R. A. Brown

Iatrogenic esophageal perforation in children: patterns of injury, presentation, management, and outcome.

Iatrogenic esophageal perforations in children are rare. To evaluate patterns of injury, clinical presentation, and treatment options for such patients, the authors reviewed the case records of 11 children who had sustained transmural injury to the esophagus during a dilatation procedure at their institution between 1967 and 1994. Strictures requiring dilatation were attributable to caustic ingestion in eight, esophageal atresia repair in two, and congenital stenosis in one. Eight were penetrating injuries, and three were disruptions. Two involved the cervical esophagus; and nine involved the thoracic esophagus. Pain, pyrexia, and tachycardia were early signs. Proximal thoracic perforations led to signs in the left chest region (effusion/pneumothorax); with distal perforation the signs were on the right side. Treatment along conventional lines (local drainage, gastrostomy, primary repair after early recognition, and antibiotic therapy) was successful, with two major complications, both empyemas. The most recent case, a disruption of a tracheoesophageal fistula stricture, was successfully treated with oral water irrigation and antibiotics only. Six had colonic interposition (all caustic ingestion), one required endoesophageal resection of a distal stricture, and four had resolution of the stricture, three without additional dilatation. The majority of children with iatrogenic injuries of the esophagus can be managed successfully by conservative measures and pleural drainage, with surgical procedures reserved for large disruptions of the esophagus, intraabdominal perforations, and cases that do not respond to appropriate conservative measures. Patients with caustic injury to the esophagus have a greater risk for the development of penetrating injury, and this may be one indicator of the severity of scarring. There are distinct clinical patterns of presentation, which depend on the level at which the esophagus is perforated. Dilatation disruption of a localized stricture has a good long-term prognosis for the esophagus and may even cure the stricture. The role of oral irrigation still must be fully evaluated where disruption has occurred as distinct from a penetrating injury.

Colorectal carcinoma in children

An increasing incidence of colorectal carcinoma has been noted at this institution. We report seven children with colorectal carcinoma. The average delay between onset of symptoms and diagnosis was 41/2 months, and in five patients distant metastases were present at the first operation. Initial symptoms were ignored in all cases and in only one was the serious nature of the condition realized at first presentation. In five lesions the histology was mucin secreting adenocarcinoma, a poor prognostic variant. All seven died on average 11 months after diagnosis. These three factors--delay in diagnosis, advanced stage of disease, and poorly differentiated histology--contribute overall to a poor prognosis in the young.

Is a gastric drainage procedure necessary at the time of antireflux surgery

BACKGROUND Gastroesophageal reflux is part of a generalized foregut motility disorder, which may also include delayed gastric emptying. With persistence of gastroesophageal reflux, or the presence of complications, including recurrent aspiration syndrome and esophageal stricture formation, surgical correction may be indicated. It is uncertain whether a procedure to resolve delayed gastric emptying is indicated at this time as well. METHODS Sixty-seven children with proven gastroesophageal reflux had preoperative gastric emptying assessed using 99Technetium-Sn-colloid labelled milk. Delayed gastric emptying was defined as a gastric residual activity of more than 40% at 2 hours after feeding. The antireflux operation was a partial anterior fundoplication. Postoperative milk scans assessed the effect of surgery on gastric emptying. RESULTS Gastric emptying at 2 hours improved overall from a median of 22% before surgery to 17% after surgery. In 17 patients delayed gastric emptying was identified before surgery; in 15 of those it returned to within normal limits after surgery. In 50 children with normal gastric emptying before surgery (gastric residual activity at 2 hours 16%), 14 (28%) showed delayed gastric emptying in the postoperative scan. CONCLUSIONS Delayed gastric emptying is common in children who undergo surgery for gastroesophageal reflux disease. A partial anterior fundoplication antireflux operation improves gastric emptying to within normal limits in the majority (88%) in this group, rendering a synchronous gastric drainage procedure unnecessary.

Radiation enteritis in children

Six children with intestinal radiation injury following cancer therapy are presented. The radiation dose varied from 3500 rads to 6600 rads. Symptoms of radiation enteritis took from 3 weeks to 3 years to develop. All patients received concomitant chemotherapy. Incomplete bowel obstruction was the most common presenting feature (four cases); five came to laparotomy. Simple adhesiolysis was successful in two cases; two children required more extensive surgical manoeuvres (small-bowel bypass and bowel resections). All are alive and well 4 to 13 years following therapy although five have other radiation effects. Radiation injury to the bowel and its management are discussed.

The deadly vomit: malrotation and midgut volvulus

Abstract137 cases of malrotation and midgut volvulus seen over a 28-year period are reviewed to emphasize the patterns of clinical presentation. Although 62% presented as neonates, 20% were over 1 year of age. Vomiting was the sympton of paramount importance in 97% but was not initially bile-stained in 20%. Sixteen percent had diarrhea as a major symptom. Abdominal pain occurred in 96% of patients over 1 year of age. Clinical signs were not apparent in most cases until gut infarction had occurred. Radiographic examination of the abdomen was considered normal in more than 20%. Barium meal was the contrast examination with most accuracy and should be diagnostic if correctly interpreted. The significant mortality (19%) in all age groups was invariably related to delay in presentation or diagnosis.

