Harry Applebaum

Focal gastrointestinal perforations not associated with necrotizing enterocolitis in very low birth weight neonates

Nine very low birth weight (VLBW) neonates (< 1,000 g) undergoing abdominal exploration for peritonitis were found to have focal perforations of the gastrointestinal (GI) tract and no clinical or histologic evidence of necrotizing enterocolitis (NEC) or other mechanical cause. Although most patients presented initially with clinical findings suggestive of NEC, none developed the traditional clinical or radiographic findings associated with this diagnosis. Most patients initially had normal bowel gas patterns or transient bowel distension on abdominal x-ray, followed within hours by a paucity of bowel gas or a totally gasless abdomen. Paracentesis was positive in 7 patients. A blue, purplish, or dusky discoloration of the abdomen was described in 7 patients prior to surgery. Surgery was performed at an average age of 16.7 days. In all, the bowel appeared grossly normal with the exception of a 0.3- to 1-cm focal perforation of the small intestine or colon. One patient had an additional similar perforation of the stomach. Treatment in most was simple exteriorization of the perforation. The one gastric perforation was oversewn. Biopsy specimens at the site of perforation from 4 patients were described as having focal necrosis without intrinsic bowel disease. Two were noted to have Candida invading the bowel wall. Unlike the typical bowel flora found on culture in infants with perforations due to NEC, these patients had cultures and histological specimens positive for Candida and/or Staphylococcus epidermidis. We conclude that focal GI perforations occurring in the VLBW infant represent a clinically distinct phenomenon and that the traditionally accepted diagnostic criteria for bowel perforation due to NEC are unreliable in this condition.(ABSTRACT TRUNCATED AT 250 WORDS)

Hospital admissions for respiratory symptoms and failure to thrive before and after Nissen fundoplication

PURPOSE The purpose of this study is to determine whether Nissen fundoplication decreases hospital admissions for respiratory symptoms and failure to thrive (FTT). METHODS A retrospective study using discharge abstract data from Southern California Kaiser Permanente hospitals during the last decade was done. Three hundred forty-two pediatric patients had at least one Nissen fundoplication. Hospital admissions for aspiration and other pneumonia, respiratory distress/apnea, and FTT were determined before and after Nissen fundoplication. Age and associated neurologic disorders were also studied. Statistical analysis was determined by chi(2) analysis, Poisson regression analysis, and relative risk. RESULTS The number of patients requiring hospital admission for aspiration and other pneumonia, respiratory distress/apnea, and FTT was similar before and after Nissen fundoplication. The proportion of readmission within 1 year after Nissen fundoplication for aspiration pneumonia was 0.1250 (95% confidence interval [CI], 0.0266-0.3236); other pneumonia, 0.5465 (95% CI, 0.4355-0.6542); respiratory distress/apnea, 0.5039 (95% CI, 0.4145-0.5931); and FTT, 0.5669 (95% CI, 0.4761-0.6545). Associated neurologic disorders independently increased hospital admissions for aspiration and other pneumonia, respiratory distress/apnea, and FTT. Age was inversely related to hospital admissions for respiratory distress and FTT. CONCLUSION Nissen fundoplication did not improve hospital admissions for pneumonia, respiratory distress/apnea, and FTT. Associated neurologic disorders increased readmissions for pneumonia, respiratory distress/apnea, and FTT, whereas increasing age decreased readmission for respiratory distress and FTT.

Long-term Antireflux Medication Use Following Pediatric Nissen Fundoplication

HYPOTHESIS Nissen fundoplication decreases the use of antireflux medications. DESIGN Retrospective cohort study using discharge abstract data and pharmacy data. SETTING Twelve regional Kaiser Permanente hospitals in southern California. PATIENTS Three hundred forty-two patients underwent Nissen fundoplication. INTERVENTION Nissen fundoplication. MAIN OUTCOME MEASURE Use of antireflux medications. RESULTS The number of patients requiring antireflux medications decreased from 233 patients (68.1%) before Nissen fundoplication to 197 (57.6%) after Nissen fundoplication. Of the 233 patients, 176 (75.6%) were restarted on antireflux medications within 1 year after Nissen fundoplication. Use of antireflux medication decreased in neurologically healthy patients but was unchanged in neurologically impaired children. CONCLUSIONS Use of antireflux medication decreased after Nissen fundoplication. Neurologically healthy children showed the biggest decrease in antireflux medication use after Nissen fundoplication.

