Michael W.L. Gauderer

Gastrostomy without laparotomy: A percutaneous endoscopic technique

A new technique has been developed to establish a tube feeding gastrostomy without a laparotomy. The procedure is particularly useful in high risk patients because general anesthesia is not usually required. The procedure is simple, safe, and rapid. It has been employed in 12 children (and 19 adults) with minimal morbidity and no mortality.

Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy.

Feeding gastrostomy is a useful means of providing nutrition in patients unable to swallow. Percutaneous endoscopic gastrostomy provides a means for creating a feeding gastrostomy without the necessity for laparotomy. It adds a new tool to the armamentarium of the therapeutic endoscopist.

Percutaneous endoscopic gastrostomy: a 10-year experience with 220 children.

This series analyzes 224 percutaneous endoscopic gastrostomies placed in 220 children. Our experience indicates that the percutaneous endoscopic gastrostomy has a wide range of indications, is advantageous in high-risk patients, and, if properly performed, compares favorably with traditional gastrostomies.

Percutaneous approaches to enteral alimentation

Feeding gastrostomy and jejunostomy provide effective access for long-term enteral nutrition. Traditional operative techniques for the performance of these procedures requires laparotomy and often, general anesthesia. This report describes our experience with two relatively new methods, percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy. Results of percutaneous gastrostomy and jejunostomy to date in 323 cases include a morbidity of 5.9 percent and a 0.3 percent operative mortality. Percutaneous endoscopic gastrostomy and jejunostomy should become the procedures of choice for the establishment of enteral access in patients requiring long-term enteral alimentation.

Cervical teratomas: An analysis. Literature review and proposed classification†

Cervical teratomas are uncommon lesions usually diagnosed at birth but occasionally reported in older children and adults. During a 58-year span, nine cervical teratomas were identified at our institution (four previously reported): three stillborns with giant tumors; five live newborns; and one adult with a malignant tumor. Of the five newborns, two prematures died within one hour of birth. Of the three survivors, 2 had respiratory distress at birth. These infants were treated with early excision and are well at 7, 6, and 2 years of age. The last patient also had cystic fibrosis. The adult died of metastatic disease 8 months after resection. A literature review disclosed 212 cases in addition to the five reported here. Previous attempts at categorizing cervical teratomas have failed to address clinical patterns and have little prognostic value. We propose a classification based on birth status, age at diagnosis, and the presence or absence of respiratory distress. Group I--stillborn and moribund live newborns: number (N), 27; mortality (M), 100%. Group II--newborn with respiratory distress: N, 99; M, 43.4%. Group III--newborn without respiratory distress: N, 37; M, 2.7%. Group IV--children age 1 month to 18 years: N, 31; M, 3.2%. Group V--adults: N, 23; M, 43.5%. Twenty-six patients in group II and one in group III died without excision of the mass. Seventy-three patients in group II, 36 in group III, and 31 in group IV had extirpation of the tumor. Operative mortality was 11%, 0%, and 3.2%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Pediatric abdominal lymphangiomas: A plea for early recognition

Abdominal lymphangiomas are usually classified together with mesenteric cysts. However, they differ by location, histology, and potential for recurrence, and should be considered a separate clinical entity. Thirteen children, aged 2 weeks to 11 years (mean, 5.8 years), with abdominal lymphangiomas were identified over the past 16 years at this institution. Of these, 12 were symptomatic. Abdominal pain (11), vomiting (8), increased abdominal girth (8), and nausea (6) predominated. Other presentations were less frequent. Symptoms were present for an average of 2 months (7 less than 1 week) before correct diagnosis. An abdominal mass was palpable in 10 cases. Intestinal gangrene secondary to volvulus was present in 2. Although multiple imaging modalities were used ultrasonography (8/8) and computed tomography (CT; 4/4) proved most expedient and reliable. In 2 cases, the lymphangioma could not be completely resected. There was 1 recurrence. Although intraabdominal cystic lesions are described in the literature as relatively symptom-free, our experience suggests otherwise. In this series, abdominal pain and an abdominal mass were common. Catastrophic complications can occur and excision is facilitated by earlier diagnosis and the benefit of smaller size. Ultrasound and CT can accurately diagnose the lesion and should be used liberally in children with intermittent or ill-defined abdominal pain, leading to prompt recognition and definitive treatment.