Reflux strictures of the esophagus in children

Although the therapeutic approach to gastroesophageal reflux in children is well established, there are differences of opinion regarding the management of esophageal strictures, viz bougienage with medical therapy, fundoplication without dilatation, preoperative dilatation followed by fundoplication with intraoperative and postoperative dilatation, or resection and interposition. Sixteen consecutive children (mean age, 30.2 months) with reflux strictures were evaluated, constituting 12% of children operated on for gastroesophageal reflux. The strictures became clinically apparent 22.4 months (mean) from the onset of symptoms and were diagnosed by contrast studies and endoscopy. At first endoscopy all the patients had well-established fibrotic strictures. The strictures were mostly situated in the middle or lower esophagus and 7 were longer than 3 cm in length. All 16 were treated with antacids, H2-receptor blockers (Cimetidine), prokinetic agents, and intense nutritional resuscitation, together with preoperative stricture dilatations (average, 3.6 times). This was followed by fundoplication when nutritional parameters had been restored, esophagitis improved, and the strictures dilated to adequate size. Seven children required concomitant gastrostomies for prograde esophageal dilatations. Twelve children needed postoperative esophageal dilatations. The results were satisfactory in 14 (88%). Two required endoesophageal resection for localized unyielding strictures. One child responded only after failed reflux surgery was corrected at a second procedure. During an average follow-up of 8.2 years (range, 3 to 11) there has been no stricture recurrence and growth velocity was restored in all. We conclude that our preferred method is preoperative in-hospital management of gastroesophageal reflux with maximum nutritional support and careful evaluation of the degree and extent of esophagitis and fibrous scarring.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous endoscopic gastrostomy in children – a 5-year experience

INTRODUCTION Percutaneous endoscopic gastrostomy (PEG) has been performed on children since 1979. The indications for a PEG are wide ranging and while there are well-established benefits, it remains a procedure with recognised complications. GOALS AND OBJECTIVES The goal of this study was to review our experience with this procedure at a South African paediatric tertiary referral hospital over a 5-year period. The objectives were to review PEGs with regard to patient characteristics, indications, anaesthesia time required and complications. METHODS The study was a retrospective case record review. RESULTS A total of 70 PEGs were performed. Patients had a mean age of 4 years and 3 months, and a mean weight of 12.2 kg at the time of performing the procedure. The mean anaesthetic time required for performing a PEG was 27 minutes. Fifty-four PEGs (77%) were performed for inability to swallow, 15 (21%) to improve caloric intake, and 1 (1%) for continuous enteral feeding. There were no deaths, 5 patients had major complications (6%), and 12 patients (17%) needed antireflux surgery subsequent to the placement of a PEG. DISCUSSION There is an increasing demand for PEGs at our institution. The indications for a PEG in this series are similar to those reported in other series, although we may be underutilising PEGs to improve caloric intake. Our complication rates compare favourably with those reported in other series. We have, however, identified post-PEG gastrooesophageal reflux disease as a complication we would like to reduce, and suggest a practical approach to do so.

Management of congenital diaphragmatic hernia.

Purpose of review To evaluate the impact of recent research on the management of congenital diaphragmatic hernia in the light of new theories on embryological development, earlier antenatal diagnosis, fetal and postnatal interventions together with advances in perinatal intensive care. Recent findings The year 2007 provided in excess of 200 publications that address various aspects of congenital diaphragmatic hernia. The genetic basis and the causes of pulmonary hypoplasia at the molecular level are slowly being unravelled. Fetal MRI of lung volume, lung–head ratio, liver position and size of diaphragmatic defect have all been evaluated as early predictors of outcome and with a view to prenatal counselling. The impact of fetal interventions such as fetal endoluminal tracheal occlusion, the mode of delivery, the surgical techniques and agents for treating pulmonary hypertension were evaluated. The influence of associated anomalies and therapeutic interventions on the outcome and quality of life of survivors continue to be appraised. Summary Deferred surgery after stabilization with gentle ventilation and reversal of pulmonary hypertension remain the cornerstones of management. Optimal presurgery and postsurgery ventilatory settings remain unproven. Continued improvement in neonatal intensive care raises the bar against which any intervention such as fetal endoluminal tracheal occlusion and extracorporeal membrane oxygenation will be judged.

Fenestrated duodenal membranes: an analysis of symptoms, signs, diagnosis, and treatment.

Duodenal obstruction typically occurs in the ampullary region and presents in the early neonatal period. If the obstruction is incomplete, as with a fenestrated duodenal membrane, the presentation may be delayed and the diagnosis overlooked. Sixteen patients with fenestrated duodenal membranes presented over a 23-year period. Six presented in the neonatal period, with vomiting; an abdominal x-ray was diagnostic in four. Ten presented later (5 weeks to 14 years) with nonspecific symptoms, ie, failure to thrive, postprandial epigastric distension, and recurrent chest infections. Vomiting occurred in all, but was of short duration (< 1 week). Two patients in the delayed group had Downs syndrome. Diagnosis was confirmed on barium meal, and optimal surgical treatment was a bypass duodeno-duodenostomy. The diagnosis of fenestrated duodenal membrane must be considered in all cases with symptoms and signs suggestive of upper gastrointestinal tract obstruction, and excluded by contrast radiology.

Corrosive strictures of the oesophagus in children

In a series of 142 children treated for corrosive burns at the University of Cape Town teaching hospitals between 1957 and 1990, 55 developed strictures of the oesophagus. Prograde dilatations with or without a guiding trans-stricture string proved successful in 22 children while 33 had an oesophageal bypass procedure. The complications following dilatations, particularly the 10 perforations of the oesophagus, are reviewed. Three of these later responded successfully to further dilatations. Since 1969, a single-staged left colon interposition was employed as the procedure of choice. The operative technique of the left colon interposition is described and the early and late complications following the bypass procedures are detailed and discussed, stenosis and strictures at the upper anastomosis being the most significant.