Keith W. Ashcraft

Surgical Treatment of Gastroesophageal Reflux in Children: A Combined Hospital Study of 7467 Patients

Objective.u2003To review retrospectively the combined clinical experience with the surgical treatment of persistently symptomatic gastroesophageal reflux (SGER) in childhood from seven large childrens surgery centers in the United States. Design.u2003During the past 20 years, 7467 children <18 years of age underwent antireflux operations for SGER at the seven participating hospitals. Fifty-six percent were neurologically normal (NN) and 44% were neurologically impaired (NI). The most frequent diagnostic studies were upper gastrointestinal series (68%), esophageal pH monitoring (54%), gastric emptying study (32%), and esophagoscopy (25%). The age at operation was under 12 months in 40% and 1 to 10 years in 48%. The type of fundoplication was Nissen (64%), Thal (34%), and Toupet (1.5%). A gastric emptying procedure was performed on 11.5% of NN patients and 40% of NI patients. Laparoscopic fundoplication was performed on 2.6% of patients. Results.u2003Good to excellent results were achieved in 95% of NN and 84.6% of NI patients. Major complications occurred in 4.2% of NN and 12.8% of NI patients. The most frequent complications were recurrent reflux attributable to wrap disruption (7.1%), respiratory (4.4%), gas bloat (3.6%), and intestinal obstruction (2.6%). Postoperative death occurred in 0.07% of NN and 0.8% of NI patients. Reoperation was performed in 3.6% of NN and 11.8% of NI patients. The results and complications were similar among the participating hospitals and did not seem related to the type of fundoplication used. Conclusion.u2003The excellent results (94% cure) and low morbidity with gastroesophageal fundoplication with or without a gastric emptying procedure from a large combined hospital study indicate that operation should be used early for SGER in NN children and to facilitate enteral feedings and care in NI children.

Hereditary presacral teratoma

Abstract Seventeen patients in six kindreds are presented with presacral teratoma and sacral defects often associated with anorectal stenosis, retrorectal abscess, and vesicoureteral reflux. The tumor complex is inherited as an autosomal dominant characteristic. One tumor was malignant causing the patients death. Family members of all patients with this tumor should be examined for the tumor.

Survival of patients with esophageal atresia: influence of birth weight, cardiac anomaly, and late respiratory complications.

PURPOSEnThe aim of this study was to determine the influence of various prognostic factors on the outcome of esophageal atresia patients.nnnMETHODSnThe authors reviewed 240 charts of patients admitted with esophageal atresia or tracheoesophageal fistula (EA-TEF) in a single institution. A logistic regression model was used with survival as the dependent variable and era of repair, birth weight, and cardiac anomaly as independent variables.nnnRESULTSnEra was statistically significant (P = .011); 87% (117 of 134) of patients survived in the era from 1980 through 1997 compared with 78% (83 of 106) from 1960 through 1979. Cardiac anomaly (CHD) was a significant risk factor (P = .001); 88% (176 of 199) survived without cardiac anomaly, whereas only 59% (24 of 41) survived with cardiac disease. Eighty-four percent (185 of 219) of infants with a birth weight (BW) of more than 1,500 g survived, compared with 71% (15 of 21) of infants with a birth weight of less than 1,500 g. This was not statistically significant (P = .59). Early hospital deaths were primarily cardiac and chromosomal (61%). Late deaths were primarily respiratory (59%; two-tailed Fishers Exact test, P = .004).nnnCONCLUSIONSn(1) Survival of patients with esophageal atresia has significantly improved in the recent years. (2) Low birth weight (<1,500 g) does not seem to affect survival. (3) Associated cardiac and chromosomal anomalies are significant causes of death, particularly for early demise. (4) Late death from respiratory disease (tracheomalacia, reactive airway disease, reflux, and aspiration) warrants attention, and a close follow-up of postoperative patients is suggested.

Survival after necrotizing enterocolitis in infants weighing less than 1,000 g: 25 Years' experience at a single institution☆

Necrotizing enterocolitis (NEC) primarily affects premature newborns. Regional and national decreases in the mean birthweight and gestational age of neonatal intensive care unit (NICU) admissions prompted a review of NEC in VLBW (very low birth weight, defined as < 1,000 g) infants in our institution over a 25-year period. There were 266 patients treated for NEC during the study interval. We compared 71 VLBW with 195 non-VLBW infants and found that VLBW infants were: fed later (6.4 days v 4.1 days, P = .009), developed NEC later (20.8 days v 13.1 days, P = .002), had significantly lower 1- and 5-minute Apgar scores, were more likely to require surgery (51% v 34%, P = .016), more often had panintestinal (defined as > 75% of intestinal length) involvement (10% v 4%, P = .043), and had poorer survival (56% v 72%, P = .013). Overall survival after NEC has improved over the study interval, both in our series and in other reports. However, the increasing number of VLBW infants who have NEC represent a subgroup who appear to be generally more ill, develop NEC later, require surgery with greater frequency than their non-VLBW counterparts, and are less likely to survive.

Early recognition and aggressive treatment of gastroesophageal reflux following repair of esophageal atresia

Twelve patients with gastroesophageal reflux following repair of esophageal atresia are presented. Reflux produced recurrent stricture, failure to thrive, repeated pneumonitis, and in one patient, respiratory arrest and nearly death. Treatment consists of positional therapy or fundoplication operation both of which seem less successful in this combination of lesions than with GER and a normal esophagus. There was one death as a late postoperative complication of fundoplication.

