Douglas R. Johnston

Superior Mesenteric Artery Syndrome after Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Gastrointestinal obstructive complications after laparoscopic Roux-en-Y gastric bypass (LRYGBP) are not uncommon. Their usual causes are strictures, internal hernias and adhesions. Superior mesenteric artery (SMA) syndrome is a rare disorder caused by compression of the third portion of the duodenum by the SMA that can occur after rapid weight loss. This has been reported in patients with scoliosis, burns, immobilization in body casts, and idiopathic weight loss. SMA syndrome following bariatric surgery has not been reported. We present 3 cases of SMA syndrome after LRYGBP and extensive weight loss. Two patients underwent laparoscopic duodenojejunostomy and the third patient was treated with intravenous hyperalimentation. All three are symptom free at 4-18 months follow-up. The diagnosis of SMA syndrome should be considered in bariatric surgery patients with rapid weight loss who develop atypical, recurrent obstructive symptoms not attributable to other common causes.

Laryngeal cleft: Evaluation and management

OBJECTIVES Review the latest diagnostic and treatment modalities for laryngeal and laryngotracheoesophageal clefts as they can be a major cause of respiratory and feeding morbidity in the infant and pediatric population. METHODS Literature review of published reports. RESULTS The presentation of laryngeal cleft usually involves respiratory symptoms, such as stridor, chronic cough, aspiration, and recurrent respiratory infections. Clefts of the larynx and trachea/esophagus can occur in isolation, as part of a syndrome (Opitz-Frias, VATER/VACTERL, Pallister Hall, CHARGE), or with other associated malformations (gastrointestinal, genitourinary, cardiac, craniofacial). This publication reviews the presenting signs/symptoms, diagnostic options, prognosis, and treatment considerations based on over a decade of experience of the senior author with laryngeal clefts. CONCLUSIONS Type I laryngeal clefts can be managed medically or surgically depending on the degree of morbidity. Types II, III, and IV require endoscopic or open surgery to avoid chronic respiratory and feeding complications.

Parapharyngeal and retropharyngeal infections in children: argument for a trial of medical therapy and intraoral drainage for medical treatment failures.

OBJECTIVE To review the outcomes of parapharyngeal infections (PPI) and retropharyngeal infections (RPI) in children after medical and surgical management. METHODS The charts of all children who presented to a tertiary-care pediatric hospital between March 2005 and February 2007 with a diagnosis of parapharyngeal infection or retropharyngeal infection were reviewed. Thirty-two patient records were analyzed. RESULTS The mean age of our patients was 4.4 years, 63% of whom were boys. The majority of patients presented during the winter months with some combination of fever, neck stiffness, and neck swelling. Ten patients had surgery less than 1 day after admission (early surgical intervention). Twenty-two patients were given a trial of at least 24h of intravenous (IV) antibiotics (medical trial group), nine of whom were treated exclusively with IV antibiotics (medical therapy alone). The remaining 13 patients failed medical therapy, and went on to surgical drainage (late surgical intervention). All patients requiring surgical drainage were treated successfully with an intraoral approach. Patients given a trial of IV antibiotics had an average hospital stay of 3.3 days (3.0 days for medical therapy alone and 3.5 days for late surgical intervention). Patients with early surgical intervention stayed 2.7 days. All patients were discharged home with oral antibiotics. There was no statistically significant difference in the length of stay between the medical trial and early intervention groups. Those who failed medical therapy had significantly larger abscesses than those who responded to medical therapy (1.53 versus 5.38 cm(2)). CONCLUSIONS A trial of IV antibiotics does not adversely affect outcome and may obviate the need for surgery, particularly for patients with smaller abscesses. When surgery is required, an intraoral procedure is usually adequate.

Postoperative Complications of Powered Intracapsular Tonsillectomy and Monopolar Electrocautery Tonsillectomy in Teens versus Adults

