Edwin I. Hatch

Stomach position as an in utero predictor of neonatal outcome in left-sided diaphragmatic hernia

An 8-year review of neonates with left-sided congenital diaphragmatic hernia who presented in severe respiratory distress at birth was retrospectively reviewed looking at stomach position, thoracic or abdominal, as a predictor of survivability. Survival was 93% with the stomach below the diaphragm compared with 29% when the stomach was thoracic in location. Stomach position may be an important early in utero predictor of high mortality in neonates with left-sided congenital diaphragmatic hernias.

Inguinal hernia repair in early infancy

Controversy regarding the management of inguinal hernias in young infants stimulated this study. It was our hypothesis that inguinal hernia in young infants can and should be repaired at the time of presentation. In order to address this issue, the following questions were examined: How frequently are these hernias incarcerated and how should this be managed? What is the best timing of repair? Should the asymptomatic contralateral groin be explored? How do the recurrence and complication rates compare with those in older children? Have advances in anesthesia affected the treatment of these infants? The records of 384 infants less than 2 months of age who underwent inguinal herniorrhaphy from January 1985 to January 1990 at Childrens Hospital and Medical Center in Seattle were reviewed. Nearly one fourth (24%) of the patients had incarcerated hernias. Preoperative reduction was successful 96% of the time. The hernia was then repaired within 48 hours. Six patients required urgent operation, but bowel resection was not necessary in any. Contralateral groin exploration was performed 96% of the time and was positive in 85%. The recurrence rate was 1.0%. Complications occurred in 2.3% of patients. There were no hernia-related deaths. Spinal anesthesia was used in 63 patients with no postoperative apnea. An aggressive approach toward prompt repair of hernias in this age group can result in a very low incidence of hernia-related complications. Repair can be carried out safely in the first 2 months of life with recurrence and complication rates comparable with those in older children. Spinal anesthesia may lower the rate of postoperative apnea.

Nonoperative initial management versus silon chimney for treatment of giant omphalocele

Giant omphalocele is a major clinical challenge for pediatric surgeons. Whereas small- to medium-sized defects can be repaired primarily, larger omphaloceles cannot be closed at birth because the liver and small bowel have lost the right of domain to the abdomen. Two divergent strategies have evolved for treating these giant defects: (1) use of a silon chimney with gradual reduction of the contents of the sac, and (2) initial nonoperative management (epithelialization) of the omphalocele followed by repair of the residual ventral hernia. In an 18-year retrospective study, we have reviewed our experience with these treatment methods. Ninety-four infants underwent treatment for omphalocele between 1975 and 1993. Primary closure (PC) was possible in 55 patients, silon chimney (SC) was used in 15, and 7 had nonoperative management (NM) with epithelialization. In the remaining 17 infants, surgery was believed to be inappropriate because of the lethality of their associated anomalies. Major (but potentially survivable) anomalies were present in 26% of PC, 13% of SC, and 71% of the NM group patients. The majority of the liver was present in 73% of SC- and 86% of NM-treated omphaloceles. There was a decrease in length of stay, time to enteral feeding, and mortality over the 18-year period. However, those patients whose defects could not be closed primarily had consistently longer hospital stays. This was particularly true for the SC patients. The decreased use of total parenteral nutrition seems to reflect a shift from SC to NM rather than a decrease in the interval to full enteral feeding in any given treatment group over time.(ABSTRACT TRUNCATED AT 250 WORDS)

Necrotizing enterocolitis in term neonates.

Necrotizing enterocolitis (NEC) is usually a disease of premature infants, but occasionally it affects the term neonate. A 5-year review of NEC at Childrens Hospital and Medical Center identified the unique features of this disease in the term neonate. Eighty-one patients with NEC were treated between January 1984 and May 1989. Ten full-term neonates with gestational age greater than 38 weeks were identified for study. Charts were reviewed for recognized risk factors, clinical course, surgical intervention, and outcome. Ninety percent had a birth weight greater than or equal to 2.7 kg, and all were above 2.1 kg. NEC developed early in this group, with onset of disease in the first 48 hours of life in 50% of the group and within the first 4 days of life in 90%. The recognized risk factors of asphyxia, hypoglycemia, polycythemia, and respiratory distress were absent in 60%. Seven of 10 patients required exploratory laparotomy, whereas 3 of 10 required only medical treatment. Indications for operation were perforation in three patients, peritonitis in three patients, and mass in one patient. All patients requiring operations had severe colonic disease, with perforation of the colon in five of seven and full-thickness necrosis without perforation in two of seven. Two patients required total abdominal colectomy. Only one patient with perforated meconium ileus and associated NEC had small bowel involvement. This patient was the only mortality of the group. Subsequent intestinal continuity was restored in all surviving patients with no late complications. Two patients required resection of additional NEC strictures prior to reanastomosis. Of the three medically treated patients, none required subsequent operation for colonic stricture. Our experience indicates that the presentation, clinical course, and operative findings in full-term neonates with NEC differ from those encountered in the premature infant with NEC.

