David E. Wesson

Nutritional assessment: A comparison of clinical judgement and objective measurements

24. Statement of an expert panel. Guidelines for essential trace element preparations for parenteral use. JAMA 1979;241:2051 25. Kurkus J, Alcock NW, Shils ME. Manganese content of large volume parenteral solutions and of nutrient additives. JPEN 1984;8:254 26. Shike M, Richie M, Shils ME. Manganese studies in long term home TPN patients. Clin Res 1986;34:804A 27. ASCN/ASPEN Working Group: Klein GL, Alfrey AA, Shike M, et al. Parenteral nutrition drug products containing aluminum as an ingredient: response to FDA notice of intent. Am J Clin Nutr 1991;53:399 28. Winters RW, Heird WC, Dell RB. History of parenteral nutrition in pediatrics with emphasis on amino acids. Fed Proc 1984;43:1407 29. Schuberth O, Wretlind A. Intravenous infusion of fat emulsions, phosphatides and emulsifying agents. Clinical and experimental studies. Acta Chir 1961; 278(suppl):3 30. Wretlind A. Complete intravenous nutrition. Theoretical and experimental background. Nutr Metab 1972;14(suppl):1 31. Shils ME, Wright WL, Turnbull A, et al. Long-term parenteral nutrition through an external arteriovenous shunt. N Engl J Med 1970;283:342 32. Scribner BH, Cole JJ, Christopher, et al. Long term parenteral nutrition: the concept of an artificial gut. JAMA 1970;212:457 33. Jeejeebhoy KN, Zohrab WJ, Langer M, et al. Total parenteral nutrition at home for 23 months, without complications and with good rehabilitation. Gastroenterology 1973;65:811 34. Shils ME. A program for total parenteral nutrition at home. Am J Clin Nutr 1975;28:1429 35. Howard L, Michalek AV. Home parenteral nutrition. Annu Rev Nutr 1984;4:69 36. Vacanti JP, Langer R. Tissue engineering: the design and fabrication of living replacement devices for surgical reconstruction and transplantation. Lancet 1999; 354(suppl 1):32

Evaluating the Accuracy of Nutritional Assessment Techniques Applied To Hospitalized Patients: Methodology and Comparisons

Herein we describe a methodology which can be used to evaluate the predictive accuracy of nutritional assessment techniques. We use this methodology to compare seven techniques of nutritional assessment in terms of their ability to predict one nutrition associated hospital complication (infection) by dividing a sample of 59 surgical patients into high risk and low risk groups. One technique was subjective global assessment (SGA) of the patients nutritional status on admission to hospital. Five techniques were single objective measurements (albumin, transferrin, delayed cutaneous hypersensitivity, anthropometry, and creatinine-height index). The 7th technique was the prognostic nutritional index. The best combination of sensitivity (0.82) and specificity (0.72) was found with SGA. The second best combination (0.88 and 0.45) was found by using either the prognostic nutritional index or creatinine-height index. We also found that combining the five objective measurements with SGA into a single index did not increase the discriminatory (or predictive) power over that of SGA alone in a clinically significant way. We conclude that a larger study comparing these approaches should be undertaken to confirm these findings and to develop methods which improve the predictive properties of SGA.

Complications of gastroesophageal antireflux surgery in neurologically impaired versus neurologically normal children

Antireflux surgery was performed in 234 children over a 5-year period; 153 were neurologically impaired (NI) and 81 were neurologically normal (NN). Initial presentation, demographic data, and type of antireflux operation were similar in the two groups. Eighty-six percent of the NI group versus 30% of the NN group had gastrostomy tubes placed. The incidence of late postoperative complications was 26% in the NI group and 12% in the NN group (P less than .01). During the late postoperative period, NI children underwent reoperation four times as frequently as NN children (19% v 5%, respectively; P less than .01). Wrap herniation accounted for 38% of complications and 59% of reoperations in the late postoperative period. Mortality due to aspiration occurred in 9% of the NI group versus 1% of the NN group. Combined failure rate (reoperation plus aspiration-induced deaths) was 28% in NI and 6% in NN (P less than .01). We conclude that neurological status is the major predictor of operative success and that wrap herniation due to crural disruption is the most common cause of operative failure.

