Nabil N. Jacir

Incarceration of inguinal hernia in infants prior to elective repair

The low morbidity and good results of elective herniorrhaphy in children are adversely affected by incarceration. Since incarceration is a potentially avoidable complication, we reviewed 908 consecutive cases to determine its incidence and consequences in children awaiting elective operation for an inguinal hernia. Eighty-five of the 908 children presented with an incarcerated hernia. Thirty of these 85 patients (35%) were known to have an inguinal hernia prior to incarceration, and 25 of the 30 were awaiting elective hernia repair. The median time from surgical office visit to planned operation was 22 days, but the mean interval from office visit to incarceration was 8 days. Eighty-five percent of the children with incarcerated hernias were infants under 1 year of age. Seventy-one of the 85 patients with an incarcerated hernia (84%) had successful manual reduction. They were all admitted and had a mean hospital stay of 2.5 days. Emergency operation after unsuccessful attempts at reduction was required in the other 14 children, increasing the average length of stay to a mean of 4.0 days. Significant complications, including infarction of the testis or ovary, bowel obstruction, intestinal necrosis, wound infection, and recurrent hernia, occurred in 26 of the 85 children (31%). We conclude that incarceration is a preventable problem. Even patients scheduled for hernia repair are at risk and the operation should be performed soon after the diagnosis is made. Infants are the highest priority group, since 35% of children less than 12 months of age experienced incarceration while awaiting elective surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Cholelithiasis in infancy: Resolution of Gallstonesin three of four infants*

Cholelithiasis in infancy is believed to be a rare finding. It is also held that all cholelithiasis in infancy has a predisposing factor such as hemolysis, prolonged fasting, congenital abnormality of the biliary tree, or the administration of TPN and is associated with severe morbidity and mortality. In the last three years, four infants at our hospital have been found on real-time ultrasonography to have gallstones. Their ages ranged from 3 weeks to 6 months. One patient had a hemolytic disease but the finding of cholelithiasis in the other three patients was incidental. A repeat sonogram in the infant with hemolysis three months after initial recognition and one day before scheduled cholecystectomy revealed spontaneous resolution of the gallstones. This led us to a conservative approach in the other three patients. Two more infants had spontaneous resolution of their gallstones and one child, now aged 16 months, is thriving with a persistent asymptomatic gallstone visible on sonogram.

The development of pyloric stenosis during transpyloric feedings

Three infants, ages 3 to 4 months, had nasojejunal feeding tubes placed for recurrent aspiration and/or feeding intolerance after upper gastrointestinal cineradiographs (ugi) had documented gastroesophageal reflux (GER) with normal pyloric channels and prompt gastric emptying. The tubes had been in place for 3 and 4 weeks, respectively, in the first two infants when classic hypertrophic pyloric stenosis (HPS) was found during fundoplication and gastrostomy tube placement. The last child had a failed attempt at nasogastric tube feedings following 3 months of nasojejunal tube feedings. A repeat ugi suggested HPS, which was confirmed by pyloric ultrasound. This infant underwent pyloromyotomy alone. The late presentation of HPS in these infants suggests that transpyloric tubes might cause the development of HPS and exacerbate the symptoms of preexisting GER. In infants who are expected to eat by mouth, pyloromyotomy alone might allow the reinstitution of orogastric feedings without the perioperative morbidity of fundoplication and gastrostomy tube placement.

Pediatric blunt liver injury and coagulopathy managed with packs and A silo : case report

Packing the abdomen can be lifesaving when severe hepatic trauma is complicated by refractory hypothermia, coagulopathy, and continuing hemorrhage requiring large-volume transfusion. This report describes the successful use of abdominal packs and a modified silo in a child following blunt liver injury.

Transanastomotic feeding tubes in repair of esophageal atresia

To avoid the need for a gastrostomy and parenteral nutrition during the 7- to 10-day healing period after esophageal anastomosis, the authors modified their technique for esophageal atresia repair to include placement of a transanastomotic feeding tube. A SILASTIC transanastomotic feeding tube and early enteral nutrition was used for 19 of 23 consecutively treated patients after repair of esophageal atresia and tracheoesophageal fistula. One of the 19 patients had recurrent fistula and another had an anastomotic leak. Five patients had significant gastroesophageal reflux (noted on barium esophagram), and four had strictures that required dilatation. Parenteral nutrition was necessary for only two patients. The authors conclude that transanastomotic feeding tubes and early enteral nutrition are safe and effective, reduce costs, and do not appear to increase the incidence of anastomotic leaks, strictures, or gastroesophageal reflux.

