John D. Burrington

Esophageal replacement with a gastric tube in infants and children

Abstract 1.1. Esophageal replacement or by-pass with a tube created from the greater curvature of the stomach has proved successful in 8 children ranging in age from 212 months to 16 years. Four of these replacements were performed for congenital esophageal atresia, three for lye stricture and one for peptic esophagitis. 2.2. When possible, the upper anastomosis should be performed at the initial operation if there is no pre-existing cervical esophagostomy. Using this technique we have had no anastomatic leaks. Angulation of the tube in the neck was minimal. 3.3. The tube serves as a relatively inert conduit and seems to retain its tone and empty quickly. There has been no problem with stasis. 4.4. Reflux can be demonstrated radiographically, but has not caused symptoms. None of the patients regurgitate and all can lie down after eating. 5.5. This type of esophagoplasty is ideally suited to the infant with associated colon or anal malformations and to those with a colonic blood supply unsuitable for support of a colon transplant.

Management of 344 Children with Intussusception

Barium enema and surgery, either separately or in combination, were used to diagnose and treat 344 children with intussusception. In the past 10 years there has been a significant increase in both the percentage of patients having initial barium enema and in the frequency of successful hydrostatic reductions. Clinical evidence of intestinal perforation or free intraperitoneal air on abdominal radiographs are the only absolute contraindications to the administration of a barium enema to a child suspected of intussusception.

A standard of comparison for acute surgical necrotizing enterocolitis

We reviewed 187 cases of documented neonatal necrotizing enterocolitis (NEC) from 1976 to 1988. Of these patients, 111 infants underwent celiotomy for acute surgical complications. The following protocol of operative indications was employed: pneumoperitoneum, localized mass, abdominal wall erythema, portal venous air, and clinical deterioration, singly or in any combination. Clinical deterioration was defined as falling platelet count, rising or falling white blood cell count, left shift in the myeloid series, persistently or progressively low pH, and increasing frequency of apnea or bradycardia. Overall mortality was 15% (28 of 187). For the patients who underwent celiotomy, all had histologic confirmation of NEC. Ninety-five had localized disease, and 16 had diffuse disease. All of the former had resection and diverting enterostomy with 85 (89.5%) surviving; none with diffuse disease survived, P less than 0.0001. Forty-one infants with NEC weighed less than 1,000 g; 25 underwent surgery and 15 (60%) survived. Fifty-one of the 159 surviving neonates (32%) developed intestinal strictures. All neonates with strictures have had resection and successful reconstruction of their gastrointestinal tract. These indications and surgical principles resulted in a high degree of diagnostic accuracy and a low degree of surgical mortality.

Occult coin perforation of the esophagus

Only a small number of ingested foreign bodies perforate the esophagus and even a smaller fraction migrate extraluminally with no symptoms. Both of these events are even rarer after coin ingestion. Between 1972 and 1984, three children (16 months to 5 years), who had unabating upper respiratory symptoms, were found to have ingested coins. In only one child could the time interval between ingestion and appearance of symptoms (3 years) be established, and in this child the diagnosis was delayed because of failure to x-ray the chest after an ingestion episode. Surgical evaluation included chest/neck films: tracheal and esophageal shadows were separated by the object and a soft tissue mass; esphagogram: deviation of the esophagus, irregularity of the lumen, and no leak or tracheoesophageal fistula (TEF) and esophagoscopy: mucosa was intact with no direct visualization of the coin. Treatment consisted of exploration: cervical, one; thoracic, two; localization: coin in extraluminal granulomatous soft tissue; removal: without resection of the soft tissue mass or esophagus, and drainage: penrose, one; chest tube, two. There was no morbidity or mortality from 1 to 13 years later. Though generally harmless, ingested coins are capable of penetrating the esophagus. Sporadic literature reports confirm that the clinical findings and operative results are typical of this seemingly intermediate stage between perforation with mediastinitis and perforation with TEF.

The decreasing incidence of pneumothorax and improving survival of infants with congenital diaphragmatic hernia.

