Robert P. Foglia

Fetal allograft survival in immunocompetent recipients is age dependent and organ specific

This study explores whether fetal allograft survival is age dependent and organ specific. Fetal rat tissue (renal, gonadal, hepatic) from the third trimester of gestation (days 15–21) was transplanted into 306 outbred adult rats for 10–30 days. Grafts were studied by morphometric and histologic analysis. Ten days after implantation, renal tissue (N = 75) from late gestation (days 19–21) showed no increase in size. In contrast, 17-day fetal grafts (N = 20) grew 6.8 ± 3.4 times,* while 15-day fetal grafts (N = 28) grew 17.5 ± 6.1* times. (The symbol “*” indicates p < 0.05, compared to original size.) Twenty days after implantation, these 15-day fetal grafts (N = 20) grew 48.8 ± 17.7* times. Ten days after grafting, the younger fetal tissue showed excellent maturation of renal elements and no sign of rejection; older fetal grafts had poor renal architecture and a dense lymphocytic infiltrate. The 15-day fetal gonadal tissue (N = 18) showed a moderate 10.6 ± 3.2* increase in size while the 15-day hepatic grafts (N = 16) were regularly rejected within 10 days. Selected fetal allografts from early in the third trimester can not only survive but can grow and mature in an immunocompetcnt recipient. This fetal graft growth appears to be both age dependent and organ specific. The use of fetal organs may broaden the potential pool for transplantation. However, further studies are needed to define the ontogeny of graft acceptance.

One-Stage Versus Two-Stage Soave Pull-Through for Hirschsprung's Disease in the First Year of Life

Several investigators have reported good results after a one-stage Soave procedure without a stoma for infants with Hirschsprungs disease. The authors reviewed their concurrent experience with the one- and two-stage approaches, comparing the two groups with respect to rate of complications and clinical outcome. Over a 3-year period, 36 infants with colonic Hirschsprungs disease presenting in the first year of life were treated with a Soave pull-through. Thirteen had a one-stage pull-through, and 23 had a two-stage procedure using an initial stoma. There was no difference with respect to median age at time of diagnosis, median follow-up period, length of aganglionosis, or male:female ratio between the groups. The incidences of major complications such as small bowel obstruction, segmental or acquired aganglionosis, anastomotic leak, and malabsorption were equal between the two groups. However, 13% of the two-stage patients required revision of the stoma. All major complications in the one-stage group were in those who weighed less than 4 kg at the time of surgery. Minor complications such as wound infection, perianal excoriation, and need for repeated dilatation were similar between the groups, but minor stoma-related complications (prolapse or retraction) occurred in 26% of the two-stage infants. When complications were stratified using a more sophisticated scale of severity, no significant difference was found between the groups. The overall complication rate was 1.5 events per patient in the one-stage group and 2.0 events per patient in the two-stage group. This small difference was related to the presence of a stoma in the two-stage group. Overall, 10 of 12 survivors in the one-stage group and 22 of 23 in the two-stage group were doing well, with normal bowel function noted on long-term follow-up (mean period, of 14 and 19 months, respectively). Both one- and two-stage approaches were associated with a significant complication rate, although long-term outcome was excellent in both groups. The higher complication rate in the two-stage group was attributable to the presence of a stoma. For small infants, it may be beneficial to delay the one-stage pull-through until weight exceeds 4 kg.

Gastroesophageal fundoplication for the management of chronic pulmonary disease in children

Gastroesophageal reflux is a common cause of chronic pulmonary disease in children. Forty-two children with recurrent pneumonia or severe asthma were evaluated and shown to have signicant reflux. Esophagography and esophageal pH testing proved the best diagnostic tests for determining reflux. Although the pulmonary symptoms were often due to repeated aspiration, they appeared in several cases to be related to bronchospasm caused by acid in the upper esophagus. All of the children underwent Nissen fundoplication and gastrostomy an average of 30 months after the onset of pulmonary symptoms. Of the children who had preoperative pneumonia, 87 percent had no recurrence after operation. In 13 of the 14 asthmatic children who underwent operation, symptoms improved and less bronchodilator medication was required. Morbidity and mortality were closely related to the duration and severity of pulmonary disease.

Current indications for decortication in the treatment of empyema in children

Although most children with empyema respond to antibiotics and pleural drainage, a recognizable number fail to improve. This study reviews experience with ten children over the past 7 years who have been selected for lung decortication for refractory empyema. Decortication was performed because of lack of clinical improvement despite drainage and multiple antibiotics during an average 20-day preoperative hospitalization. Responsible organisms included beta-hemolytic Streptococcus, Streptococcus pneumoniae, and Hemophilus influenzae. A computerized tomographic (CT) scan of the chest was performed in the last eight patients and showed at least a 50% limitation of lung expansion by the products of the empyema in each case. Following decortication, chest tubes were removed, antibiotics stopped, and temperature and white blood cell count returned promptly to normal. The advantages of early decortication in selected patients with empyema who do not respond to antibiotics and drainage include low morbidity, shorter hospitalization, and excellent long-term results.

