Joseph L. Lelli

The Kasai portoenterostomy for biliary atresia: a review of a 27-year experience with 81 patients

PURPOSE The aim of this study was to utilize clinical outcome methodology through multivariable analysis of perioperative factors to predict a successful Kasai-portoenterostomy (PE). METHODS Records of 81 patients treated for biliary atresia (BA) were reviewed. Outcome was defined as successful if the patient was alive and had no liver transplant (LT). To predict future successful or failed PE, patients were categorized at 6 months post-PE into 2 groups: Success: direct bilirubin (DB) less than 2.0 mg/dL; Failure: DB greater than 2 mg/dL, or the patient was listed/had undergone LT, or had died. Groups were analyzed for positive or negative predictive values (PPV, NPV) at 2 and 5 years after PE. Cox regression was used to determine risk factors for PE. RESULTS PE was successful in 38% and failed in 62%. PPV of future success was 96% at 2 years post-PE and 95% at 5 years post-PE, NPV of failure was 76% and 74%, respectively. Bridging liver fibrosis at the time of PE and postoperative cholangitic episodes were interdependent risk factors for a failed PE (P <.05). Other covariates showed no significant relationship for PE outcome. CONCLUSION Classifying of patients 6 months postoperatively allowed us to determine a successful PE outcome. Bridging liver fibrosis at the time of the Kasai, and the increased number of postoperative cholangitic episodes were predictive of a poor PE outcome.

Increased respiratory symptoms following surgery in children exposed to environmental tobacco smoke.

Objective: The aim of this study was to determine if children exposed to environmental tobacco smoke (ETS) via parental smoking (ETS+) developed more respiratory symptoms resulting in longer recovery times following surgical outpatient procedures compared with children of nonsmoking parents (ETS−).

Hypoxia-induced bacterial translocation in the puppy

Because hypoxia is one of the most common major stresses to which a neonate is exposed, we postulated that it alone might be the cause of intestinal bacterial translocation, which could be the underlying etiology of neonatal sepsis. An animal model, in which hypoxia is the sole stress, was developed in our laboratory and tested in 18 puppies to determine the effect of hypoxia and reoxygenation on intestinal bacterial translocation. In group I (n = 8), following laparotomy and cannulation of the superior mesenteric vein (SMV), the FIO2 was decreased from 21% to 9% for 90 minutes followed by reoxygenation at 21% for 120 minutes. The abdomen was closed and the animals were allowed to recover. After 24 hours the mesenteric lymph nodes (MLNs), spleen, and liver were harvested for bacterial determination and the ileum and jejunum for histological evaluation. Group II (n = 7) was treated the same as group I with the FIO2 maintained at 21%. Group III (n = 3) animals were killed, without intervention, for bacterial analysis. In group I, the systemic PO2 decreased by 75%, SMV PO2 decreased by 64%, and oxygen delivery to the small bowel decreased by 80% in comparison with group II. The mean arterial pressure and cardiac output were not significantly different between group I and group II; however, the mucosal blood flow was decreased by 60% (P less than .001) in group I. Arterial and SMV blood lactic acid levels were unchanged in group I in comparison with group II, suggesting that anaerobic metabolism was not initiated in the splanchnic circulation during hypoxia.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of very delayed repair of congenital diaphragmatic hernia on survival and extracorporeal life support use

BACKGROUND Since November 1992, operative repair in neonates with congenital diaphragmatic hernia (CDH) at this institution was delayed until respiratory insufficiency had resolved. METHODS A retrospective analysis was performed (n = 33) comparing delayed repair with our previously reported institutional experience with immediate repair from January 1988 to October 1992 (n = 66). Infants with severe genetic defects or moribund conditions or who were premature were not considered candidates for repair or extracorporeal life support (ECLS), but they were included in the survival analysis. Survival was defined as hospital discharge. Data were compared with an independent t test or Pearson chi-squared test. RESULTS Mean age at repair was 8.9 +/- 4.5 days (range, 3 to 20 days). Eleven infants in the study group were placed on ECLS (33% versus 68% in the comparison group; p = 0.001). Six of these infants survived (55% versus 58% in the comparison group; p = 0.846). Of these survivors, one patient was repaired while on ECLS, and the remainder underwent repair after decannulation from ECLS. All 20 of the remaining candidates for repair survived without need for ECLS. Overall survival was 79% versus 56% in the comparison group (p = 0.027). CONCLUSIONS Our current data suggest that very delayed repair of newborns with CDHs is associated with an increase in the overall survival and a decrease in the use of ECLS when compared with previous experience at this institution.

Historical changes in the postoperative treatment of appendicitis in children: impact on medical outcome.

BACKGROUND/PURPOSE The introduction of managed care in the 1980s caused increased pressure to reduce costs for hospitalized patients. The authors hypothesized that these market forces have resulted in a decreased hospital stay and utilization of sophisticated diagnostic testing in children treated for appendicitis. If true, the impact of this paradigm shift on patient outcome is unknown. METHODS Hospital records for 913 pediatric patients treated for appendicitis from 1974 to 1998 were reviewed retrospectively. Patients were stratified into those with perforated appendicitis (PA) and nonperforated appendicitis (NPA). Demographics, perioperative hospital course, diagnostic testing, complications, and long-term outcomes were analyzed after stratification into time intervals. RESULTS Over time, children with NPA were treated with shorter antibiotic courses (P<.05) and were placed on a regular diet earlier (P<.05). These changes in treatment resulted in an earlier discharge (P<.05). The amount of time to become afebrile with a normal white blood cell count (WBC) did not change over time. Children with PA exhibited similar results with shorter antibiotic courses (P<.05), earlier dietary intake (P<.05) and earlier hospital discharge (P<.05) over time. In all children with appendicitis there was no significant difference in the rate of wound infections, abscesses requiring drains, readmission, or reoperations overtime. The utilization of abdominal radiographs (83%) and ultrasonography (USN; 40%) was high and remained unchanged over time. Utilization of computed tomography (CT scan) was low (4.3%) in the early decades and was not used as a preoperative test from 1991 to 1994. Given the high diagnostic accuracy of a pediatric surgeon for this disease, Bayesian analysis indicates that USN utilization rates should be 15%. CONCLUSIONS The market pressures of managed care have resulted in a new treatment paradigm with an earlier discharge of all children with appendicitis. There has been no concomitant increase in the complication rate in either group as a result of this paradigm shift. Bayesian analysis indicates that USN and abdominal radiographs are overutilized in our institution.