Objectives This study was performed to determine whether teens have different rates of posttonsillectomy hemorrhage, admission for dehydration, or recurrent tonsillitis compared to adults. Specifically, these parameters were compared within two groups: patients who underwent powered intracapsular tonsillectomy (PIT) and those who underwent monopolar electrocautery tonsillectomy (MET). Methods In a retrospective review of 579 patients at least 12 years of age from January 2000 to July 2006 in a tertiary referral center, outcome measures of reoperation for hemorrhage, readmission or emergency room visit for dehydration, and postoperative tonsillitis were compared for 200 patients 12 to 19 years of age and 379 patients more than 19 years of age. These outcome measures in teens were compared to those in adults who had tonsillectomy by the same technique (101 teens who underwent PIT compared to 117 adults who underwent PIT, and 99 teens who underwent MET compared to 262 adults who underwent MET). Outcome measures were also compared within the PIT and MET groups based on the indication for surgery (chronic tonsillitis, tonsillar hypertrophy, or both). Results In comparing teens to adults who underwent the same technique (PIT versus PIT, or MET versus MET), no statistically significant differences existed in the incidence of hemorrhage, dehydration, or postoperative tonsillitis. Greater hemorrhage rates for adults who underwent MET compared to teens, however, almost met statistical significance (p = 0.053). Analyzing complication rates by indication within the PIT and MET groups exclusively revealed higher rates of hemorrhage in adults who underwent the MET technique for the indication of chronic tonsillitis. Within the PIT comparison, no significant differences were found on the basis of indication for surgery. Conclusions Teenage patients who undergo tonsillectomy should be considered unique as far as complication rates are concerned. Comparison of technique-specific complication rates between adults and teens showed no significant differences in either the PIT or MET groups, although adults who underwent MET had greater hemorrhage rates that almost met significance (p = 0.053). Adults who were undergoing tonsillectomy for chronic tonsillitis were more likely than teens to encounter postoperative hemorrhage if they underwent the MET technique.

Role of direct laryngoscopy and bronchoscopy in recurrent croup.

Objective To determine risk factors in children with recurrent croup that predict moderate/severe findings on direct laryngoscopy and bronchoscopy and need for further operative interventions. Study Design Retrospective chart review cohort. Setting Tertiary care children’s hospital. Subjects and Methods Retrospective chart review of 103 patients diagnosed with recurrent croup who underwent diagnostic laryngoscopy and bronchoscopy from January 2004 to August 2013. Statistical analysis determined risk factors significantly associated with moderate/severe operative findings. A probability tree was formulated. Results Of 103 patients, 30.1% had history of intubation, 6.8% had a history of subglottic stenosis, 6.8% had a history of previous airway procedure, 11.7% consultations were inpatient, 64.1% had asthma, 47.6% had seasonal allergies, 60.2% had gastroesophageal reflux disease, 15.5% were aged ≤12 months, and 51.5% were ≤36 months. Statistically significant risk factors in predicting moderately/severely abnormal operative findings included consultation location (P = .010), history of intubation (P = .003), age younger than 36 months (P = .013), and seasonal allergies (P = .035). When using location of consultation, history of intubation, and age in a statistical model, diagnostic accuracy equaled 93.5%. Of children without history of intubation but who underwent inpatient otolaryngology consultation, 28.6% had moderate/severe findings. Likewise, 41.2% of children with a history of intubation who were younger than 36 months of age had moderate/severe findings. Conclusion Moderate to severe operative findings are encountered in only 8.7% of children with recurrent croup. Using statistical modeling, 2 high-risk groups are (1) patients without a history of intubation but inpatient consultation and (2) patients with a history of intubation and age younger than 36 months.

Prevalence of dental caries in children with neurofibromatosis 1

Neurofibromatosis 1 (NF1), which affects one in 3,500 individuals, is a progressive autosomal dominant disorder characterized by café-au-lait spots, neurofibromas, optic gliomas, and osseous abnormalities [1]. The oral health of NF1 patients has not yet been fully investigated, but a recent careful study in Finland reported a lower incidence of caries on dental examination in NF1 patients under 35 years of age, as compared to age group controls [2]. This result conflicted with an earlier family study done by our group showing increased self-reported caries in family members with NF1 when compared to their unaffected siblings [3]. As part of a separate sibling-controlled study designed to characterize further the bone health of NF1-affected children, we collected data by dental examination on the oral health status of 18 patients with NF1 and their unaffected siblings. One child with NF1 and one unaffected sibling in each family were studied in an attempt to minimize the effects of factors unrelated to NF1, such as background genetics, diet, and oral hygiene habits, that may impact dental health. Our participant families came from British Columbia, and the majority of participants were from middle class families who were well informed about the importance of dental hygiene. Eighteen children with NF1 and one unaffected sibling of each child, 6–20 years of age, were enrolled. All but one affected child represented a new mutation. The mean ages of affected children and their unaffected siblings were 13.9±3.3 years (range 6.5–18.9) and 14.9±3.9 years (range 6.7–20.6), respectively. The affected child’s age ranged from 4.1 years younger to 4.4 years older than the unaffected control sib. Of the 19 girls enrolled, eight were affected, and 11 were unaffected. All children underwent dental examinations, during which the numbers of past and present caries were recorded using a decayed, missing, or filled teeth (dmft/DMFT) index. The dmft/DMFT index, also employed by the Finnish group, refers to the number of decayed (d;D), missing (m;M), or filled (f;F) deciduous (lower case letters) or permanent (upper case letters) teeth [4]. Results of the dental examinations are summarized in Table 1. We found a similar prevalence of carries in the affected subjects (8/18) and their unaffected sibs (5/18). Our data do not support the lower prevalence of caries in NF1 patients recently reported by Visnapuu et al. [2] or the higher prevalence we observed in a previous sib-controlled questionnaire study of 37 NF1 patients [3]. In addition to attempting to replicate the simple binary analysis performed by the Finnish group, we compared the number of carious teeth per subject in our paired samples. Neither analysis showed any difference in the prevalence of dental caries in affected and unaffected sibling pairs (p= 0.22, McNemar’s test; p=0.76, Wilcoxon signed ranks test). A direct comparison of our data to those from the Finnish group for NF1 patients is presented in Table 2. We E. S. Tsang (*) : P. Birch : J. M. Friedman : T. Tucker : L. Armstrong Department of Medical Genetics, University of British Columbia, Box 153, 4500 Oak Street, Vancouver, BC V6H 3N1, Canada e-mail: ertsang@interchange.ubc.ca

