Edward G. Ford

Malrotation of the intestine in children.

Intestinal malrotation may be complicated by volvulus and intestinal necrosis. One hundred two children (64 male, 38 female) undergoing surgical abdominal exploration from 1977 to 1987 had malrotation. Fifty-two patients were less than 7 days of age, 13 from 8 to 30 days, 26 from 31 to 365 days, and 11 were older than 1 year of age. Of infants, 39 of 65 had 40-week gestations, 18 of 65 had 36− to 39-week gestations, and 8 of 65 had less than 36-week gestations. Chief symptomatology included: bilious emesis (47), intestinal obstruction (19), abdominal pain (11), and bloody stools (7). Seventy patients had congenital anomalies (50 single, 20 multiple). Diagnostic evaluations included 56 upper gastrointestinal series and 27 barium enemas. Each patient underwent correction of malrotation and appendectomy, and correction of congenital anomalies (omphalocoele—9, gastros-chisis—6, diaphragmatic hernia—7). Complications included short gut (2), sepsis (5), feeding difficulties (2), pneumonia (3), small bowel obstruction (2), and other (15). Nine patients (8.8%) died (trisomy 18—1, trisomy 13—1, intestinal necrosis—3, hepatic failure—1, prematurity—1, other sepsis—2). Two hundred sixteen children with intestinal malrotation have been treated from 1937 to 1987. Mortality rate has improved from 23% to 2.9%.

Communicating bronchopulmonary foregut malformations: Classification and embryogenesis

Communicating bronchopulmonary foregut malformations (CBPFMs) are characterized by a fistula between an isolated portion of respiratory tissue (ie, a lung, a lung lobe, or a segment) and esophagus or stomach. We combine our 30-year (1959 to 1989) experience of 6 cases with 51 reported patients to propose a CBPFM classification supported by a proposed embryogenesis theory. Group I (16%): anomaly is associated with esophageal atresia and tracheoesophageal fistula. Group II (33%): one lung originates from the lower esophagus. Group III (46%): an isolated anatomic lung lobe or segment communicates with the esophagus or stomach. Group IV (5%): A portion of the normal bronchial system communicates with the esophagus. The portion of the lung served by the communicating bronchus receives systemic blood supply. The right and left lung sacs curve dorsally to embrace the lower esophagus during normal lung development. At this stage a part of the lung bud joins the esophagus. This segment then breaks away from the main pulmonary anlage to form a CBPFM. CBPFMs should be considered in the workup of infants with respiratory distress and/or recurrent pneumonias. Patients with suspected pulmonary sequestration should undergo contrast studies to exclude a gastrointestinal communication.

Serum albumin (oncotic pressure) correlates, with enteral feeding tolerance in the pediatric surgical patient

The influence of serum oncotic pressure (Serum Albumin [SA]) on gastrointestinal (GI) tolerance of enteral feedings was prospectively studied in two phases. Phase I consisted of 46 patients, aged 3 months to 12 years, (mean 47 months) selected for enteral tube feeding via the stomach or small bowel. Twenty-eight patients had an SA greater than 3.0 g/dL and received 82% of predicted caloric and protein needs. Administration of the enteral diet was stopped for two or more days in four of the 28 patients because of GI intolerance. Eighteen patients had an SA less than 3.0 g/dL and received 51% of predicted protein needs. Ten of the 18 patients had diet intolerance for two or more days, (P less than .001). Students t-test was used for data analysis. In phase II, 20 patients, aged 4 months to 14 years (mean 49 months), with an SA less than 3.0 g/dL underwent repletion with salt poor albumin as calculated by the following formula: Albumin Replacement = [3.5 g/dL--Serum Albumin (g/dL)] X [weight (kg) X 3] Mean prereplacement SA was 2.31 g/dL; immediately after replacement it was 3.43 g/dL, and 1 week later it was 3.41 g/dL. These patients received 87% of predicted calories and nitrogen and only two of 20 had diet intolerance for two or more days. These data suggest that correction of SA levels allows for better tolerance of enteral diets and that SA will remain normal after intravenous replacement if adequate nutrients are provided while correcting the SA.

The impact of extracorporeal membrane support in the treatment of congenital diaphragmatic hernia

Neonates with congenital diaphragmatic hernia (CDH) treated by immediate surgical intervention and conventional ventilatory support have an overall poor survival. The potential of extracorporeal membrane oxygenation (ECMO) therapy to improve survival of infants with CDH remains controversial. Comparison was made in a single institutions pre-ECMO and post-ECMO survival statistics to establish efficacy of extracorporeal support for persistent pulmonary hypertension (PPH). This study was accomplished by stratifying patients by an oxygen index (OI). Sixty-eight patients were treated for CDH from 1977 to 1986 without ECMO. Fifty-eight patients underwent repair of CDH within the first 24 hours of life. Data could be retrieved for calculation of the OI in 46 patients. Nineteen patients developed an OI of 40 or greater; one survived (5%). Three of 27 patients with an OI less than 40 died (OIs = 34, 38, and 38). Thirty-one patients were treated from 1987 to 1989 and none were excluded from ECMO based on a minimum PO2. Fifteen had an OI less than 40 (range, 1 to 38), were treated conventionally, and 13 survived (87%). Sixteen patients had an OI greater than 40 and 13 qualified for ECMO. Nine of 13 survived (69%). Comparing pre-ECMO and post-ECMO survival for infants with an OI of 40 or greater (5% v 69%), there is a significant improvement in survival when ECMO is used (P less than .001). ECMO support offers a strong adjunct in management of neonates with CDH who develop PPH.

