Alex W. Auldist

Intussusception: Trends in clinical presentation and management

Background:  The association of a rotavirus vaccine and intussusception has renewed interest in understanding the incidence, clinical presentation and outcome of intussusception.

Secondary esophageal surgery following repair of esophageal atresia with distal tracheoesophageal fistula

During the period 1948 through 1988, 498 patients with esophageal atresia and distal tracheoesophageal fistula were admitted to the Royal Childrens Hospital, Melbourne. Fifty patients had a second operative procedure on the esophagus, for anastomotic stricture (30), recurrent fistula (15), both (4), and a postmyotomy diverticulum (1). During the same period, nine patients underwent esophageal replacement and 33 patients a Nissen fundoplication. Improvements in the technique of esophageal anastomosis, and in recent years the use of fundoplication to correct gastroesophageal reflux have led to a marked reduction in the need for secondary surgery to the esophagus after repair of esophageal atresia. Esophageal replacement is rarely required in esophageal atresia and distal tracheoesophageal fistula. One-layer end-to-end esophageal anastomosis using interrupted sutures resulted in the lowest rate of recurrent fistula and anastomotic stricture.

THE LEARNING CURVE IN LEARNING THE CURVE: A REVIEW OF NUSS PROCEDURE IN TEENAGERS

Background:  The Nuss procedure is a new minimally invasive repair for pectus excavatum that was first published in 1998. Modifications in technique are constantly evolving to minimize complications, especially bar displacement, which are higher in adolescents and adults. The present study reviews our early experience with this procedure in a much older group of children than previously reported and suggests an alternative method of avoiding bar displacement.

Review of the outcome of management of Graves' disease in children and adolescents.

Objective: To review our recent experience in the management of paediatric Graves’ disease, the leading cause of hyperthyroidism in childhood, in view of ongoing international debate regarding therapy.

The diagnostically difficult intussusception: its characteristics and consequences

In the absence of classical symptomatology, the diagnosis of intussusception may be difficult to make. A retrospective review of 630 episodes of intussusception admitted to the Royal Childrens Hospital, Melbourne, over a 15-year period revealed difficulties in diagnosis in 318 cases. The adverse effect of an incorrect initial diagnosis on duration of symptoms at the commencement of treatment, need for surgery, resection rate, complications, and hospital stay is examined. Problems in the assessment of children with intussuception are identified and discussed in the hope that an increased awareness of the diagnostic difficulties and potential pitfalls will reduce the morbidity of this common paediatric condition.

Influence of congenital heart disease on management of oesophageal atresia

Congenital heart disease (CHD) is the commonest abnormality associated with oesophageal atresia, occurring in about 20% of cases. Echocardiography should be performed prior to repair of the atresia to identify CHD and lateralise the aorta. Knowledge of the anatomical type and physiological consequences of the CHD enables a co-ordinated plan of management. In patients who are non-duct-dependent for systemic or pulmonary blood flow the oesophagus can be repaired early while pulmonary vascular resistance is high; definitive treatment of the CHD is undertaken later. Duct-dependent lesions usually can be temporarily palliated with prostaglandin E1 infusions commenced prior to repair of the atresia. It is extremely rare that palliative or reparative cardiac surgery is required prior to division of the tracheo-oesophageal fistula and repair of the oesophageal atresia.

Urinary tract abnormalities in association with oesophageal atresia: frequency, significance, and influence on management

Urinary tract abnormalities occur in about 24% of infants with oesophageal atresia. It is important in the neonatal period to recognise those that may cause renal damage if untreated so that the long-term complications of renal disease, e. g., reflux-associated nephropathy, can be prevented. Our current practice is to obtain a renal ultrasound and micturating cystourethrogram during the first admission. If the infant has not been observed to pass urine, then renal ultrasound should be performed before repair of the oesophageal atresia, because there is inadequate functioning renal tissue for long-term survival in 3% of oesophageal atresia patients. The absence of Potters syndrome in infants with both oesophageal atresia and bilateral renal agenesis means that these patients often cannot be identified pre-operatively on clinical grounds alone.

Trends in the use of fundoplication in children with gastro-oesophageal reflux.

Objectives: To document changing trends in the indications for fundoplication in children with gastro‐oesophageal reflux and to identify the main shortcomings and complications of the procedure.

Contemporary surgical treatment for choledochal cysts

Congenital choledochal cyst is an uncommon anomaly of the common bile duct, and the pathogenesis is uncertain. Although various surgical approaches have been used, cyst excision with a Roux-en-Y anastomosis has proved to be the most successful. A total of 21 patients (17F:4M) have been treated by this method with minimal surgical morbidity at the Royal Childrens Hospital, Melbourne. Diagnosis proved difficult in some cases, and in 2 patients was delayed for some years because of misinterpretation of radiological and pathological findings.

Oesophagal atresia with proximal tracheo-oesophageal fistula

Oesophageal atresia with proximal tracheo-oesophageal fistula is an uncommon sub-group comprising 2% of infants with oesophageal atresia. Of those infants with oesophageal atresia presenting with a gasless abdomen on initial abdominal X-ray, 23.5% had oesophageal atresia with proximal tracheo-oesphageal fistula and these infants thus warrant a careful study of the upper oesophagus. The fistula may be difficult to demonstrate and the early appearance of contrast material in the trachea may be misinterpreted as due to aspiration or “spillover”. All cases were treated differently but a plan of management evolved whose main features are the accurate demonstration of anatomy by pre-operative contrast radiology, intra-operative assessment of the distal oesophagus, and, where possible, primary anastomosis. We recommend that a gastrotomy be routinely performed at the initial operation, at which time the length of the distal oesophagus is assessed by the passage of a sound. If sufficient length is present, then an immediate primary anastomosis should be performed with thoracic ligation of the fistula if exposure is adequate. If at initial assessment the length of the gap is judged to be too long, the fistula should be divided via the appropriate route, cervical or thoracic, and alimentary continuity can be affected at a later time by delayed anastomosis or oesophageal replacement. The major morbidity and mortality (40%) occurred in the group with a long gap between oesophageal segments.