Operative treatment for the gastroesophageal reflux syndrome in children

Surgical treatment for symptomatic gastroesophageal reflux (GER) was performed on 420 infants and children over a 19-year period. Esophageal motility disorders were present in more than 35% of patients and delayed gastric emptying (DGE) was present in approximately 50% of patients studied. Gastroesophageal fundoplication (GEF) alone was performed for 357 patients, whereas 51 patients underwent GEF and pyloroplasty; 12 patients underwent pyloroplasty alone. When there is more than 60% gastric retention of technetium-99m sulphur colloid in semisolid feedings at 90 minutes, pyloroplasty appears to be useful. Twenty-two percent of the last 275 refluxing children underwent pyloroplasty combined with GEF. Most infants and young children undergoing evaluation for severe GER, particularly those with neurologic disorders, may benefit from having a gastric emptying study. Children with severe reflux and esophageal dysmotility should have a loose GEF performed. The absence of persistent dumping, and the very low incidence of complications suggests that pyloroplasty should be used more frequently when significant DGE is present.

Pulmonary edema and fluid mobilization as determinants of the duration of ECMO support

The physiological variables that govern recovery of pulmonary function during neonatal extracorporeal membrane oxygenation (ECMO) remain poorly understood. We hypothesized that pulmonary hypertension (PHN) resolves soon after starting ECMO and that neonatal weight gain, pulmonary edema, and fluid mobilization are major determinants of recovery of pulmonary function and the ability to decrease ECMO support. To evaluate this, 17 consecutive neonates requiring ECMO for severe respiratory failure were reviewed. PHN was studied by daily echocardiography to assess the direction of ductal shunting. To evaluate fluid flux, pulmonary function, and edema during ECMO, we measured body weight, urine output, and ECMO flow every 12 hours. To evaluate pulmonary edema, serial chest radiographs obtained every 12 hours were randomly reviewed and scored by two radiologists with a semiquantitative chest radiograph index score (CRIS). By 25% of bypass time, PHN had resolved in all patients. However, at that time, weight had increased to 9.16% +/- 1.78% above birth weight, and the CRIS was 44% worse than the value just prior to ECMO. From 25% time on bypass, as urine output increased, patient weight and CRIS progressively decreased, allowing ECMO support to be weaned. At the time of discontinuation of ECMO support, weight had decreased to 2.0% +/- 1.3% above birth weight, and urine output remained steady at 3.0 +/- 0.3 mL/kg/h. Within 24 hours of stopping ECMO, the CRIS showed a 58% improvement compared to maximal scores during ECMO. We conclude that PHN decreases early in ECMO and that edema and its mobilization are important determinants of the improvement in pulmonary function and duration of ECMO.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment of the gastroesophageal reflux syndrome in infants and children

During an 18 year period, 352 infants and children under 18 years of age underwent surgical treatment for symptomatic gastroesophageal reflux. Delayed gastric emptying was present in more than 50 percent as evidenced by more than 50 percent retention of technetium-99m sulfur colloid in semisolid feedings at 90 minutes. Esophageal motility disorders occurred in over 35 percent of the patients with symptomatic reflux, militating against performing a tight antireflux operation. Of 352 patients who had operation for symptomatic gastroesophageal reflux, 308 underwent gastroesophageal fundoplication alone, 26 underwent gastroesophageal fundoplication and pyloroplasty, 12 had pyloroplasty alone, and 6 had gastroesophageal fundoplication followed by pyloroplasty as a second operation because of residual delay in gastric emptying. An abnormal result of esophageal pH monitoring and decreased lower esophageal sphincter pressure with normal gastric emptying suggest use of the gastroesophageal fundoplication alone. Delay in gastric emptying combined with decreased lower esophageal sphincter pressure and abnormal results of esophageal pH monitoring indicate the use of gastroesophageal fundoplication plus pyloroplasty. A mildly abnormal esophageal pH value in combination with a high-normal lower esophageal sphincter pressure and marked delay in gastric emptying (over 60 percent retention at 90 minutes) suggest the use of pyloroplasty alone. The excellent clinical results achieved with gastroesophageal fundoplication, with or without pyloroplasty, and the low morbidity and mortality rates indicate that these procedures should be used early in the management of infants and children with symptomatic gastroesophageal reflux syndrome.