Wound collagenase activity correlates directly with collagen glycosylation in diabetic rats

Extracellular glycosylation of proteins in diabetics may contribute to observed impairments in wound healing. We investigated the interactions of blood glucose concentration and wound collagen glycosylation, collagen content, and proteolytic activity during wound healing in diabetic animals. Rats were made differentially hyperglycemic with intraperitoneal injection of streptozotocin (0-65 mg/kg body weight). Animals with blood glucose concentrations greater than 240 mg glucose/dL were classified as diabetic, those with blood glucose concentrations less than 160 were grouped as nondiabetic. Polytetrafluoroethelene (PTFE) wound cylinders were surgically implanted in 32 rats and removed on postoperative day 5. Harvested cylinders were analyzed for hydroxyproline content, collagen glycosylation, and collagenase and protease activity. Collagenase activity was 14% higher in diabetics than nondiabetics (P less than .001). Glycosylation of wound collagen averaged 48.0% higher in diabetics (P less than .001). Wound hydroxyproline content was 39% lower in diabetics (P less than .05). Studies show a high degree of correlation (Pearson) of wound collagen nonenzymatic extracellular glycosylation (NEG) with mean blood glucose concentration (r = .98, P less than .001). Wound collagen glycosylation correlates strongly with both protease activity (r = .86, P less than .001) and collagenase activity (r = .83, P less than .001). This study demonstrates a significant blood glucose concentration dependent increase of glycosylation in newly synthesized collagen in hyperglycemic animals that is associated with increased collagenase activity and decreased wound collagen content.

The effect of perioperative exogenous growth hormone on wound bursting strength in normal and malnourished rats

Patients with significant malnutrition secondary to underlying disease may require major surgical intervention on an urgent basis. Nutritional restoration using enteral or intravenous alimentation requires a delay of 10 to 14 days and is frequently not practical. With the availability of human growth hormone (GH) produced by recombinant DNA technology, this study was undertaken to evaluate the effect of exogenous GH on wound tensile strength in a rat model. Fifty-four animals were divided into three groups: group I, normal nourished control; group II, malnourished; group III, malnourished, rat GH treated (1 mg GH administered 3 days preoperative and 5 days postoperative celiotomy). Wound tensile strength was measured at 6 days postoperatively. Wound strengths in malnourished rats were significantly less than in normal controls (P less than .001). With the administration of growth hormone in group III, wound strength was significantly improved when slightly improved over normally nourished controls (P less than .05). A dose response curve demonstrated progressive improvement in wound tensile strength from 0.01 mg/d to 1.0 mg/d. Thus growth hormone administration to malnourished animals significantly enhances wound strength. With the availability of recombinant produced human GH these observations may be clinically applicable.

Stimulation of wound bursting strength during protein malnutrition.

Nutrition is one of the most important factors affecting wound healing. Patients who have significant protein malnutrition and require emergency surgery are frequently encountered. Conventional nutritional preparation for surgery, with intravenous hyperalimentation, requires 10 to 14 days to demonstrate advantageous reversal of catabolism. Growth hormone is known to have an anabolic effect in malnourished animals. The purpose of this investigation was to study the ability of growth hormone, administered from the time of celiotomy, to improve wound strength in protein-malnourished animals and compare its efficacy with preoperative nutritional repletion. Rats were divided into four groups: Group I--normal control rats, group II--malnourished rats, group III--malnourished rats treated with growth hormone for 5 postoperative days, and group IV--malnourished rats refed normal chow for 3 days before operation. Controlled laparotomy wounds were closed with monofilament nylon which was removed at the time wound bursting strength was tested. Bursting strengths at the sixth day postoperative were as follows (means +/- SD): (table; see text) Wound strength of malnourished animals was significantly less than that of controls, (P less than 0.001). Wound bursting strength of groups III and IV was significantly improved over that of malnourished animals (group II), P less than 0.001. The bursting strength of group IV was significantly higher than that of group III. Growth hormone administration following celiotomy is nearly as effective in improving wound healing as preoperative nutritional repletion. These results suggest that growth hormone may be clinically applicable in preventing wound complications in malnourished patients requiring urgent or emergency laparotomy.

It may be more significant than you think: BB air rifle injury to a child's head

BB guns of 20 years ago were constructed of coils and springs which generated relatively little force, so that a projectile posed little threat of serious injury. Today, the coil and spring construction has been replaced by pump action pneumatic chambers which allow generation of muzzle velocities near 350 ft/sec. Speeds of 150 ft/sec and 200 ft/sec are required for skin penetration and bone penetration, respectively. We present a seven-year-old boy who suffered intracranial parenchymal injury from an air-powered BB gun projectile while playing with friends. We discuss literature which suggests these once-innocent toys are now harbingers of severe, if not fatal, injury.

Clinical presentation and radiographic identification of small bowel rupture following blunt trauma in children

The incidence of significant intraabdominal injuries from blunt trauma in children is low (1–8%); however, a missed intestinal laceration may result in a devastating, if not morbid, consequence. We present retrospective case studies of eight children with intestinal lacerations following blunt trauma. Each patient has a unique anatomic defect with misleading initial laboratory and radiographic studies. We did not find a single laboratory or roentgenographic study to be consistently reliable for diagnosis of hollow viscus laceration. The combination of a high index of suspicion and serial abdominal examinations, coupled with subsequent comparative laboratory and radiographic evaluations, proved most reliable in identifying patients with intestinal injury.

Congenital portocaval shunt

Several congenital anomalies of the portal vein and inferior vena cava (IVC) have been reported; however, reports of a congenital communication between the portal vein and IVC are few. We report a patient who was found to have a natural shunt between the extrahepatic portal vein and the IVC that was discovered when she underwent a right hepatic lobectomy for an undifferentiated liver sarcoma. The patient also had agenesis of the right kidney. We have not been able to find a similar case reported in English literature.