Raymond A. Amoury

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.

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.

Relief of Subglottic Stenosis by Anterior Cricoid Resection: An Operation for the Difficult Case

Anterior cricoid resection is an effective procedure to relieve subglottic stenosis. This is well documented in adults, although reports of the procedure in growing airways are limited. Over an 11-year period, seven pediatric patients underwent anterior cricoid resection for recalcitrant subglottic stenosis. In four patients, the stricture was secondary to prolonged intubation, one developed subglottic stenosis following a high placement of tracheostomy for epiglottitis and another had congenital subglottic stenosis. One child had subglottic stenosis combined with laryngotracheoesophageal cleft and more distally located tracheoesophageal fistula. All patients had failed to respond to previous treatment: dilatations (3 to 20), steroid injection (3 patients), and Evans tracheoplasty (2 patients). All patients had an excellent result from anterior cricoid resection. The median age of children undergoing anterior cricoid resection was 3 years. There was no mortality. Tracheostomy decannulation was accomplished within 12 weeks following operation in all patients. It was necessary to remove a tracheal granuloma in one patient. Anterior cricoid wedge resection leaving the posterior portion of the cricoid in place is done to avoid recurrent nerve injury. It is a relatively simple and effective procedure. There has been minimal morbidity and no mortality. Follow-up from 1 to 11 years shows no recurrence of stenosis. There has been normal laryngeal and airway growth.

Gasoline Immersion Burn

DESPITE its widespread use, there are few reports of injuries after prolonged immersion in gasoline. Case Report A 12-year-old boy was trapped for an hour under an overturned tractor. His clothing ...

Multiple gastrointestinal atresias with cystic dilatation of the biliary duct

Abstract A term newborn developed signs and symptoms of an upper-intestinal obstruction. A palpable transverse upper-abdominal mass was identified. An ultrasound examination demonstrated a cystic mass with massive dilatation of the biliary tree. At laparotomy, dozens of segmental intestinal atresias (IA) from the jejunum to the rectum were identified. The cystic mass was the duodenum, obstructed distally from the atresias and proximally from an antral web. The biliary dilatation was due to normal drainage into a closed-loop duodenal obstruction, and was relieved by division of the web. The multiple atresias were explored, but establishment of intestinal continuity was impossible. The entity of multiple segmental IAs in association with cystic biliary dilation has been previously described, but there are no recorded survivors; 35 patients have been reported in the world literature. Our patient was the longest survivor; she finally died after 2 years of gastrostomy-tube drainage and total parenteral nutrition while awaiting intestinal transplantation. Only 5 patients other than ours had documented immune-system abnormalities. We review the findings and management of this rare syndrome.

Necrotizing enterocolitis: a continuing problem in the neonate.

Necrotizing enterocolitis (NEC) is a syndrome of diverse etiologies with a significant mortality rate affecting mostly prematurely born stressed infants. Now recognized as a discrete entity, it had been poorly defined because other conditions seem to represent the same entity. A number of risk factors have been identified that appear to “trigger” NEC, though these have been questioned because they have been present just as frequently in premature and older infants who did not develop NEC as in those that did. Recently, maternal cocaine use has been added to the suspected risk factors. A steady improvement in the survival of babies with NEC has been due largely to a high index of suspicion of the disease and early, aggressive medical management.RésuméLentérite nécrosante regroupe un ensemble de syndromes détiologies diverses comprenant des cas de pronostic favorable comme un ileus ou un syndrome appendiculaire reversibles mais aussi des cas dinfarctus massif avec perforation et péritonite, de pronostic redoutable. La pathogénèse nest pas connue mais il semble que différents facteurs de “stress périnataux” peuvent être incriminés. Les rôles respectifs des clostridia, des staphylocoques coagulase-négatifs et des entérocoques sont importants à connaître. Le rôle des agents pharmacologiquement actifs, tel les xanthines, la vitamine E, les prostaglandines, le surfactant, les radicaux libres toxiques et la cocaïne (chez la mère) sont aussi à considérer. Lamélioration du pronostic est à rapprocher de laugmentation de la fréquence avec laquelle le diagnostic est évoqué. La présence dair dans les parois intestinales est un signe pathognomonique. En cas de pneumopéritoine, de signes de gangrène à la ponction lavage diagnostique, un érythème de la paroi abdominale, une masse abdominale ou la persistence dune anse intestinale dilatée sur les clichés de labdomen sans préparation successifs sont autant dindications à la chirurgie. Le chirurgien se doit dêtre aussi conservateurintervention que raisonable, lintestin viable doit être extériorisé en stomie dans la plupart des cas. Une relaparotomie (pour voir) est souvent nécessaire. Lalimentation parentérale associée est impérative. Avec une telle attitude, la survie a augmenté de 24% en 1967 à plus de 70% en 1984. Vingt à 25% des enfants développeront des sténoses, entre 3 et 12 semaines après le début de la maladie, certaines nécessitant des résections ultérieures.ResumenLa enterocolitis necrotizante es un síndrome de etiologías diversas que se caracteriza por una significativa tasa de mortalidad. Fue descrito por primera vez como entidad definida en 1964 y la primera experiencia quirúrgica fue publicada en 1967. Por muchos años permaneció como una entidad no bien definida; su incidencia, en un estudio prospectivo fue de 2.1% de las admisiones a unidades de cuidado intensivo neonatal en 12 centros. Se presenta con un cuadro variado que va desde los casos leves que se recuperan sin secuelas, hasta la necrosis intestinal con perforación, peritonitis, sepsis y muerte. Se presenta con mayor frecuencia en los prematuros con factores de riesgo de estrés; la neumatosis intestinal es una caracterítica patológica y radiológica. Su patogénesis no ha sido establecida. En el presente artículo se revisa la microbiología, el papel de los agentes farmacológicos como factor etiológico, igual que de diversos agentes humorales, con énfasis en la isquemia, la lésion de reperfusión y los radicales tóxicos de oxígeno. Se ha informado un mayor riesgo de enterocolitis necrotizante en madres que abusan de la cocaína. Se revisa el uso de imágenes diagnósticas y plantean las indicaciones para intervención quirúrgica, así como el tipo de operación, cuyo propósito es la resección del intestino isquémico o perforado.

Perforation of the gastrointestinal tract and pneumoperitoneum in newborns treated with continuous lung distending pressures

In newborns with respiratory distress being treated with continuous lung distending pressures, the development of pneumoperitoneum could be a manifestation of an air-block phenomenon but it can also be due to a real perforation of the bowel. When this clinical situation arises upright films or cross-table lateral films will be helpful to demonstrate air fluid levels and some consideration should be given to inserting aqueous contrast material into the stomach and take sequential films in order to demonstrate the presence or absence of a perforation. Six illustrative cases are reported.

Hereditary Pancreatitis: Report of a Kindred

Abstract The natural history of hereditary pancreatitis has been outlined and another family is presented with this rare disease. In our patient a complicating pancreatic pseudocyst evolved during hospitalization. The development of the pseudocyst and its subsequent course after drainage has been illustrated by serial roentgenograms. Hereditary pancreatitis can be differentiated from other causes of pancreatitis in childhood, and the management of this disease has been indicated.