Albert W. Dibbins

Gastroesophageal reflux in children: An underrated disease☆

Gastroesophageal reflux in infants and children is a complex disease. The diagnosis in 14 operative patients was made utilizing a careful history, barium swallow, technetium radionuclide milk scan, and endoscopy with esophageal biopsy. Symptoms were intractable vomiting, failure to thrive, recurrent pneumonia, apnea, asthma and bronchitis, esophagitis, and esophageal stricture. The pernicious aspects of this disease include a potentially significant mortality in children with severe apnea episodes, increased morbidity with esophagitis, and psychosocial disruption for those children that progress to the teenage years with recurrent vomiting, rumination, heartburn and stricture formation. A high incidence of gastroesophageal reflux unresponsive to medical management was noted with esophageal atresia and neurologic disease. The Nissen fundoplication was used in all patients and proved an effective procedure with a low morbidity and recurrence rate.

Bilateral chylothorax in a newborn

Bilateral chylothorax as a result of superior vena cava (SVC) thrombosis is reported. A 1.6-kg infant drained an average of 240 ml per day from an indwelling chest tube during a 3-wk period after thrombosis of the SVC secondary to an indwelling silastic catheter. This daily fluid loss was 1.7 times the patients blood volume and was replaced ml for ml with fresh frozen plasma. This extraordinary volume continued despite the patient being NPO and receiving peripheral intravenous nutrition. Since no improvement occurred after a 3-wk period, a thoracotomy was performed. A parietal pleurectomy was performed since on specific site for a chyle leak was identified. The chylothorax cleared immediately following the operation. This patient is unique in both the total volume of chylous drainage obtained (5000 ml) and the surgical technique employed to correct this problem.

Prenatal diagnosis of congenital anomalies requiring surgical correction. Implications for the future.

With the use of maternal ultrasonography, 22 infants had an anomaly identified before delivery. Nine had gastrochisis. In all, ultrasonography was performed because of an elevated maternal serum alpha 1 fetoprotein level. Ultrasonography for other indications identified three infants with omphaloceles, three with cystic adenomatoid malformation of the lung, two with duodenal atresia, two with posterior urethral valves, and one each with obstruction of the ureteropelvic junction, a retroperitoneal teratoma, and an ovarian cyst. Infants were delivered in a neonatal center able to provide total care from the time of birth, thus the risks of transport over long distances were avoided. One of the infants with cystic adenomatoid malformation was incorrectly diagnosed as having a congenital diaphragmatic hernia, and the complete posterior urethral valve bilateral hydronephrosis complex was not identified in this infant until after delivery. The ability to diagnose complex anomalies correctly places new responsibilities on the surgeon who must counsel the parents on his ability to successfully treat the identified anomaly. Improved diagnostic accuracy, increased case findings, careful counselling, and delivery of high-risk infants in regional centers must be major priorities to improve neonatal surgical care in the next decade.

Compressed air injury to the esophagus: case report.

Compressed air injuries to the esophagus are uncommon. They characteristically present with respiratory distress, subcutaneous and mediastinal emphysema, and may have a pneumothorax. The distal esophagus is always the site of rupture and requires prompt surgical repair to avoid serious morbidity and potential lethal complications.

CT of an actively-hemorrhaging liver laceration in a 9-year-old child

A 9-year-old female with blunt abdominal trauma following a motor vehicle accident was referred from the Emergency Room for abdominal CT imaging. CT demonstrated the unusual and heretofore unreported finding of an actively hemorrhaging liver laceration.

New anthropometric classification scheme of preoperative nutritional status in children: a retrospective observational cohort study

Objective WHO uses anthropometric classification scheme of childhood acute and chronic malnutrition based on low body mass index (BMI) (‘wasting’) and height for age (‘stunting’), respectively. The goal of this study was to describe a novel two-axis nutritional classification scheme to (1) characterise nutritional profiles in children undergoing abdominal surgery and (2) characterise relationships between preoperative nutritional status and postoperative morbidity. Design This was a retrospective observational cohort study. Setting The setting was 50 hospitals caring for children in North America that participated in the American College of Surgeons National Surgical Quality Improvement Program Paediatric from 2011 to 2013. Participants Children >28 days who underwent major abdominal operations were identified. Interventions/main predictor The cohort of children was divided into five nutritional profile groups based on both BMI and height for age Z-scores: (1) underweight/short, (2) underweight/tall, (3) overweight/short, (4) overweight/tall and (5) non-outliers (controls). Main outcome measures Multiple variable logistic regressions were used to quantify the association between 30-day morbidity and nutritional profile groups while adjusting for procedure case mix, age and American Society of Anaesthesiologists class. Results A total of 39 520 cases distributed as follows: underweight/short (656, 2.2%); underweight/tall (252, 0.8%); overweight/short (733, 2.4%) and overweight/tall (1534, 5.1%). Regression analyses revealed increased adjusted odds of composite morbidity (35%) and reintervention events (75%) in the underweight/short group, while overweight/short patients had increased adjusted odds of composite morbidity and healthcare-associated infections (43%), and reintervention events (79%) compared with controls. Conclusion Stratification of preoperative nutritional status using a scheme incorporating both BMI and height for age is feasible. Further research is needed to validate this nutritional risk classification scheme for other surgical procedures in children.