Surgical options in the management of large omphaloceles

Forty-six neonates with omphaloceles seen at the Childrens Hospital and Medical Center in Seattle from 1975 to 1985 were reviewed. There was an 87 percent survival rate in those surgically managed. The 23 neonates who underwent primary closure all survived. The 13 neonates with giant omphaloceles with the liver in the defect who received silon chimneys had a 46 percent mortality rate and a high complication rate, with prolonged hospitalization. Two neonates with giant omphaloceles were managed by leaving the sac intact, and silver sulfadiazine cream was used as an escharotic agent. We believe it is a safer alternative than the silon chimney in neonates whose defects cannot be closed primarily.

Surgical management of the infant with mesenchymal hamartoma of the chest wall

Mesenchymal hamartoma of the chest wall is a rare lesion that presents as a chest wall mass. Four infants are reported, three of whom underwent extensive chest wall resection.

Individualized management of colonic atresia

Atresia of the colon represents the least common cause of neonatal intestinal obstruction, comprising less than 10 percent of gastrointestinal atresias. Eleven patients underwent surgical repair of colonic atresia during a 5 year period. Five of the patients were premature. Two had associated gastroschisis and other congenital anomalies were present in three patients. Hypaque enema was utilized to diagnose intestinal atresia and laparotomy was then undertaken. Primary repair could be performed in four patients, one with type I and three with type 3 atresias. These four patients did well and were discharged within 13 days after operation. Three deaths occurred in patients with associated anomalies, yielding a mortality rate of 28 percent. Operative therapy of colonic atresia should be individualized, based on the condition of the patient at presentation and the presence of associated birth defects.

Gastroschisis wringer clamp: a safe, simplified method for delayed primary closure.

When primary abdominal wall closure in a newborn with gastroschisis cannot be accomplished safely, placement of a reinforced Silastic silo facilitates delayed primary closure (DPC). In this report we describe our experience with the gastroschisis wringer clamp (GWC). The GWC is an autoclavable, 140-g, aluminum alloy device reminiscent of an old wringer washing machine. It consists of two apposing serrated rollers that pull the Silastic silo through a slotted base plate. This protects the intestine and converts the circular defect into a vertical slit to ease DPC. The GWC is adjusted daily on the awake newborn in the nursery and the magnitude of each adjustment is gauged by the infants cardiac and pulmonary status. For the past 10 years we have cared for 116 newborns with gastroschisis. The average birth weight was 2,530 g (range, 1,380 to 3,300 g). Eighty-six infants (74.1%) have undergone primary closure. The remaining 30 infants (25.9%) were treated by placement of a Silastic silo and application of the GWC, forming the basis of this report. The DPC operation was performed an average of 6.7 days (range, 3 to 23 days) following the application of the silo. Extubation was usually possible prior to the DPC, with the mean length of mechanical ventilation being 3.8 days. Three patients developed serious complications including two dehiscences of the silo-fascia interface. There were no deaths in this group of 30 patients. The GWC offers many technical advantages and can be easily reversed when the infants cardiopulmonary status deteriorates. We advocate its adoption as a method of choice in the newborn with gastroschisis who requires DPC.

Bacterial ileocecitis caused by Escherichia coli O157:H7.

Escherichia coli O157:H7 is most commonly linked to hemorrhagic colitis and the hemolytic uremic syndrome. Diagnostic ultrasound was used to demonstrate terminal ileum abnormalities suggestive of bacterial ileocecitis, a recently described entity that resembles acute appendicitis, in a patient whose stool culture yielded E. coli O157:H7. This case extends the spectrum of disease caused by E. coli O157:H7 and expands the number of organisms that can cause bacterial ileocecitis.

Pitfalls in the use of barium enema in early appendicitis in children

Appendicitis remains the most common intraabdominal indication for surgery in children. Recently, barium enema has been helpful in increasing the accuracy of diagnosis in difficult cases. Experience with 202 barium enemas in children with abdominal pain entertaining the diagnosis of acute appendicitis revealed some of the problems encountered in using this procedure as a diagnostic tool. Of the 66 children who underwent surgery, there were 32 children who were felt to have a positive barium enema and 31 of these turned out to have acute appendicitis. In the group that had negative barium enemas, there were 3 false negatives and 2 of these children had early perforations by the time of their surgery. The third group were equivocal barium enemas and they pointed out the difficulty in obtaining a normal barium enema in a child who does not have appendicitis. It was felt that the use of barium enema as an adjunct was helpful especially if it were positive, but a negative barium enema could not be relied upon to delay surgery in the child with right lower quadrant peritoneal signs.