Robert T. Soper

Gastric bypass for morbid obesity in children and adolescents

This report reviews 25 patients 20 yr of age or younger who were treated for morbid obesity by gastric bypass or gastroplasty. Eighteen genetically normal obese adolescents averaged 15% body weight loss 6 mo after operation and 25% weight loss 36 mo postoperatively; the eight males lost more weight than did the ten females. Seven younger children had Prader-Willi syndrome; six of them lost weight postoperatively although not so dramatically as the genetically normal obese patients. Four patients required later revisions to reduce the size of the gastric pouch or stoma. These operations were performed with acceptable morbidity and no mortality. Growth in height was not interrupted and no metabolic problems were encountered postoperatively. Gastric bypass is a safe and effective method of controlling body weight in morbidly obese children and adolescents.

Sodium deficit causing decreased weight gain and metabolic acidosis in infants with ileostomy

The records of 11 infants, 25 to 38 weeks gestation, with metabolic abnormalities induced by ileostomy fluid losses were reviewed. At operation for necrotizing enterocolitis (NEC) (9) or meconium ileus (MI) (2), they weighed between 1,100 and 3,100 g and were from one to 41 days old. All developed total body sodium depletion and metabolic acidosis from ileostomy bicarbonate loss. In seven, sodium depletion was severe enough to require supplementation; six initially lost or failed to gain weight despite being fed adequate diet and calories. However, after receiving sodium supplementation (three with NaCl and three with NaHCO3), these six patients gained weight and improved their metabolic acidosis. The other five subjects did not initially receive sodium supplementation. Four gained weight; one of these later received supplemental NaHCO3 for a metabolic acidosis. The fifth patient failed to thrive until his ileostomy was closed. All infants initially had urine Na less than 10 mEq/L and normal serum Na. All infants whose urine Na rose above 10 mEq/L and had serum HCO3- greater than or equal to 20 mEq/L grew adequately. A direct relationship existed between ileostomy output and sodium intake required for growth. This expressed mathematically (Na intake = 1.2 + [0.13 x ileostomy output] shows a basal sodium need (with no ileostomy output) of 1.2 mEq/kg/d and an additional requirement of 0.13 mEq/kg/d of sodium for each mL/kg/d of ileostomy output. We conclude that infants with ileostomies are at extreme risk of total body sodium depletion with resultant metabolic acidosis and inadequate weight gain. These infants require sodium supplementation with a combination of NaCl and NaHCO3.(ABSTRACT TRUNCATED AT 250 WORDS)

Foramen of Morgagni hernia in identical twins : is this an inheritable defect ?

Twins with Downs syndrome, foramen of Morgagni hernias, and similar cardiac anomalies are described. While diaphragmatic hernias are not uncommon, the occurrence of this congenital defect in twins with very similar congenital anomalies raises the possibility that diaphragmatic hernias may result from an inheritable defect.

Creation and repair of diaphragmatic hernia in the fetal lamb: techniques and survival

Diaphragmatic hernias were created in 54 fetal lambs at 72 to 82 days gestation via a left thoracotomy. The diaphragmatic hernia was repaired in 30 lambs at 106 to 123 days gestation, and 14 of these lambs subsequently aborted. The majority of those surviving to term were delivered for survival. Four lambs with an unrepaired diaphragmatic hernia were intensively resuscitated at delivery and their diaphragmatic hernias repaired; survival in these lambs ranged from 20 minutes to 89 hours. Nine lambs with repaired diaphragmatic hernia were resuscitated following delivery; survival times ranged from one hour, 45 minutes to 123 days, with three lambs surviving to be sacrificed at 43, 62, and 123 days. Three of the lambs that died before sacrifice, died of causes unrelated to their lung function. These results show that in-utero repair of the diaphragmatic hernia in the fetal lamb results in improved survival. We feel, however, that direct application of these results in humans would be premature.

Aortosternopexy for tracheomalacia following repair of esophageal atresia: Evaluation by cine-CT and technical refinement

During the period of 1 year (1988 to 1989), five infants, aged 3 weeks to 10 months, presented with recurrent respiratory distress following repair of esophageal atresia with tracheoesphageal fistula (EA/TEF). These patients had associated congenital anomalies, including right aortic arch (1), biliary atresia (1), and a long gap that required esophageal elongation by spiral myotomy (1). The patients were evaluated for tracheomalacia using cinecomputed tomography (cine-CT; C-100 Scanner, Imatron, San Francisco, CA), which provides images of eight levels (8-mm interval) simultaneously with 0.7 second time intervals of cine-CT. Dynamic studies of the trachea by cine-CT showed tracheal collapse that was most significant during expiration in the segment immediately above and at the aortic arch. These patients underwent aortosternopexy. Via a right second intercostal approach, the ascending aorta and aortic arch were lifted anteriorly using two to four sutures of 5-0 Tevdek on pledgets placed between the tunica media and adventitia of the side walls of the aorta and the adjacent sternum. Respiratory distress was significantly improved postoperatively. Preliminary experience with these patients allows us to conclude that (1) cine-CT is a useful technique for diagnosing tracheomalacia; (2) it provides objective indication for its correction by aortosternopexy; and (3) the refined technique in placing sutures on the aorta may reduce the surgical risks of aortosternopexy.