Efficacy of partial wrap fundoplication for gastroesophageal reflux after repair of esophageal atresia

Gastroesophageal reflux (GER) often develops in children who have undergone prior repair of esophageal atresia/tracheoesophageal fistula (EA/TEF). Fundoplication is necessary in many of these children. The complete wrap (Nissen) fundoplication is often used in this setting. However, poor results have been noted, with a mean failure rate of 30% reported in four recent studies. A partial wrap fundoplication for GER associated with EA/TEF is theoretically attractive, because the poor esophageal motility and diminished acid clearance (already physiologically present) is exacerbated by a complete wrap fundoplication. The authors reviewed their extensive experience with partial wrap (Thal) fundoplication in EA/TEF to determine if the failure rate was better than that reported for the Nissen fundoplication. In the past 18 years, the authors performed 1,467 fundoplication procedures. During the same period, 143 children underwent repair of EA/TEF. Fifty-nine children underwent fundoplication after a previous EA/TEF repair. Most of the fundoplications (58 of 59, 98%) were Thal procedures. Defining failure strictly as a need for reoperation, the failure rate in our series was 15% (9 of 59 children). Compared with the failure rate in the 1,408 non-EA/TEF patients (61 of 1408, 4.3%), results were significantly worse for the EA/TEF group (P > .001). The failure rate of Thal fundoplication performed for GER in the EA/TEF population is substantially higher than the non-EA/TEF patients. The same factors responsible for the development of reflux in these children (poor acid clearance, altered motility, esophageal shortening) may contribute to the higher failure rate. Although partial wrap fundoplication frequently failed (15%), the results were still substantially better than those reported for Nissen fundoplication in these children (30% failure rate).

Balloon extraction of esophageal foreign bodies in children.

BACKGROUNDnWhereas esophageal foreign bodies are commonly removed with rigid esophagoscopy under general anesthesia, selected foreign bodies also can be removed using a Foley catheter balloon under fluoroscopic control without anesthesia. The authors prefer to initially attempt removal of smooth, radiopaque esophageal foreign bodies using the balloon technique and then proceed to rigid esophagoscopy if unsuccessful.nnnMETHODSnThe authors reviewed their 7-year experience with this approach in 276 children with esophageal foreign bodies.nnnRESULTSnOne hundred seventy-three children underwent attempted balloon extraction, and 146 of these underwent successful removal with this method. Fifteen remained lodged in the esophagus and were subsequently removed by esophagoscopy, and 12 passed into the stomach and were observed. The only complication was one episode of epistaxis that resolved. Success of the balloon method was not related to patient age, foreign body duration, location, or presenting symptoms. The use of more than 5 minutes of fluoroscopy time was associated with a low likelihood of successful extraction.nnnCONCLUSIONnThe balloon extraction technique is a safe and effective alternative to rigid esophagoscopy for the removal of selected esophageal foreign bodies in children.

Esophageal duplication cyst with esophageal web and tracheoesophageal fistula

The authors report the case of lower cervical/upper thoracic esophageal duplication associated with an obstructing esophageal web. This presented in the newborn period as an esophageal atresia. Initial resection of the web and closure of the fistula were performed. The duplication was excised electively at 2 months of age. Persistent symptomatic tracheomalacia required aortopexy, after which the child recovered uneventfully. There are only three other reports (four cases) in the literature of esophageal atresia (or variants) associated with esophageal duplication.

Thal Fundoplication in Neurologically Impaired Children

Children with neurological impairment (NI) frequently require feeding gastrostomy, and this often aggravates or produces gastroesophageal reflux (GER). From 1976 to 1994, 141 children with severe NI underwent Thal fundoplication and gastrostomy (GT). GER was evident in 80%; in the rest, fundoplication was an adjunct to GT. Ph results were positive in 38 cases, and 57 children had reflux according to the barium studies. There were no major intraoperative complications. Disruption of the repair and/or recurrent GER was noted in 14 cases (10%); 8 were redone as Thals, and 6 were converted to Nissen procedures. Pyloroplasty was done later in 9 children (6%). Bowel obstruction was seen in 4 patients (3%). Clinical follow-up (mean, 54 months) showed improvement in 96%; only 5 of the 141 (3.2%) have residual symptoms. Of the patients with an intact Thal, 67% could burp or vomit. The ability to vomit may protect the Thal fundoplication and avoid disruption of the repair.

Rectal prolapse: 17-year experience with the posterior repair and suspension

Using a posterior repair and rectal suspension procedure for those patients who need surgical treatment of rectal prolapse, we have treated 46 patients over a period of 17 years at Childrens Mercy Hospital in Kansas City, MO. One patient with caudal dysgenesis died of multiple congenital anomalies following two unsuccessful attempts at posterior repair and suspension. Four patients developed a recurrence afterwards, which was found to be due to sigmoid intussusception and, presumably, had played a major part in their original prolapse. Two of these required resection, one from the transanal approach and one from the transabdominal approach. One resolved spontaneously and another is as yet unresolved. Three patients had minor mucosal prolapse that was transient and two patients had extrusion of silk sutures but continued to have a very satisfactory result. Overall, 42 patients had satisfactory resolution of their rectal prolapse. Three of the four patients who had unsatisfactory results had associated anomalies that contributed to their poor outcome.