Efficacy of the Transthoracic Modified Heller Myotomy in Children With Achalasia -A 21-Year Experience

From 1974 to 1995, 19 children with achalasia of the esophagus have been treated at our institution. Presenting symptoms included vomiting (n = 14), dysphagia (n = 13), failure to thrive (n = 6), and odynophagia (n = 1). Diagnosis was established by a barium swallow in 19, with eight also undergoing esophageal manometry. Six boys and 13 girls with an average age of 10 years (range, 1.3 to 17.6) underwent a transthoracic, modified anterior Heller esophagomyotomy (HM). Five underwent a concomitant, modified, Belsey fundoplication (BF). Follow-up ranging from 6 months to 21 years (mean, 9 years) was accomplished in all 19 patients by both office visits and telephone interviews. Early postoperative follow-up showed initial swallowing difficulty in two (14%) patients with a HM alone and in four out of five (80%) patients treated with a HM and BF. All patients (n = 5) with a HM and BF and one with a HM alone required one esophageal dilation during the first postoperative year. These initial swallowing difficulties resolved in all six patients during this first postoperative year. Late postoperative follow-up, however, indicates occasional, mild dysphagia in two out of five with an HM and BF resulting in complete relief of presenting symptoms in 17 of the 19 patients (90%). All patients rated their overall result as either excellent (68%) or good (32%) with none rating it as fair or poor. None of the 19 patients had clinical evidence of gastroesophageal reflux, although five patients had evidence of nonpathologic reflux noted during upper gastrointestinal x-ray. Recurrent vomiting, asthma, wheezing, or esophagitis symptoms have not been reported by any patients. No patients required reoperation, and there were no deaths or postoperative complications. Modified Heller esophagomyotomy is safe (0% mortality) and effective (90% relief of symptoms) in children with achalasia. A concurrent modified Belsey fundoplication results in early and late mild postoperative dysphagia that was responsive to esophageal dilation. The transthoracic, modified Heller esophagomyotomy without a fundoplication is currently our treatment of choice for achalasia in children.

The lateral approach for open splenectomy

BACKGROUND Laparoscopic splenectomy (LS) has been used increasingly to treat children with hematologic disorders and has been reported to have advantages over open splenectomy performed through a standard vertical or subcostal incision. The authors perform open splenectomy (OS) through a lateral, muscle-splitting approach, and believe their approach is more reasonable in comparison with LS. METHODS Thirty-nine consecutive open splenectomies performed between 1991 and 1995 were reviewed retrospectively and compared with recent reports of LS. The series included 24 boys and 15 girls with an average age of 9 years and average weight of 37.5 kg. Indications included immune thrombocytopenic purpura (n = 20), hereditary spherocytosis (n = 18), and sickle cell anemia (n = 1). The operation was performed with the child in the lateral decubitus position through a left upper abdominal muscle-splitting incision (off the 11th rib), sparing the rectus muscle. RESULTS All 39 cases were completed without intraoperative complications with an average surgical time of 98.0 minutes (range, 30 to 302). The average surgical blood loss was 89 mL (range, 10 to 300). The children started feeding an average of 1.2 days (range, 0 to 4) postoperatively, were on a regular diet at an average of 2.0 days (range, 1 to 6) postoperatively, and had an average length of stay of 2.7 days (range, 1 to 6). There was no mortality or morbidity. CONCLUSIONS Open lateral splenectomy is performed with shorter surgical times, less blood loss, an excellent cosmetic result, no complications, and a length of stay comparable to any of the published series on laparoscopic splenectomy in children. This approach provides a reasonable basis for comparison with laparoscopic splenectomy.

Silastic catheterization of the axillary vein in neonates: An alternative to the internal jugular vein

The axillary vein is a suitable alternative to the jugular venous system for tunnelled silastic catheterization in neonates, and should be included in the armamentarium of the surgeon who treats neonates. It is technically easy and is comparable to the internal jugular vein in terms of complications. Proper positioning of the catheter tip can sometimes be problematic, but without a resultant increase in morbidity or mortality.

Laparoscopy-Assisted Proctocolectomy for Ulcerative Colitis: A More Rational Approach

Purpose: To evaluate a modified approach to a proctocolectomy for ulcerative colitis using a laparoscopy-assisted technique. Methods: Four 5-mm ports (epigastric, umbilical, and left and right lower quadrants) are used for colonic mobilization without ligation of the mesenteric vessels. A low suprapubic transverse incision is then made, and the colon is pulled out with sequential ligation of mesenteric vessels. The remainder of the endorectal dissection and pull-through is performed in a conventional manner. At the end of the procedure, the right lower quadrant port site is converted to an ileostomy. Results: Seven patients underwent this approach over 2 years. There were five girls, and the mean age was 10.3 ± 3.9 years. All operations were successfully performed, and the mean operating time was 8.5 ± 1.1 hours. The operative time decreased from 10 hours for the first case to 7.25 hours for the last case. The mean number of hospital days was 5.5 ± 0.5. There was one postoperative small-bowel obstruction,...