In the 6-year period between 1977 and 1982 inclusive, 75 newborn infants with congenital diaphragmatic hernia of Bochdelek underwent corrective surgery during the first 24 hours of life. A total of 40 infants (53%) survived. Beginning in January 1980, a standardized approach to care including early use of mechanical ventilation and paralysis with pancuronium as well as dopamine use prior to any Priscoline infusion, was instituted. To determine whether these approaches improved outcome, term infants without malformations from the years 1977 to 1979 were compared with a similar group treated after institution of standardized care between 1980 and 1982 inclusive. The infants were comparable in all respects, but survival improved from 45% to 82% between the two periods (P less than 0.03). There was an associated decrease in the incidence of pneumothorax (45% in first period; 14% in second period) paralleled by a concomitant increase in pancuronium use (18% and 85%, respectively). Although factors responsible for the improved survival are multifactorial these data indicate the detrimental effect of pneumothorax on outcome and the beneficial effect of a standardized approach to care using conventional intensive care techniques.

Complications of the martin procedure for total colonic aganglionosis

From 1976 to 1986 inclusive, 122 patients were cared for with Hirschsprungs disease. Sixteen of these were treated for total colonic aganglionosis, with or without small bowel involvement. The male to female ratio was 2.2:1. Two children died prior to definitive surgical therapy and two others were transferred following initial therapy. Twelve children underwent Martins procedure with a 0% mortality rate and an 81.8% morbidity rate. This study would indicate, as do others, that even though the Martin procedure can safely be performed, the long-term results require close scrutiny. A re-evaluation of this procedure and its alternatives is necessary in order to improve long-term results.

Virilizing tumors of the adrenal gland in childhood: Report of eight cases

Abstract Eight previously unreported cases of virilizing tumors of the adrenal cortex in children are discussed. One child of the 5 with carcinoma still survives at 18 years and 2 of the 3 with adenomas are alive after 312 and 2 years, respectively. One infant was virilized at birth and had evidence of excess androgen in utero, presumably from the tumor. Three had virilization before one year of age and 2 of these are dead from metastases. All children with virilism regardless of age should have a complete assessment of endocrine function as soon as possible.

Rhabdomyosarcoma of the paratesticular tissues in children report of eight cases

Abstract Six of 8 boys with paratesticular rhabdomyosarcomas survive, one to 20 years, after definitive therapy. Two children who underwent excision of secondary tumor deposits now survive, free of tumor, 6 and 20 years later. The combination of radical orchiectomy, retroperitoneal lymph node dissection up to and including the renal hilar lymph nodes, and local radiation offers the best chance of prolonged survival. Wide excision of secondary tumor deposits can be curative since early recurrences tend to be either in the incision or in the lymphatic channels draining the area. There is no evidence that chemotherapy increases survival in children with paratesticular rhabdomyosarcoma.

Immunologic response in splenectomized and partially splenectomized rats

One of the following procedures was carried out in 112, 200-gr, Sprague-Dawley rats: (A) sham operation, (B) hemisplenectomy, (C) 90% splenectomy, (D) total splenectomy and autologous spleen transplants in either omental, muscle, or subcutaneous pouch after total splenectomy, and (E) homologous splenic transplants after splenectomy. The rats were challenged intravenously with sheep, cat and guinea pig erythrocytes 6 wk, 3 mo, and 6 mo postoperative. All totally splenectomized rats had significantly reduced primary responses, regardless of whether fragments of splenic tissue had been grafted or not. There was initial lowering of primary response in partially splenectomized animals but they responded significantly better than totally splenectomized rats. After 6 mo the primary response in the hemisplenectomy group was not significantly different from the nonoperated control group. The primary response in the 90% splenectomy group had improved significantly when compared to the total splenectomy group and normal controls. Total splenectomy and partial splenectomy did not appreciably reduce the ability to mount secondary and teritary responses.

Surgery of acquired lobar emphysema in the neonate

Surgical treatment for pulmonary interstitial emphysema (PIE) has been reported with increasing frequency. We have done pulmonary lobectomies in 14 neonates with the localized form of PIE. This type of treatment was successful in 11 patients. Two patients expired in the hospital and one showed no improvement. Another six very compromised patients with diffuse PIE were treated during the same period with multiple visceral pleurotomies. Only one survived. Infants with diffuse PIE are usually poor surgical candidates, while those with acquired lobar emphysema (ALE) have been treated successfully with lobectomies.