Recognition and management of nonpenetrating cardiac trauma in children

OBJECTIVE To characterize the evaluation and clinical course of children with nonpenetrating injury to the heart. METHODS We reviewed the medical records for children admitted to St. Louis Childrens Hospital between the years 1987 to 1992 with traumatic cardiac injury. Patients with penetrating trauma were excluded; eight children, ages 4 to 13 years, were the study subjects. Chest x-ray studies, electrocardiograms, and serum creatine kinase values were obtained on admission. Two-dimensional echocardiography was performed when indicated by unexplained hemodynamic instability or abnormal radiographic findings. RESULTS All children with nonpenetrating cardiac trauma were involved in a motor vehicle accident. The principal cardiac diagnoses were ventricular septal defect (1), mitral regurgitation (1), pericardial effusion (2), contusion (3), and arrhythmia (1). Multisystem injury was present in each case, but cardiac injury was not suspected at the time of admission in seven of the eight patients. The hemodynamic status of four children was compromised 12 to 48 hours after admission; echocardiography was diagnostic in each instance, but the electrocardiogram and creatine kinase values were nonspecific. Two patients eventually required cardiac surgery. CONCLUSIONS Recognition of blunt cardiac trauma in children may be confounded by associated multisystem injury and the delayed onset of clinical manifestations. Echocardiography is a sensitive diagnostic tool for hemodynamically significant disease, and should be performed promptly when patients have unexplained hypotension or diminished peripheral perfusion.

Intestinal obstruction after lung transplantation in children with cystic fibrosis.

BACKGROUND/PURPOSE Distal intestinal obstruction syndrome (DIOS) occurs in 15% of patients with cystic fibrosis (CF). The authors reviewed their experience to determine the incidence, risk factors, and natural history of adhesive intestinal obstruction and DIOS after lung transplantation. METHODS Eighty-three bilateral transplants were performed in 70 CF patients between January 1990 and September 1998. All were on pancreatic enzymes preoperatively, and none had preoperative bowel preparation. Fifty-six patients (80%) had prior gastrostomy (n = 54) or jejunostomy (n = 2). Eighteen patients (25.7%) had a previous laparotomy for meconium ileus (n = 8), fundoplication (n = 4), liver transplant (n = 1), jejunal atresia (n = 1), Janeway gastrostomy takedown (n = 1), pyloromyotomy (n = 1), free air (n = 1), or appendectomy (n = 1). RESULTS After lung transplantation, 7 patients (10%) required laparotomy for bowel obstruction (6 during the same hospitalization, and 1 during a subsequent hospitalization). The causes of obstruction were adhesions only (n = 1), DIOS only (n = 2), and a combination of DIOS and adhesions (n = 4). Adhesiolysis was performed in the 5 patients with adhesions, and a small bowel resection was also performed in 1 patient. DIOS was treated by milking secretions distally without an enterotomy (n = 3) with an enterotomy and primary closure (n = 1) or with an end ileostomy and mucus fistula (n = 2). Five had recurrent DIOS early postoperatively. One resolved with intestinal lavage, 2 were treated successfully with hypaque disimpaction, and 2 underwent reoperation; 1 required an ileostomy. The most important risk factor for posttransplant obstruction was a previous major abdominal operation. Obstruction occurred in 7 of 18 (39%) who had undergone a prior laparotomy versus 0 of 52 who had not (P < .001, chi2). CONCLUSIONS (1) The incidence of intestinal obstruction is high after lung transplantation in children with CF. (2) Previous laparotomy is a significant risk factor. (3) Recurrent obstruction after surgery for this condition is common. (4) Preventive measures such as pretransplant bowel preparation and early postoperative bowel lavage may be beneficial in these patients.

Fetal and Postnatal Testis Shows Immunoprivilege as Donor Tissue

We evaluated the immunogenicity of the testis by transplanting adult, postnatal, and fetal rat testicular tissue into outbred adult female and male rats for 10 days. Testis grafts were evaluated morphometrically and histologically, and selectively compared to renal grafts previously reported in part. Testis grafts from days 15 to 21 of gestation, and from three, nine, 12 and 15 days after birth showed an overall increase in growth, with maintenance of architecture and minimal lymphocytic infiltrate. In contrast, only fetal renal tissue from days 15 to 17 demonstrated an increase in growth with maintenance of architecture and minimal lymphocytic infiltrate; grafts from later in gestation grew only slightly and showed progressive deterioration in architecture with an increasing lymphocytic infiltrate. Fifteen day fetal testis grafts were also implanted for longer intervals up to 45 days. The fetal testis grafts implanted for 20 and 30 days showed an increase in size with maintenance of architecture and minimal lymphocytic infiltrate. The observed fetal and postnatal testis growth in the non-immunosuppressed adult host makes compelling further studies directed at determining those factors contributing to the decreased immunogenicity of this organ.