Jessie L. Ternberg

Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging.

A method of clinical staging for infants with necrotizing enterocolitis (NEC) is proposed. On the basis of assigned stage at the time of diagnosis, 48 infants were treated with graded intervention. For Stage I infants, vigorous diagnostic and supportive measures are appropriate. Stage II infants are treated medically, including parenteral and gavage aminoglycoside antibiotic, and Stage III patients require operation. All Stage I patients survived, and 32 of 38 Stage II and III patients (85%) survived the acute episode of NEC. Bacteriologic evaluation of the gastrointestinal microflora in these neonates has revealed a wide range of enteric organisms including anaerobes. Enteric organisms were cultured from the blood of four infants dying of NEC. Sequential cultures of enteric organisms reveal an alteration of flora during gavage antibiotic therapy. These studies support the use of combination antimicrobial therapy in the treatment of infants with NEC.

One-Stage Versus Two-Stage Soave Pull-Through for Hirschsprung's Disease in the First Year of Life

Several investigators have reported good results after a one-stage Soave procedure without a stoma for infants with Hirschsprungs disease. The authors reviewed their concurrent experience with the one- and two-stage approaches, comparing the two groups with respect to rate of complications and clinical outcome. Over a 3-year period, 36 infants with colonic Hirschsprungs disease presenting in the first year of life were treated with a Soave pull-through. Thirteen had a one-stage pull-through, and 23 had a two-stage procedure using an initial stoma. There was no difference with respect to median age at time of diagnosis, median follow-up period, length of aganglionosis, or male:female ratio between the groups. The incidences of major complications such as small bowel obstruction, segmental or acquired aganglionosis, anastomotic leak, and malabsorption were equal between the two groups. However, 13% of the two-stage patients required revision of the stoma. All major complications in the one-stage group were in those who weighed less than 4 kg at the time of surgery. Minor complications such as wound infection, perianal excoriation, and need for repeated dilatation were similar between the groups, but minor stoma-related complications (prolapse or retraction) occurred in 26% of the two-stage infants. When complications were stratified using a more sophisticated scale of severity, no significant difference was found between the groups. The overall complication rate was 1.5 events per patient in the one-stage group and 2.0 events per patient in the two-stage group. This small difference was related to the presence of a stoma in the two-stage group. Overall, 10 of 12 survivors in the one-stage group and 22 of 23 in the two-stage group were doing well, with normal bowel function noted on long-term follow-up (mean period, of 14 and 19 months, respectively). Both one- and two-stage approaches were associated with a significant complication rate, although long-term outcome was excellent in both groups. The higher complication rate in the two-stage group was attributable to the presence of a stoma. For small infants, it may be beneficial to delay the one-stage pull-through until weight exceeds 4 kg.

Blood-Flow Relation between Hepatic Artery and Portal Vein

Blood flows in the hepatic artery and portal vein have been measured with a square-wave, electromagnetic flow meter. Hepatic arterial flow increased when portal venous flow was decreased, but, when hepatic arterial flow was decreased, portal venous flow also decreased. The relation between the two blood systems can be explained as the simple mechanical effect of interposing a slower-flowing stream in the path of a faster-flowing stream.

POG 8625: A randomized trial comparing chemotherapy with chemoradiotherapy for children and adolescents with stages I, IIA, IIIA 1 Hodgkin disease: A report from the children's oncology group

To determine if 6 courses of chemotherapy alone could achieve the same or better outcome than 4 courses of chemotherapy followed by radiation therapy (chemoradiotherapy) in pediatric and adolescent patients with Hodgkin disease. Children ≤21 years old with biopsy-proven, pathologically staged I, IIA, or IIIA1 Hodgkin disease were randomly assigned 6 courses of alternating nitrogen mustard, oncovin, prednisone, and procarbazine/doxorubicin, bleomycin, vinblastine, and dacarbazine (treatment 1) or 4 courses of alternating nitrogen mustard, oncovin, prednisone, and procarbazine/doxorubicin, bleomycin, vinblastine, and dacarbazine +2550 cGy involved-field radiotherapy (treatment 2). The complete response rate was 89%, with a complete response and partial response rate of 99.4%. There was no statistically significant difference in event-free survival (EFS) or overall survival between arms. The EFS for those who achieved an early complete response was significantly higher than for those who did not. For pediatric patients with asymptomatic low-stage and intermediate-stage Hodgkin disease, chemotherapy and chemoradiotherapy both resulted in 3-year EFS of approximately 90% and statistically indistinguishable 8-year EFS and overall survival, without significant long-term toxicity. Early response to therapy was associated with higher EFS, a concept that has led to the Childrens Oncology Group paradigm of response-based risk-adapted therapy for pediatric Hodgkin disease.

