Dennis J. Hoelzer

Lower esophageal pressure changes with tube gastrostomy: a causative factor of gastroesophageal reflux in children?

In children, Stamm tube gastrostomy can initiate gastroesophageal reflux (GER) or worsen preexisting GER. We identified a possible mechanism for this problem in 25 children with GER who had esophageal manometry performed in conjunction with an antireflux operation. Intraoperative lower esophageal high pressure zone (LEHPZ) pressure and length were recorded for a simulated gastrostomy in all patients prior to performing the antireflux operation. These same parameters were then recorded for a simulated (11 patients) or real gastrostomy (14 patients) following the antireflux procedure. The LEHPZ pressure decreased with simulated Stamm gastrostomy (7.8 +/- 1.1----6.6 +/- 1.1 mm Hg, NS: Normal = 11.2 +/- 0.9 mm Hg). This decrease was less significant than the decrease in LEHPZ length (1.1 +/- 0.1----0.8 +/- 0.1 cm, P less than .01: Normal = 1.3 +/- 0.1 cm). Following Boerema gastropexy, simulated gastrostomy produced a similar decrease in LEHPZ pressure (20.8 +/- 3.8----17.1 +/- 2.7 mm Hg, NS) and length (3.3 +/- 0.4----2.5 +/- 0.3 cm, P less than .025). The LEHPZ pressure and length were not decreased by real gastrostomy performed with modified Thal fundoplication or with Nissen fundoplication. Thus, a decrease in LEHPZ length may be one mechanism whereby GER is initiated or worsened by tube gastrostomy in children. Tube gastrostomy has a similar effect when performed with a Boerema gastropexy, but not when performed with a Nissen or modified Thal fundoplication.

Percutaneous subclavian venous catheters in neonates and children

There were 191 central venous catheters placed through the subclavian vein in 135 neonates and children over a 20-mo period, providing central venous access for a total of 4525 patient days. There were 132 (69.2%) catheters inserted in patients who were in their first year of life and 60 (31.4%) weighed less than 2.5 kg. The procedure was associated with a low technical complication rate. The greatest potential intermediate or long-term complication was the development of primary catheter sepsis that occurred in 11 (5.8%) of the catheters placed.

Gastric emptying in children with gastroesophageal reflux. II. The relationship to retching symptoms following antireflux surgery.

Following antireflux surgery, children with persistent retching symptoms are presumably more likely to have delayed gastric emptying. We report 66 children between 2 weeks and 16 years of age who had an operation to control gastroesophageal reflux (GER). All patients had GER confirmed by 18- to 24-hour esophageal pH monitoring. Preoperative gastric emptying studies were performed in each patient with 99m-Tc sulfur colloid in apple juice. In addition to the percent gastric emptying (%GE), an effective gastric emptying was estimated by correcting the %GE for postcibal reflux (corrected %GE). Repeat 18- to 24-hour esophageal pH monitoring was performed postoperatively in all patients, and a repeat gastric emptying study was performed in 32 patients. After an average postoperative follow up of 6 months (range of 1 to 18 months), persistent retching was present in 12 (18%) patients. The retching was associated with dumping symptoms in six patients. Retching was seen in patients with a preoperative increase in effective gastric emptying (10/34, 29%, P less than .05) or a decrease in effective gastric emptying (2/15, 13%, NS), and not in patients with an effective gastric emptying within the control range (0/17, 0%). Postoperatively, retching with dumping symptoms was associated with an increased effective gastric emptying, and retching without dumping symptoms with a decreased effective gastric emptying. In conclusion, persistent retching followed anti-reflux surgery in children is related to extremes in effective gastric emptying. The preoperative measurement of corrected %GE identifies children at increased risk for this postoperative problem.

Postoperative small bowel obstruction in infants and children: A problem following nissen fundoplication

A serious consequence of antireflux surgery is postoperative small bowel obstruction in an infant who cannot speak and has been rendered unable to vomit. We reviewed the operative rate for small bowel obstruction following all antireflux operations (210 Nissen fundoplications, 16 Hill fundoplications, 12 modified Thal fundoplications, and 3 Boerema anterior gastropexies) performed on children at our institution between January 1977 and July 1984. Eighteen patients (17 Nissen fundoplications, one Hill fundoplication) were operated upon for small bowel obstruction within two years after the primary operation. The most consistent clinical findings in these children were abdominal distention and a decreased frequency of bowel movements. For operations performed between January 1982 and July 1984, reoperation for small bowel obstruction was needed in 6.1% (6/99) of children following Nissen fundoplication as compared to 0.9% (6/649), P less than 0.001) of children following other major laparotomies. A combination of our experience with that reported by others suggests an estimated incidence of postoperative adhesive small bowel obstruction of 5.5% (24/436) for Nissen fundoplication, 0.9% (3/347) for modified Thal fundoplication, and 0.8% (1/126) for Boerema anterior gastropexy. The performance of a Nissen fundoplication has led to a significant rate of reoperation for small bowel obstruction compared with other major laparotomies and antireflux operations performed in children.

Acute pancreatitis: The difficulties of diagnosis and therapy

Acute pancreatitis in children is uncommon but is being recognized frequently. Twenty-four children provided clinical data to review the various manifestations and therapy of acute pancreatitis, all of these patients having survived a clinical episode. Recognition of acute pancreatitis has been improved by the advent of new diagnostic procedures such as serum amylase isoenzymes, amylase/creatinine ratio, ultrasonography, endoscopic retrograde cholangiopancreatography (ERCP), computerized axial tomography (CAT) scan, and peritoneal lavage. The causative factors in our series were: trauma, biliary disease,, viral (mumps), and steroid therapy. Treatment of acute pancreatitis was nonsurgical unless a specific surgical lesion was present.

