Itzhak Vinograd

Dumping syndrome following Nissen fundoplication, diagnosis, and treatment

We evaluated the prevalence, diagnosis, and treatment of dumping syndrome (DS) following Nissen fundoplication in 50 consecutive infants and children who underwent the operation for gastroesophageal reflux. Examination included a preoperative dietary assessment with emphasis on specific postprandial clinical symptoms and technetium scintigraphy to evaluate gastric emptying. In the immediate postoperative period, postprandial glucose levels were examined in all patients with symptoms clinically suggestive of DS. In the late postoperative period (6 months to 5.5 years), all patients with more than one specific clinical symptom of DS were further evaluated by glucose tolerance test (GTT), HbA1C levels, and gastric technetium scintigraphy. DS was diagnosed in 15 patients (30%). Five patients had immediate severe DS (SDS), and 10 in the late postoperative course had latent postoperative DS (LDS). In all patients with DS, preoperative and postoperative gastric emptying scan T1/2 did not show any statistical significance. High levels of HbA1C ranging from 7.9 to 9% (mean, 8.25 +/- 0.5) were found in only three patients. Treatment included parenteral nutrition in one patient. All the others were successfully managed with nutritional manipulation alone, using a combination of lactose-free formula and fat emulsion. In patients whose postprandial symptoms persisted, pectin 5-15 g/day divided into six doses was added to the diet. Following 6 months of dietary treatment, the postprandial normoglycomic response was restored. Eleven patients experienced complete resolution of symptoms (78.5%), and three patients (21.4%) showed significant clinical improvement. This study indicates that DS is a common complication following Nissen fundoplication. The GTT is the most reliable examination for establishing the diagnosis. Treatment is simple and effective. The technetium gastric emptying scan and HbA1C level do not play a significant role in the diagnosis.

Intussusception : A 9-year survey (1986-1995)

BACKGROUND Acute intussusception has different clinical features in various parts of the world. The goal of this study was to determine the clinical presentation in different ethnic groups in Israel. METHODS A retrospective chart review of a 9-year period (1985-1995) was carried out at a university medical center. Data extracted included age, sex, ethnic origin, presenting symptoms and signs, the type of enema (barium or air), and the success rate of non-surgical reduction of the intussusception. RESULTS Ninety patients suffering from intestinal obstruction due to acute intussusception were admitted. The triad of intermittent screaming attacks, lethargy, and vomiting was observed in 37.5% of study subjects. The majority of patients were admitted during the warmer months of the year. The average age of the patients was 7.8 +/- 3.7 months; 70% of them were between the ages of 4 and 9 months and 92.5% under 1 year of age. The female-to-male ratio was 1:2.1. Air enema was superior to the barium enema in achieving reduction (p < 0.01). The incidence in the Jewish population was similar to that observed in other surveys, and twice that found in the Arab population in our region (p < 0.05). CONCLUSIONS The overall clinical presentation of acute intussusception found in our study does not differ from other studies. The lower incidence of acute intussusception found in the Arab population can be explained by ethnic, genetic, or nutritional factors.

Unilateral Hydroureteronephrosis Caused by Abdominoscrotal Hydrocele

Abdominoscrotal hydrocele is extremely rare in children. A case is presented of an unusually large abdominoscrotal hydrocele in a child, with secondary right hydroureteronephrosis due to contiguous pressure and right cryptorchidism. This entity, although unusual, should be considered in the differential diagnosis of a lower abdominal mass in children, as well as a cause of hydroureteronephrosis. Diagnosis is made with ultrasound, computerized tomography and occasionally excretory urography. Complete surgical excision through a groin incision is recommended, but optional inguinoabdominal or abdominal incisions have been reported. After surgical removal, healing is usually complete, including regression of the hydroureteronephrosis.