Congenital bronchobiliary fistula: Diagnosis and postoperative surveillance with HIDA scan

Congenital bronchobiliary fistula (CBBF) is an extremely rare anomaly with myriad presentations that often include common bile duct abnormalities. Traditionally, bronchoscopy and bronchography have been used to establish the diagnosis. A full-term neonate with pneumonia and bilious secretions was diagnosed as having CBBF by means of a HIDA scan. Successful repair consisted of a right thoracotomy, high ligation of the fistula via an extrapleural approach, and cholecystography to confirm biliary drainage into the duodenum. The HIDA scan is a safe and efficient means to diagnose CBBF. When used in combination with surgical contrast studies, it provides clear delineation of all variations of this abnormality, enabling one-stage correction.

Training general surgery residents in pediatric surgery: educational value vs time and cost

BACKGROUND This study evaluated the educational value of pediatric surgery rotations, the likelihood of performing pediatric operations upon completing general surgery (GS) residency, and time and cost of training GS residents in pediatric surgery. METHODS A survey was administered to GS residents that evaluated the pediatric surgery rotation and anticipated practice intentions. A retrospective analysis (2005-2006) of operative times for unilateral inguinal hernia repair, bilateral inguinal hernia repair, and umbilical hernia repair was also performed. Procedure times were compared for operations performed by a pediatric surgeon with and without GS residents. Cost analysis was based on time differences. RESULTS General surgery residents (n = 19) considered the pediatric surgery rotation to have high educational value (4.7 +/- 0.6 of 5) with extensive teaching (4.6 +/- 0.7) and operative experience (4.4 +/- 0.8). Residents listed pediatric surgery exposure, operative technique, and observed work ethic as most valuable. Upon graduation, residents expect to perform pediatric operations 2 to 3 times annually. Thirty-seven percent of residents felt competent to perform appendectomy (patients >5 years), 32% appendectomy (3-5 years), 21% gastrostomy (>1 year), and 11% inguinal herniorrhaphy (>1 year). Operative times and costs were significantly higher in operative procedures performed with a GS resident. CONCLUSION General surgery residents considered pediatric surgery as a valuable educational experience. Residents anticipate performing pediatric operations a few times annually. Training GS residents in pediatric surgery increased operative time and cost. This information may be useful in determining the appropriate setting for resident education as well as budget planning for pediatric surgical practices.

A comparison of the hemodynamic and ventilatory effects of abdominal insufflation with helium and carbon dioxide in young swine

Abdominal CO2 insufflation has been shown to cause hypercarbia, acidemia, and decreased oxygenation in a pediatric animal model. Such metabolic derangements have prompted a search for alternative insufflation gases. This study compares the hemodynamic and ventilatory changes that occur during pneumoperitoneum with CO2 and helium. Four juvenile swine were intubated and given general anesthesia. Minute ventilation was adjusted to obtain a baseline Pco2 of between 32 and 36 mm Hg, and was kept constant for the duration of the experiment. The subjects initially were insufflated with CO2 or helium at a pressure of 10 mm Hg. Peak ventilatory pressure, end-tidal CO2 (ETCO2) arterial pH, Pco2, Po2, and right atrial and inferior vena caval pressures were measured before and during a 1-hour insufflation period. After desufflation, Pco2 and pH were restabilized. The same parameters were then measured during reinsufflation with the alternate gas. CO2 insufflation caused significant decreases in pH, from 7.51 +/- 0.03 to 7.32 +/- 0.06, and Po2 increased from 261 +/- 49 to 189 +/- 33 mm Hg. Pco2 increased from 35.0 +/- 1.4 to 57.9 +/- 6.3 mm Hg. ETCO2 also increased, from 29.0 +/- 2.2 to 47.2 +/- 5.0 mm Hg. Helium insufflation caused pH to decrease from 7.51 +/- 0.01 to 7.42 +/- 0.04. Pco2 increased from 32.8 +/- 0.8 to 43.5 +/- 3.9 mm Hg, and ETCO2 increased from 27.8 +/- 0.5 to 36.8 +/- 3.1 mm Hg. These alterations were significantly less than those with CO2 pneumoperitoneum. Po2 decreased as well-from 266 +/- 30 to 212 +/- 21 mm Hg. During insufflation with both gases, peak ventilatory pressure and right atrial pressure increased significantly. Abdominal insufflation with CO2 or helium causes hypercarbia, acidemia, and increased ETCO2 in this juvenile animal model. These derangements are significantly less with helium. This gas may prove to be the more suitable insufflation agent for pediatric patients.