The safety and cost-effectiveness of polyethylene glycol electrolyte solution bowel preparation in infants and children

Golytely, a polyethylene glycol electrolyte solution (Braintree Laboratories, Braintree, MA), was evaluated in the preoperative bowel preparation of 21 infants and children. Weight, temperature, pulse, respiratory rate, and electrolyte concentrations were documented before and after mechanical bowel preparation. All children were given 25 mL/kg/h of Golytely until rectal effluent was clear and free of particulate matter. All preparations were started and completed the afternoon prior to surgery. Weight, vital signs, and electrolyte concentrations did not change significantly. All preparations were felt to be fair or excellent. Follow-up for 1 month postoperatively revealed no infectious complications. Golytely is safe and effective in preparing the bowel prior to surgery in children. Using Golytely can eliminate the need for multiple-day hospitalizations for bowel preparation and thus decrease the cost of medical care.

The efficacy of thal fundoplication in the treatment of gastroesophageal reflux: The influence of central nervous system impairment

One hundred sixteen patients underwent a modified Thal fundoplication to correct gastroesophageal reflux (GER) between July 1, 1983, and January 30, 1987. Ninety-one percent of patients were relieved of GER. When patients were evaluated with respect to the presence or absence of CNS impairment there was a marked difference in the success rate of this procedure. Eight of 48 patients with CNS disorders had recurrent reflux with gastrostomy feedings after a modified Thal fundoplication (16%) while only two of 68 neurologically normal children had a failure of operation (3%; P less than .05). These data indicate that the modified Thal fundoplication is very effective in correcting GER in neurologically normal children but is less effective in children with CNS impairment.

Route of Pediatric Parenteral Nutrition: Proposed Criteria Revision

This study reviews the experience of the Nutrition Support Service at the Childrens Hospital of Philadelphia over a 13-mo period from 1977 to 1979. Parenteral nutrition was administered to 585 children, 385 by peripheral vein infusion and 200 by central vein infusion. Weight gain was seen in 63% of those patients receiving peripheral vein infusions and 82.5% of those receiving central vein nutrients, and this apparent difference is likely due to the longer duration of therapy in the central vein recipients (33.7 versus 11.4 mean days) and the greater caloric intake delivered to these same patients (128 Kcal/kg/day versus 63.2 Kcal/kg/day). The complication rates were calculated for the more than 11,000 patient days of therapy surveyed; 35 of the 385 peripheral vein patients developed complications, the primary type being solution administration soft tissue sloughs. This amounted to an incidence of 9.08%. Central vein patients in 40 circumstances likewise had complications, 21 being infectious and 12 being metabolic. This accounted for 20% of all central vein recipients, a difference from the peripheral vein group significant to a p value of less than .01. However, when total days of therapy are considered in this complication incidence, a per diem complication rate between these two groups is not different, and in fact, is somewhat worse for the peripheral vein nutrient recipients. Vascular access in this group of patients was via peripheral vein cannulation or via central venous catheter placement, the latter more recenty done exclusively by percutaneous subclavian vein catheter insertions. This technique was safe and allowed repeated access to the central venous system. These data suggest that the only legitimate determining factor for selecting proper nutritional support of the pediatric patient is the caloric need of the individual.

Agenesis of the left diaphragm: Surgical repair and physiologic consequences

Agenesis of the hemidiaphragm is an unusual congenital anomaly associated with a high mortality. This paper presents the fourth patient to survive the neonatal period with agenesis of the hemidiaphragm. He was an identical twin, weighing 1.5 kg and his clinical course was characterized by ipsilateral pulmonary hypoplasia, large alveolar-arterial gradient for oxygen, persistent fetal circulatory pattern and ventilator dependence. These abnormalities suggest a pathophysiology similar to that observed in patients with Bochdalek hernia. The surgical correction, postoperative care and observation of pulmonary function following repair of agenesis of the left diaphragm are described.

Intraoperative esophageal manometry and early postoperative esophageal pH monitoring in children

Intraoperative esophageal manometry has not been correlated with early postoperative extended esophageal pH monitoring (EEpHM) in children with gastroesophageal reflux. Twenty-seven children were studied with the following design: (1) abnormal preoperative EEpHM; (2) intraoperative measurement of lower esophageal high pressure zone (LEHPZ) pressure and length prior to and upon completion of an antireflux procedure; and (3) EEpHM seven to ten days postoperatively. Sixteen had a Nissen or modified Thal fundoplication and eleven a Boerema gastropexy. The postoperative EEpHM was normal in patients with fundoplication regardless of the increase in LEHPZ pressure (-4 to 36 mmHg) or length (0 to 2.5 cm). Four of the patients (36%) who had a gastropexy had abnormal EEpHM. The postoperative frequency of reflux was related inversely to the elevation of LEHPZ pressure (-3 to 39 mmHg), but not to the LEHPZ length (0 to 4.5 cm). Duration of reflux was independent of observed intraoperative manometric changes. In conclusion, early postoperative EEpHM in children having a gastropexy correlates with intraoperative increases in the LEHPZ pressure. There is no such correlation in children having a fundoplication procedure.