took from 3 weeks to 3 years to develop. All patients received concomitant chemotherapy. Incomplete bowel obstruction was the most common presenting feature (four cases); five came to laparotomy. Simple adhesiolysis was successful in two cases; two children required more extensive surgical manoeuvres (small-bowel bypass and bowel resections). All are alive and well 4 to 13 years following therapy although five have other radiation effects. Radiation injury to the bowel and its management are discussed.

Mercury absorption following button battery ingestion

A case of button battery ingestion with resulting disintegration of the battery, mercury spillage, and absorption of elemental mercury from the colon is reported. In the light of this case and other recorded complications following button battery ingestion, a plan of management is suggested.

Intestinal atresia and Hirschsprung's disease

Intestinal atresia associated with Hirschsprungs disease has been reported in only 26 cases (20 of small bowel and 6 of colon). Three additional patients are reported, two with associated myelomenigocoele. The significance of the myelomeningocoele and possible aetiological mechanisms of these associations are discussed with particular reference to the role of a vascular accident or the embryological failure of migration of nerve cells. The most likely cause is a volvulus proximal to the aganglionic bowel resulting in the associated atresia.