Hemodynamic and ventilatory effects of abdominal CO2 insufflation at various pressures in the young swine

Laparoscopic procedures requiring abdominal CO2 insufflation are applied with increasing frequency to the pediatric age group. Whereas the physiological effects accompanying insufflation have been studied in laboratory and clinical adult subjects, little is known of these effects in the juvenile subject. Young swine (weight, 10 to 12 kg, approximate age, 6 weeks) were subjected to abdominal CO2 insufflation at 10 and 15-mm Hg insufflation pressures (IP) to evaluate potential metabolic and hemodynamic effects. After intubation, minute ventilation was adjusted to obtain a baseline PCO2 between 38 and 42 mm Hg, and was kept constant during the subsequent study period. Four subjects underwent a total of eight trials, with insufflation periods of 1 hour each. Serial measurements of peak ventilatory pressure, tidal volume, end tidal CO2, arterial pH, PCO2, PO2, right atrial (RA), and inferior vena caval (IVC) pressure were obtained. Mean pH decreased from 7.45 +/- 0.03 to 7.22 +/- 0.03 at 10 mm Hg IP, and from 7.44 +/- 0.01 to 7.19 +/- 0.03 at 15 mm Hg IP. Mean PCO2 increased from 39.9 +/- 0.4 to 70.0 +/- 1.0 mm Hg at 10 mm Hg IP, and from 39.9 +/- 0.5 to 76.8 +/- 1.6 mm Hg at 15 mm Hg IP. PO2 decreased by approximately 37% at both IPs. End-tidal CO2 increased by 53% at 10 mm Hg IP, and by 68% at 15 mm Hg IP. Right atrial pressure did not increase significantly, and IVC pressure increased in proportion to the IP. Abdominal CO2 insufflation in this model produced marked acidemia, hypercapnia, decreased oxygenation, and increased exhaled CO2.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term follow-up of patients treated with ileoendorectal pull-through and right colon onlay patch for total colonic aganglionosis

BACKGROUND/PURPOSE This study was performed to assess the long-term follow-up of five patients who underwent one-stage ileoendorectal pull-through with right colon onlay patch for total colonic aganglionosis (TCA) at Kaiser Permanente Medical Center. METHODS A retrospective review of inpatient and outpatient charts and telephone follow-up of all patients were conducted to obtain current data regarding growth, development, bowel function, and postoperative and late complications. RESULTS Follow-up has ranged from 2 to 11 years. All patients are at or above the 50th percentile for weight by age and are continent with 1 to 5 daily bowel movements. Only two patients required reoperation. A perirectal abscess developed in one patient 2 months postoperatively. In the second patient a functional obstruction was relieved by sphincterotomy. CONCLUSIONS Ileoendorectal pull-through with right colon onlay patch is associated with few early and late postoperative complications; it appears to be superior to other procedures in the early postoperative period because of the more rapid return to acceptable stooling patterns. This method of reconstruction provides an excellent opportunity for normal growth, development, and long-term bowel function.

Abdominal Expansion as a Bridging Technique in Stage IV-S Neuroblastoma With Massive Hepatomegaly

Stage IV-S neuroblastoma has a relatively favorable outcome. However, urgent surgical treatment may be necessary for management of life-threatening complications related to massive hepatomegaly caused by metastatic tumor infiltration. The enlarged liver often becomes of primary concern because diaphragmatic elevation results in life-threatening respiratory embarrassment. An external SILAS-TIC dome has been used as a temporizing procedure to decrease the intraabdominal pressure. The authors developed a modification of this approach using an internal polytetrafluoroethylene patch to create a ventral hernia. This technique decreases the potential complications of prosthetic material use, namely, risk of infection. The graft may be left in place for an extended period and removed in staged operations as the bulk of the metastatic tumor regresses.

Contrast enema for pediatric intussusception: is reflux into the terminal ileum necessary for complete reduction?

PURPOSE Complete contrast enema reduction of intussusception is traditionally considered confirmed when contrast is seen refluxing into the terminal ileum. Operative intervention is typically indicated when the intussusception is not completely reduced. This study reviews the outcomes after symptomatic reduction of intussusception without requiring reflux of contrast into the terminal ileum. METHODS A retrospective review of all pediatric patients treated for intussusception between 1996 and 2006 was performed. Diagnostic modality, operative reports, and hospital records were reviewed. RESULTS One hundred sixty-eight patients were treated for intussusception during the study period. Median age was 9.9 months (59 days to 16.7 years). One hundred thirty-seven (81.5%) patients underwent contrast enema as the initial diagnostic/therapeutic modality. On contrast enema, 15 (10.9%) patients demonstrated reduction of the intussusception but without contrast refluxing into the terminal ileum. All 15 patients had improvement of symptoms. Six (40%) patients underwent operative intervention and were found to have a completely reduced intussusception. Two (13.3%) patients had repeat contrast enema the next day confirming complete reduction. The remaining 7 (46.7%) patients were observed without further radiographic studies, and all 7 patients were discharged the following day tolerating full feedings. There were no recurrent intussusceptions. CONCLUSION Nonoperative management may be used in patients with reduced intussusception despite lack of contrast refluxing into the terminal ileum if symptoms resolve.