Timing of surgery for congenital diaphragmatic hernia: Is emergency operation necessary?

Congenital diaphragmatic hernia (CDH) is considered by most researchers to be a surgical emergency. However, early repair does not necessarily improve respiratory function or reverse fetal circulation, and many patients deteriorate postoperatively. As a result, in 1985, we began to employ a protocol in which surgery was delayed until the PCO2 was maintained below 40 and the child was hemodynamically stable; children in whom these criteria could not be achieved died without surgical repair. Sixty-one consecutive infants with CDH were managed over 4 years; 31 from 1983 to 1984 (group 1) and 30 from 1985 to 1986 (group 2). The groups were similar with respect to sex, side of the defect, birth weight, gestational age, incidence of pneumothorax, and blood gases. High frequency oscillation was used with increasing frequency during the study period, for patients with refractory hypercarbia (13% in group 1, 30% in group 2). All patients were initially paralyzed and ventilated. Mean time from admission to surgery was 4.1 hours in group 1 and 24.4 hours in group 2 (P less than .05). In group 1, 87% of patients had surgical repair (77% within eight hours of admission, 10% after eight hours), and in group 2 only 70% of patients had surgery (10% within eight hours, 60% after eight hours). All patients who were not operated on died. Overall mortality was 58% in group 1 and 50% in group 2; this difference was not statistically significant. These data indicate that our current approach has not increased overall mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Ruptured spleen—When to operate?

Sixty-three patients with splenic injuries were treated during a 5-yr period from 1974-1979. The decision to operate was based on the patients clinical course, not on the presence of splenic injury alone. Those who were stable on admission or after initial resuscitation were treated nonoperatively. This consisted of strict bed rest, nasogastric suction, and i.v. fluids--including blood--as required. Those who bled massively were operated on promptly. At operation, the spleen was repaired if possible or excised if damaged beyond repair. Forty patients were treated nonoperatively. Sixteen of these required blood transfusions (mean 31.2 +/- 5.3 ml/kg). One patient in this group developed a large defect on spleen scan at 3 wk post injury. There was no other morbidity and no mortality following nonoperative treatment. Nineteen required operation all within 16 hr of admission. Fifteen underwent splenectomy, 2 partial splenectomy, and 1 splenorrhaphy. In 1 the bleeding had stopped. All required blood before operation (mean 80.4 +/- 10.1 ml/kg). Seven in this group died (6 from head injuries and 1 from bleeding). Thus surgery was avoided in 2 out of 3 and the spleen saved in 3 out of 4 patients with documented splenic injuries. We believe that where adequate facilities exist nonoperative treatment of splenic injuries is both safe and effective. When bleeding is massive from the beginning or replacement requirements exceed 40 ml/kg, operation is indicated.

Factors influencing postoperative recurrence of Crohn's disease in childhood.