Transverse testicular ectopia

In transverse or crossed testicular ectopia, the affected gonad lies in the same canal as the normally descended testis. During a 5-yr span, three children with this form of ectopia were seen. All presented with a symptomatic right inguinal hernia and an empty scrotum on the left side. The ages at operation were 1, 3, and 5 mo. Only the first patient was reoperated. In this child, the diagnosis of transverse testicular ectopia was made during the herniorrhaphy and the ectopic, but otherwise normal, gonad returned to the abdominal cavity. A subsequent left orchidopexy through a celiotomy was done. In the last two patients, the correct diagnosis was made preoperatively. Both gonads were of equal size and normal, occupying the same hemiscrotum. A herniorrhaphy with fixation of the ectopic gonad to the opposite hemiscrotum was done in both. All three children are otherwise normal. Cases collected from the literature are discussed. The condition should be suspected if a unilateral hernia is associated with a contralateral, nonpalpable testis and may not be as rare as formerly thought.

Flexible fiberoptic bronchoscopy in the management of tracheobronchial foreign bodies in children: The value of a combined approach with open tube bronchoscopy

Fifty-two pediatric patients suspected of having a pulmonary foreign body but in whom there was insufficient evidence to warrant open tube bronchoscopy. In 19% of these patients, foreign bodies were found. Twenty-six percent of patients who had previously had foreign bodies removed and who subsequently underwent flexible bronchoscopy for a variety of indications were found to have residual foreign bodies. Clinically unsuspected foreign bodies were found in 1% of 1,054 additional patients who had flexible bronchoscopy for other reasons. The diagnostic use of the pediatric flexible bronchoscope is a safe, definitive, and cost-effective method for the identification of patients with pulmonary foreign bodies when other techniques yield equivocal or negative results. Patients known to have a foreign body should undergo open tube bronchoscopy for foreign body removal.

Percutaneous endoscopic gastrostomy following previous abdominal surgery

During a 36-month period, 89 patients have undergone percutaneous endoscopic gastrostomy without mortality. Of these patients, 25 (13 infants and children, 12 adults) had prior abdominal procedures that increased their risk for the endoscopic procedure. With two exceptions, all gastrostomies were performed utilizing local anesthesia. There was one major complication, a gastrocolic fistula, which was successfully managed by repeating the endoscopic gastrostomy procedure at a location more cephalad in the stomach. Twenty-two of the gastrostomies were placed for feeding purposes and all of these patients were able to leave the hospital with alimentation accomplished via the tube. Three of the endoscopically placed gastrostomies were for gastrointestinal tract decompression. A total of 255 patient months have been accumulated in these patients with the endoscopically placed gastrostomy in situ. The technique can be safely performed in patients with prior abdominal surgery and in the majority of cases is the technique of choice for establishing a tube gastrostomy.

Infected Urachal Cysts: A Review of 10 Cases

Disorders of urachal remnants are uncommon. While a urachal cyst usually is asymptomatic, infection may mimic a variety of acute intra-abdominal or pelvic processes. We describe 10 patients in 2 distinct age groups (the young child and the young adult) with an infected urachal cyst. The presenting symptoms and signs in most patients included dysuria, severe lower abdominal pain and fever. In 7 patients the correct preoperative diagnosis was made. Diagnoses at referral included Crohns disease, bladder carcinoma and pelvic inflammatory disease. A single procedure was performed in 7 cases and a staged technique was used in 3. The differential diagnosis of acute abdominal and pelvic pain or a midline lower abdominal mass in the pediatric or young adult age group should include infection of a urachal remnant.