Epidemiologic and bacteriologic evaluation of neonatal necrotizing enterocolitis

The incidence of necrotizing enterocolitis (NEC) in our neonatal unit has varied from 4.7% to zero to 4.4% during three time periods. Simultaneously, significant changes have occurred in the spectrum of bacterial species in the gastrointestinal tract of unaffected infants in the same unit. During the first period of increased attack rate, 82% of gastric and 88% of fecal Enterobacteriaceae were E. coli and K. pneumoniae. When the attack rate decreased the frequencies were 11% (gastric) and 47% (fecal), and P. mirabilis was retrieved with increased frequency. The return of E. coli and K. pneumoniae as the dominant organisms was associated with an increase in NEC. Infants with NEC, compared with controls, had a statistically significant increased frequency of retrieval of E. coli and K. pneumoniae from gastric and fecal samplings. The data suggest an active role for certain enteric bacteria in the pathogenesis of NEC.

Caudal Epidural Anesthesia in Conscious Premature and High-Risk Infants

Twenty premature or high-risk infants received caudal epidural anesthesia for inguinal herniorrhaphy, orchiopexy, and circumcision. Mean gestational age at surgery was 48 +/- 12 weeks; mean weight at surgery was 4,100 +/- 1,400 g. Caudal anesthesia, performed with 1 mL/kg of 0.375% bupivacaine, was successful in 19 of 20 infants. Onset of anesthesia occurred in 14 +/- 1 minutes; duration of surgical anesthesia was 89 +/- 8 minutes. Surgical conditions were generally excellent and the infants tolerated anesthesia and surgery well. No postoperative complications were observed. Caudal epidural anesthesia is an acceptable alternative to general or spinal anesthesia in premature and high-risk infants.

Intestinal Stricture in Necrotizing Enterocolitis

In a 3-yr period, eight infants among 43 survivors of acute NEC developed intestinal stricture. Four infants developed multiple stricture after proximal diversion procedures, and four had single strictures after medical therapy. Nineteen cases of intestinal stricture after NEC were collected from the literature. Radiographic examinations at the time of the acute disease were not predictive of the risk of subsequent stricture. Histologic examination showed various stages of wound healing, most prominently in the submucosa. Stricture should be considered as the cause of intestinal malfunction in any child who survives acute NEC.

A technique to increase jejunal mucosa surface area

Abstract Ingrowth of new jejunal mucosa over a colon-patched jejunal defect occurs in dogs. An increase in jejunal surface area has thus been achieved.

Optimum Concentration of Bupivacaine for Combined Caudal-General Anesthesia in Children

Caudal epidural anesthesia has become widely accepted as a means of providing postoperative pain relief and intraoperative supplementation to general anesthesia for children. To determine the best concentration of bupivacaine for combined general-caudal anesthesia in children, 122 children aged 1-8 yr scheduled for outpatient inguinal herniorrhaphy were randomized to receive, in a double-blind fashion, caudal anesthesia with bupivacaine in one of six concentrations (0.125, 0.15, 0.175, 0.2, 0.225, or 0.25%). After incision, a programmed reduction in inspired halothane resulted, if tolerated by the subject, in an inspired halothane concentration of 0.5% 10 min after incision. End-tidal halothane concentration at hernia sac ligation for subjects receiving 0.175% bupivacaine (0.55 +/- 0.03%) was less than that for subjects receiving 0.15% bupivacaine (0.75 +/- 0.05%; P less than 0.05). Subjects receiving 0.175% bupivacaine also were discharged earlier from the postanesthesia care unit (PACU) (27 +/- 1 min) than were subjects receiving 0.15% bupivacaine (38 +/- 5 min; P = 0.05). Children receiving greater than or equal to 0.2% bupivacaine tended to complain more of leg weakness after surgery; however, the difference did not reach statistical significance (39 of 67 vs. 16 of 47; P = 0.057). The incidence of complaints of leg weakness and paresthesia was positively correlated with bupivacaine concentration (r = 0.706; P = 0.05). Subjects receiving 0.125% bupivacaine had higher pain scores on arrival to the PACU than did those receiving 0.2% bupivacaine (P = 0.05); there were no other differences in pain scores.(ABSTRACT TRUNCATED AT 250 WORDS)

An Extrarenal Wilms' Tumor Arising from a Sacrococcygeal Teratoma

From the Edward Mallinckrodt Department of Pediatrics, Department of Surgery, Washington University School of Medicine, Division of Hematology and Oncology, Division of Pediatric Surgery, St. Louis Children’s Hospital, St. Louis, Mo. 63110. ILMS’ TUMOR, or nephroblastoma, though one of the commonest abdominal tumors in childhood, rarely arises outside of a kidney; only five documented cases have been described in an extra-abdominal