We have reviewed the outcome of all patients undergoing their first intestinal resection for Crohns disease at this hospital between 1970 and 1987. Recurrence rates, defined by recurrent intestinal symptoms and radiological confirmation of mucosal disease, were calculated using survival analysis. Age, sex, anatomical location of disease, indication for surgery, preoperative duration of symptomatic disease, use of preoperative bowel rest, and pathological features of the resected bowel were analysed individually and jointly as potential risk factors influencing postoperative recurrence of disease. Eighty two patients (age, mean (SD) 14.8 (2.5) years) underwent intestinal resection and were followed postoperatively for a minimum of one year (mean 5.3 (3.3) years). Anatomical location of disease, indication for surgery, and preoperative duration of symptomatic disease were the only factors that significantly influenced the duration of the recurrence free interval. Patients with diffuse ileocolonic inflammation experienced earlier recurrence (50% at one year) than children with predominantly small bowel disease (50% recurrence at five years, p less than 0.0001). Failure of medical therapy independent of disease location as the sole indication for surgery was associated with an earlier relapse than when surgery was performed for a specific intestinal complication such as abscess or obstruction (p less than 0.003). Patients undergoing resection within one year of onset of symptoms experienced delayed recrudescence of active disease (30% recurrence by eight years) compared with patients whose preoperative duration of symptomatic disease was longer (50% recurrence by four years when preoperative duration of disease was one to four years and 50% by three years when disease had been present greater than four years preoperatively, p = 0.03). The mean height velocity of patients with growth potential increased from 2.4 (2.3) cm per year preoperatively to 8.1 (3.4) cm per year in the first postoperative year (p=0.0001). These results support an early approach to surgery in the management of ileal Crohns disease with or without caecal or right colonic involvement, especially when complicated by persistent growth failure. The higher recurrence rates in more diffuse ileocolonic disease emphasise the need for alternative treatment strategies in these children.

A 13-year experience with peritoneal drainage under local anesthesia for necrotizing enterocolitis perforation

Between 1974 and 1986, inclusive, over 400 newborns with clinical, radiological, and/or pathological evidence of necrotizing enterocolitis (NEC) were treated at the Hospital for Sick Children, Toronto, Ontario. Within this group were 37 babies who had a bowel perforation that was treated with peritoneal drainage under local anesthesia. Eighty-eight percent of the 41 weighed less than 1,500 g and 65% weighed less than 1,000 g; during the same time 40 other neonates (9% of the total) with perforated NEC had laparotomies. Twelve neonates (32%) required only drainage with complete recovery of their intestinal tracts. The remaining 25 (68%) fell into one of three groups: (1) nine (24%) had rapid downhill course, sepsis, and death without laparotomy; (2) nine (24%) had rapid downhill course, sepsis, and laparotomy (five deaths); (3) seven (20%) had slow development of bowel obstruction requiring operation (two deaths). The overall survival rate was 56%. These results continue to indicate that this method is effective in temporizing 88% of the small and/or very ill babies with a NEC perforation. However, an added bonus is that 32% of these newborns treated in this fashion had complete resolution of their disease.

Ultrasonographic and clinical predictors of intussusception

OBJECTIVE The objective of this study was to determine the positive and negative clinical predictors of intussusception and the correlation of ultrasonography and air enema in establishing this diagnosis. STUDY DESIGN This was a prospective descriptive cohort study. SETTING This study was performed in a tertiary care pediatric emergency department. PARTICIPANTS Eighty-eight of 245 candidates were assessed for clinical predictors of intussusception. All 245 cases were examined for correlation between ultrasonography and air enema. INTERVENTIONS A questionnaire, ultrasonography, and air enema were used. RESULTS Thirty-five of the 88 patients assessed for clinical predictors were positive for intussusception. Significant positive predictors were right upper quadrant abdominal mass (positive predictive value [PPV] 94%), gross blood in stool (PPV 80%), blood on rectal examination (PPV 78%), the triad of intermittent abdominal pain, vomiting, and right upper quadrant abdominal mass (PPV 93%, p = 0.0001), and the triad with occult or gross blood per rectum (PPV 100%, p = not significant). Significant negative predictors were a combination of > or = 3 of 10 clinically significant negative features (negative predictive value 77%, p = 0.035). Of the total 245 cases, intussusception (as confirmed by doughnut, target, or pseudokidney sign) was ruled out by ultrasonography in 97.4%. Alternate ultrasound findings comprised 27% of negative cases. CONCLUSIONS Excellent positive predictors of intussusception were identified prospectively. Although no reliable negative predictors were found, patients at low risk may be screened by ultrasonography.