Subcuticular Skin Closure as a Standard Approach to Emergency Appendectomy in Children: Prospective Clinical Trial

Abstract. We evaluated the morbidity associated with primary closure by interrupted subcuticular absorbable sutures following emergency appendectomy. In a prospective clinical trial over a 12-month period, 216 children who underwent emergency appendectomy had skin closure using subcuticular interrupted absorbable polyglactin 4-0 sutures. Preoperative prophylactic antibiotics consisting of metronidazole alone or in combination with gentamicin were used in patients with suspected phlegmonous appendicitis; a combination of metronidazole, gentamicin, and ampicillin was used when perforation of the appendix was suspected. Postoperatively, in patients with phlegmonous appendicitis metronidazole was given for 24 hours, whereas in those with peritonitis the triple antibiotics were continued for 7 to 10 days. All patients were assessed for complications resulting from the technique of wound closure. No intraabdominal abscesses or serious complications were recorded. The overall incidence of wound infection was 1.8%. Among children with a perforated appendix the rate of superficial wound infection was 5.7%. There was no difference in the rate of wound infection between patients who received metronidazole alone or metronidazole plus gentamicin preoperatively. All the patients and their families were satisfied with the cosmetic results and with the fact that removal of skin sutures was unnecessary. We conclude that the use of prophylactic antibiotics permits standard skin closure by interrupted absorbable subcuticular suture.

Balloon catheter dilatation of focal colonic strictures following necrotizing enterocolitis

Two infants with severe colonic strictures secondary to necrotizing enterocolitis (NEC) were successfully dilated with balloon catheters. The procedures were performed under mild sedation, with fluoroscopic guidance. Results were sustained for more than 4 years follow-up. This procedure proved to be a safe and effective alternative to operative repair.

Continuous esophageal pH monitoring during laparoscopic cholecystectomy

Gastro-esophageal regurgitation (GER) and eventual aspiration is considered a major risk during general anesthesia. High intraperitoneal pressure produced during laparoscopic cholecystectomy (LC) is a possible source of increased GER. We investigated the incidence of GER using continuous esophageal pH monitoring in 14 patients undergoing elective LC. Only two brief episodes of acid reflux (pH<4) occurred during LC. Apparently the high intraperitoneal pressure during LC carries no increased risk of regurgitation and aspiration.

Acute colonic obstruction induced by torsion of a wandering spleen

Torsion of a wandering spleen is a very rare entity that is usually unsuspected preoperatively. A case of acute colonic obstruction due to torsion of a wandering spleen in an adolescent is presented. The unusual clinical picture developed 4 years after a previous splenopexy. Fixation of the spleen to the left upper quadrant is considered the treatment of choice. Marlex mesh fixation of the spleen to the abdominal wall at the iliac crest level is suggested as an optional therapeutic approach in specific cases where classical splenopexy is not technically possible.

Oral blast injury caused by an accident.

Blast trauma within the oropharyngeal cavity may be associated with superficial or deep injuries. Superficial injury generally needs only observation; deeper injury that violates the retropharyngeal space may produce dissecting emphysema into the neck and mediastinum followed by prevertebral soft tissue infections and mediastinitis. Injury involving the parapharyngeal space might damage vital cervical vessels. Life-threatening complications may result unless treatment is adequate. Three children who sustained oropharyngeal blast injury are presented. The direct cause was the blast effect of a new, spoiled, orange-flavor beverage just released on the market. The bottle cap of the soft drink and its effervescent liquid “exploded” into their mouths while they were trying to open the bottle with their teeth. Obviously, the failure to observe due precautions, as frequently happens among children, contributed to the occurrence of the accidents. This paper describes the diagnosis, management, and relevant educational and preventive measures of the problem.

Laparoscopic cholecystectomy in early infancy

Infantile cholelithiasis is being diagnosed with increasing frequency. In infants, idiopathic cholelithiasis has rarely been diagnosed on abdominal ultrasound examination in the course of investigation for abdominal colic, but with no apparent biliary pathology. We report two infants, aged 1 and 2 months, in whom cholelithiasis was found during evaluation for vomiting and severe abdominal distress that was clinically suggestive of hypertrophic pyloric stenosis. Both infants, who remained symptomatic, underwent modified laparoscopic cholecystectomy (LC). This first presentation of LC in infants highlights the applicability of this novel technique in this very young age group.

Case Report: Selective Occipital Lobe Hydrocephalus and Agenesis of the Left Lobe of the Liver in Congenital Myotonic Dystrophy

Myotonic dystrophy (Steinerts disease) is an uncommon familial autosomal dominant disease, characterized by progressive muscular atrophy and myotonia. Mental retardation, frontal baldness, cortical lenticular opacities and testicular atrophy are other prominent features of a disease that involves predominantly striated muscle. There is little information regarding this disease in the radiological literature. The present report introduces two additional findings involving the skull and the liver.