Pedro Olivares

Colonic interposition for esophageal replacement in children remains a good choice: 33-year median follow-up of 65 patients

INTRODUCTION Gastric pull-up has become the predominant technique for esophageal replacement because of allegedly deficient results of colon grafts. This retrospective study examines the long-term results in a large series of colonic interpositions. PATIENTS AND METHOD One hundred six children (median, 2.9 years; range, 0.32-15 years) had their esophagus replaced between 1965 and 2008, of which 96 had colon grafts. Those survivors who were 18 years and older were contacted and, if willing, interviewed, examined, and had their functional ability rated using the Karnofsky index. RESULTS Ninety-six children had undergone a colon graft, and of these, 9 (9.3%) died. There were 65 long-term survivors whose indications for surgery included caustic injury (n = 32), failed tracheoesophageal fistula repair (n = 16), pure esophageal atresia (n = 14), and others (n = 3). The graft was either retrosternal (n = 49) or mediastinal (n = 16 patients). Twelve patients were unavailable for long-term assessment. After a median follow-up of 33.3 (11-41) years, 23 (43%) of 53 individuals experienced mild symptoms of reflux; scoliosis, 12 (22%) of 53, and/or other complications, 15 (27%) of 53 required further surgery. Thirty-two patients (60%) with Karnofsky indexes of 80% or higher felt healthy, 19 (36%) had mild life-style limitations (index, 40%-80%), and 2 had indexes less than 40%. Most patients live normal lives. CONCLUSIONS Colon conduits restored gastrointestinal continuity with limited mortality and considerable morbidity but good functional outcome and health perception in the long-term. Our study suggests that colon grafts are no worse than gastric pull-ups in the long-term.

Functional Results of Laparoscopic Fundoplication in Children

BACKGROUND There is no evidence that the results of laparoscopic fundoplication in children match those of the open procedure. In the current report, pre- and postoperative function of the antireflux barrier is examined in children having laparoscopic fundoplication for gastroesophageal reflux. METHODS Twenty-seven patients with gastroesophageal reflux, aged 7.2+/-4.5 years, were operated on for unremitting gastrointestinal symptoms (n = 24), with respiratory tract disease (n = 11), cystic fibrosis (n = 2), or brain damage (n = 11). Gastrostomy was added in 5 cases. Barium contrast study, pH-metering, endoscopic examination, and biopsy were performed before and after a median of 19 months (range, 8 to 46) after operation. RESULTS At diagnosis, 15 of 21 patients had esophagitis that was moderate or severe in 11 (1 with Barretts esophagus). Symptoms disappeared after fundoplication in all but 2 patients, in whom they became milder. The reflux index decreased from 20.2+/-20% to 4.9+/-9% and became normal in all except 4 children (2 with brain damage and 1 with cystic fibrosis). Open repair of the failed wrap was considered necessary in only 1 of them. CONCLUSIONS Laparoscopic fundoplication is as effective as the open procedure (14% overall failure rate). However, the failure rate in neurologic patients (18%) suggests that before reaching conclusions on the benefits of this approach, careful long-term assessment of the functional results is necessary.

Tumor carcinoide bronquial y apendicular

Antecedentes El tumor carcinoide es una rara neoplasia neuroendocrina con localizaciones diversas, capaz de producir sustancias vasoactivas y asociada ocasionalmente al sindrome carcinoide (enrojecimiento, diarrea y sibilancias). Pacientes y metodos Revisamos las historias de los pacientes con diagnostico de tumor carcinoide en nuestro servicio entre 1966 y 2003. Resultados Diez pacientes (5 ninos y 5 ninas con una edad media de 8 anos) fueron diagnosticados de tumor carcinoide. Ocho tenian carcinoides apendiculares de los que cuatro presentaron sintomas de apendicitis aguda. De estos ocho, siete eran menores de 2 cm y estaban localizados en la punta del apendice. El paciente restante presentaba un tumor carcinoide de 3,5 cm en la base apendicular por lo que fue reintervenido para realizar una reseccion ileocecal. Dos pacientes de 4 y 6 anos presentaron un tumor carcinoide bronquial asociado a sintomatologia respiratoria cronica y se llego en ambos al diagnostico acertado tras un ano de seguimiento. Se realizo neumonectomia en un caso y reseccion bronquial con anastomosis traqueobronquial en el otro. Ningun paciente de la serie presento sintomatologia carcinoide. Se realizaron controles bioquimicos, radiologicos y fibrobroncoscopicos en los bronquiales. Todos se encuentran actualmente libres de enfermedad. Conclusiones El tumor carcinoide apendicular no se asocia a sintomatologia caracteristica de apendicitis aguda en la mitad de los pacientes. Encontramos que el sindrome carcinoide asociado al tumor carcinoide es excepcional en la edad pediatrica. En la mayor parte de los tumores carcinoides apendiculares la apendicectomia simple es suficiente con un pronostico excelente. El tumor carcinoide bronquial es diagnosticado generalmente de manera tardia por lo que debemos considerar este diagnostico en pacientes con sintomatologia respiratoria cronica.

Infectious strictures requiring esophageal replacement in children

Esophagitis caused by herpes virus or Candida albicans infection may occur in patients with immune depression or cancer in whom the defense against these agents may be impaired, but it is rare in immunocompetent individuals. These infections seldom lead to complications, and they usually can be managed with antimycotic drugs. Esophageal strictures of these origins, like those of other causes, can be managed successfully by repeated dilatations in most patients, and esophageal replacement rarely is needed. We report two children with intractable esophageal strictures caused respectively by herpes virus and Candida infections who required esophageal replacement after failure of dilatations and medical treatment.

Defective upper gastrointestinal function after repair of combined esophageal and duodenal atresia.

BACKGROUND Both esophageal atresia (EA) and duodenal atresia (DA) involve deficient anti-reflux barrier, poor esophageal function and eventually, duodenogastric reflux. This study aims at examining the upper gastrointestinal functional status in a cohort of patients with both EA and DA. METHODS A retrospective survey of patients treated for EA and DA between 1965 and 2012 was conducted. Clinical charts, office visits, imaging, upper gastrointestinal endoscopy and esophageal pH metry/impedance were used to assess the long-term condition of the esophagus, the presence of gastroesophageal reflux disease (GERD) and/or the need for fundoplication. RESULTS Twenty out of 581 patients treated for EA had associated DA. Ten/twenty children survived; 1 had primary esophageal replacement. With a median follow-up of 9 years, 8/9 had complicated outcomes and 5 still suffered digestive ailments: 2 GER; 1 eosinophilic esophagitis; 1 nodular gastritis, and 1 wrap herniation. A total of 10 procedures were performed: 8 fundoplications, 1 esophagogastric dissociation and 1 replacement with colon. DISCUSSION The association of EA with DA involves a poor upper digestive function with high risks of GERD and fundoplication failure. The lifelong synergistic play of esophageal, gastric and duodenal dysfunctions in these patients prompts long-term follow-up, and eventually active treatment.