Esophageal Atresia and Tracheoesophageal Fistula: Surgical Experience Over Two Decades

BACKGROUND Despite improvements in survival, for infants born with esophageal atresia tracheoesophageal fistula, or both, the morbidity associated with repair of these anomalies remains high. METHODS This report retrospectively analyzes 81 patients with esophageal atresia, tracheoesophageal fistula, or both presenting to our institution between 1975 and 1995, with a focus on anastomotic complications. RESULTS There were 46 male and 35 female patients with a mean gestational age of 37 weeks and mean birth weight of 2443 g. Forty-four patients underwent primary esophageal anastomoses, 7 underwent delayed primary anastomoses, 12 patients underwent staged repairs, and 5 underwent repair of H-type fistulas. Among 62 patients with anastomoses, complications included stricture in 25/62 patients (40%), leakage in 12/62 patients (19%), and recurrent tracheoesophageal fistulas in 6/62 patients (10%). Stricture rates for esophagoclonic anastomoses versus esophagoesophageal anastomoses were 4/8 cases (50%) versus 21/54 cases (39%). This difference was not statistically significant. All esophagoesophageal strictures were managed successfully with dilations; three of four esophagocolonic strictures required anastomotic revision. The leakage rate for esophagocolonic anastomoses versus esophagoesophageal anastomoses was 6/8 cases (75%) versus 6/54 cases (11%). This difference was statistically significant (p = 0.0003). Two patients required revision of their colon grafts secondary to necrosis. Eighteen of 81 patients (22%) died. Operative mortality was 9/74 (12%). Causes of death included associated anomalies (n = 15), recurrent aspiration and sepsis secondary to missed fistula (n = 1), and unknown (n = 2). CONCLUSIONS Although the morbidity associated with surgical repair of these anomalies is high, this does not affect the overall survival. The high complication rate associated with colonic interposition suggests that one should preserve the native esophagus as a primary conduit whenever feasible.

Esophageal atresia with distal tracheoesophageal fistula: Associated anomalies and prognosis in the 1980s*

Ninety-seven newborns with esophageal atresia and distal tracheoesophageal fistula (EA-TEF) were treated between 1979 and 1985 inclusive; there were 54 boys and 43 girls. Their weights ranged from 800 to 4,000 g (average, 2.5 kg). They included: 28 neonates with cardiac defects (most common: patent ductus arteriosus [PDA], ventricular septal defect and atrial septal defect [VSD-ASD]), of whom 18 survived (64%); 17 babies with other gastrointestinal anomalies (imperforate anus, duodenal atresia), of whom 12 survived (70%); 12 patients with skeletal malformations (digital, vertebral), of whom 11 survived (91%); 8 newborns with genitourinary abnormalities (hypospadias, undescended testis), of whom 6 survived (75%); and 16 infants with other congenital lesions (trisomy 18, lung agenesis-hypoplasia), of whom 3 survived (18%). Forty-six infants (average, 2.7 kg) had no other anomalies and all survived. As the number of systems with defects increased, both the weight of the baby and survival rate decreased. From this entire series of 97 newborns with EA-TEF, 81 (83%) survived (average, 2.3 kg). Sixteen babies died (average, 1.9 kg); 11 had defects incompatible with life. Eleven of the 16 were never operated on (seven patients with trisomy died within 5 days, and four patients with complex cardiac defects died within 3 weeks). Four of the 16 who were operated on died between 3 months and 2 years from chest problems and one newborn died in the operating room. We concluded that (1) newborns who have the common type of EA-TEF will almost certainly survive if there are no other anomalies; (2) the most frequently associated congenital defects are cardiovascular (28%), gastrointestinal (17%), skeletal (12%), and genitourinary (8%); (3) as the number of systems with defects increases, the weight of the baby and its survival rate fall; and (4) 11% will have trisomy and/or complex cardiac defects with no survival.