Surgical restraint in Burkitt's lymphoma in children☆

Burkitts lymphoma is a disease of unique cytokinetics that account for the bulky tumors, variety of presenting symptoms, and sensitivity to chemotherapy. A need to ascertain the role of surgery in the treatment of this illness prompted this review. Of nine children 5 to 12 years of age with Burkitts lymphoma, eight had abdominal involvement. Two of the eight patients also had oral lesions and staging was done by biopsy of the oral lesion and noninvasive imaging of the abdominal tumors. The other six patients presented with abdominal complaints. One of these had diagnostic paracentesis, another had only gastroscopy, and four underwent exploratory laparotomy. The four children in whom the diagnosis was established either by biopsy of an oral lesion, biopsy of an abdominal mass, or resection of an abdominal tumor are alive without evidence of disease 6 months to 6 years after treatment. Each of these children had rapid initiation of chemotherapy. Of the other four who died, two had delayed induction of drug therapy following cytoreduction or gastroscopic biopsy. The best outcomes were associated with prompt chemotherapy. We conclude that except in rare instances in which a solitary lesion lends itself to total or near-total resection, the proper role of surgery is a simple, safe procedure to obtain enough viable tumor for accurate diagnosis and prompt chemotherapy.

Recurrence of immune thrombocytopenic purpura after splenectomy

Immune thrombocytopenic purpura (ITP) frequently leads to splenectomy. Accessory spleens maybe found in a variety of locations, and may not be readily apparent. Retained accessory splenic tissue can lead to recurrent ITP, which, this report (involving multiple relapses in a single patient) demonstrates.

Cystic duodenal duplication: Staged management in a premature infant

Cystic duplication of the duodenum is a rare anomaly of the gastrointestinal tract. Patients may present in early childhood with symptoms of upper intestinal obstruction. Successful, staged management of a cystic duodenal duplication in an 880-g infant is described.

Technique of the transabdominal uncut Collis-Nissen fundoplication

Antireflux operations are commonly performed in infants and children with complicated gastroesophageal reflux. The Nissen fundoplication has emerged as the “gold standard” antireflux procedure, although troublesome problems with wrap slippage over the stomach, complete or partial wrap disruption, and herniation of the wrap into the posterior mediastinum are frequent complications, leading to recurrent symptoms of reflux and a difficult reoperative procedure. We presently perform the uncut Collis-Nissen fundoplication as a primary antireflux procedure. This operation is particularly useful in the treatment of children with failed Nissen fundoplication. In this report, we describe our technique of performing this operation through a transabdominal approach and outline the advantages of the procedure.

EXPERIMENTAL VOLUME REPLACEMENT THROUGH LOWER EXTREMITY VEINS

Hypovolemic shock was produced in anesthetized pigs by removal of 40% of blood volume over 10 minutes. Following blood loss, the inferior vena cava (IVC) was occluded below the renal veins to simulate the hemodynamics of emergency surgical treatment. Control animals were not treated. Experimental animals received intravenous lactated Ringers solution equal to three times the blood loss given through catheters either in the IVC or the superior vena cava (SVC) to determine if lower extremity access would be efficacious in this model. To define the path taken by the resuscitation fluids, an additional group of animals received technetium-99m-labelled crystalloid through lower extremity catheters with continuous recording of isotope counts in the IVC and right atrium. The treated animals in all experimental groups had significant improvements in mean arterial pressure, cardiac output, and pH compared with controls. There was no significant difference in hemodynamic response in animals receiving volume replacement through the IVC compared with the SVC. When fluid was infused below a clamped IVC, the arrival of isotope in the right atrium was delayed only 1.5 seconds. We conclude that in a model simulating emergency control of potentially lethal hemorrhage, the beneficial effects of fluid resuscitation are unrelated to the site of venous access. Lower extremity veins provide a valuable site for volume replacement even with IVC occlusion. These findings should have direct application to resuscitation and surgical care of seriously injured patients.