The creation and repair of diaphragmatic hernia in fetal lambs: Morphology of the type II alveolar cell

A model for creating and repairing diaphragmatic hernia in fetal lambs has been developed. Morphometric studies of the type II alveolar cells were carried out in three groups of term lambs. The upper lobes only were sampled. Morphometric analysis of the 30 type II cells from each lobe showed that while there were no differences between the left upper lobe (LUL) and right upper lobe (RUL) cells in normal lambs, there were significant differences between sides in the experimental groups. In lambs with a nonrepaired diaphragmatic hernia (DH) the type II cells were significantly smaller in the LUL compared with the RUL. In lambs with a repaired DH, the LUL type II cells were significantly larger than those in the RUL. There were some trends when the groups were compared, but in general they did not reach statistical significance. These findings suggest that local factors profoundly influence the development of these cells.

Candida osteomyelitis associated with intravenous alimentation

Abstract Since the introduction of intravenous alimentation (IVA) the incidence of fungemia has increased. The treatment of Candida osteomyelitis with 5-flucytosine (5-FC) has not been previously reported.

Magnetic resonance imaging as an adjunct to planning an anorectal pull-through

Magnetic resonance imaging (MRI) is a relatively new diagnostic tool that generates images of sections of the body taken in any plane. We report the use of MRI as a tool to plan surgical procedures in patients with imperforate anus, imaging the pelvis and lumbosacral spine in the sagittal, transverse, and coronal planes. MRI clearly reveals the extent of the pelvic musculature even in patients with severe sacral agenesis. MRI is extremely useful in assessing patients under consideration for reoperation, clearly demonstrating the relationship between the pulled through colon and the striated muscle complex. A very useful addition is the ability, on the same study, to detect previously unsuspected anomalies such as tethered cord, lipoma of the filum terminale, and renal dysplasia. We conclude that MRI is a very useful examination in selected patients with imperforate anus.

The isolated bowel segment (Iowa model II); Motility across the anastomosis with or without mesenteric division

In previous reports, anastomosis has been shown to disrupt the myoelectric activity of the bowel. However, these studies have failed to delineate the role of the extrinsic nerves. Using an isolated bowel segment (IBS) and an amesenteric bowel segment (ABS), motility was evaluated by myoelectric recording across a bowel anastomosis. Ten rats were divided equally into the experimental group with the IBS and the control group with the ABS. In the IBS group, an 8-cm segment of jejunum was divided, reanastomosed, and coapted to the liver margin (Iowa model II). In the ABS group, an 8-cm segment of jejunum was coapted to the liver margin without disruption of bowel continuity (Iowa model II variant). Two weeks later, bipolar electrodes were implanted in the IBS and ABS, and normal jejunum in both groups. Mesenteric division (MD) was performed 4 weeks later to eliminate extrinsic innervation. Myoelectrical recordings were taken 2 weeks before and after MD. In the control group with IBS, incoordination in the propagation of the migrating motor complex (MMC) and reduction in the frequency of slow waves (FSW) were observed across the anastomosis and were unchanged by MD. In the control group with the ABS, the MMC and FSW were identical to that in the normal jejunum and were unaffected by MD. In both groups postprandial inhibition of the MMC was the same as in the normal jejunum and was unaffected by MD. This study confirms that incoordination in propagation of the MMC and reduction in FSW occur across a bowel anastomosis, and elimination of extrinsic innervation does not affect the autonomy of these changes.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic advantages of manual compression fluoroscopy in the radiologic work-up of vomiting neonates

This paper describes a simple and effective fluoroscopic technique that remarkably improves diagnostic accuracy when evaluating vomiting newborns. The technique also minimizes the time of the examination and the radiation dose to the patient and radiology personnel. Several examples are presented illustrating the superiority of gloved hand or nonopaque compression technique to conventional contrast radiography, emphasizing babies with pyloric stenosis and midgut malrotation. The technical limitations and diagnostic pitfalls of conventional contrast modalities are compared to the highly diagnostic images obtained with manual compression fluoroscopy. All of the classic radiographic signs of pyloric stenosis can be mimicked by antral spasm or pylorospasm. Gloved hand compression overcomes antral spasm and clearly shows the true length and diameter of the pyloric canal in these two conditions. Malposition of the duodenojejunal junction is the only consistently diagnostic sign of midgut malrotation. Nonfixation of the duodenojejunal junction can be competently assessed by compression fluoroscopy, confirming malrotation and midgut volvulus simultaneously and bringing the patient to operation much sooner than with less precise conventional techniques. Gloved hand compression technique also evaluates stenotic areas in the upper gastrointestinal tract, distinguishing spasm from organic marrowing and clearly identifying those which need surgical intervention. Facilitating intubation of the duodenum is a final contribution of compression fluoroscopy.