Ophthalmologic Disorders in Children With Syndromic and Nonsyndromic Hearing Loss

OBJECTIVE To determine the rate of ophthalmologic anomalies among patients with syndromic and nonsyndromic, congenital sensorineural hearing loss (SNHL) to assess the need for comprehensive ophthalmologic evaluation in these children. DESIGN Retrospective medical chart review of children with SNHL who underwent comprehensive evaluation by pediatric ophthalmologists and geneticists. SETTING Tertiary care pediatric hospital. PATIENTS Seventy-seven patients with SNHL. MAIN OUTCOME MEASURES Degree of hearing loss (HL) and presence of ophthalmologic and genetic disorders. RESULTS The overall rate of ophthalmologic disorders was 32% (25 of 77 patients). When children with multisystem genetic disorders known to be related to visual loss were excluded, the rate fell to 23% (12 of 53 vs 13 of 24; P = .006). There was no statistically significant difference in the degree of HL between patients with and without eye disorders (mean [SD], 46.5 [29.9] vs 49.1 [32.3] dB HL; P = .75). Patients with eye disorders were significantly more likely to have a multisystem genetic disorder (13 of 25 [52%] vs 11 of 52 [21%]; P = .006). No patients with ocular abnormalities had isolated otologic disorders, but 9 of 52 (17%) of those patients without ocular abnormalities did. CONCLUSIONS Comprehensive ophthalmologic examination revealed a rate of ophthalmologic disorders in children with SNHL in the lower end of the previously reported rates of 31% to 61%. Children with nonsyndromic SNHL have an approximately 2- to 3-fold increase in ocular abnormalities compared with the general pediatric population. Ophthalmologic and genetic consultations are warranted in patients with congenital SNHL.

Penalties for health care fraud and abuse: January 2007-March 2008.

This commentary details the providers, penalties, and affected regions resulting from US health care fraud and abuse prosecutions from January 2007 to March 2008. Database review found that over

Diagnostic and surgical challenge: Middle ear dermoid cyst in 12 month old with branchio-oto-renal syndrome and multiple middle-ear congenital anomalies

3 billion in fines as well as incarceration in some cases were ordered for 21 convicted providers, 68 percent of whom were physicians, and to 41 nonproviders, most of whom were vendors of durable medical goods (36%), individual citizens (18%) and health care corporations (17%). Fewer claims were found against pharmaceutical firms (7%) and medical equipment manufacturers (4%). Most verdicts were in the state of Florida. False claims accounted for most of the violations for both providers and nonproviders. These severe repercussions of malfeasance should promote careful consideration and construction of the terms of engagement between health care providers, corporations, and payers.

Unusual Fibrosclerotic Lesion of the Laryngotracheal Complex Presenting as Subglottic Stenosis

Described is the first case report, to our knowledge, of a middle-ear dermoid in a child with branchio-oto-renal (BOR) syndrome. Radiographic, pathologic, and intraoperative figures are shown. This was a diagnostic and surgical challenge as the presentation was similar to a congenital cholesteatoma and the child had numerous significant temporal bone abnormalities. After the intraoperative findings suggested a non-destructive process, the treatment strategy was altered. This case reiterates the need for a cautious, flexible operative approach in a syndromic child. Included is a relevant review of the literature and a detailed clinical analysis.