Susan R. Luck

Intestinal bypass of the esophagus

Esophageal replacement by a segment of isoperistaltic ileum with cecum or by transverse or left colon will allow near-normal swallowing for many years. The authors reviewed the course of 59 children who had bypass of their entire esophagus and of four whose distal esophagus was resected and replaced. The follow-up period ranges from 1 to 37 years; in 36 cases, it exceeds 5 years. Thirty children had caustic strictures and 25 had either isolated esophageal atresia or atresia with fistula. Two children with esophageal injury caused by foreign body ingestion and two with congenital strictures also required complete bypass. Four patients required resection and replacement of the distal esophagus only; two had acquired strictures from gastroesophageal reflux, one had varices, and one had a teratoma involving the esophagus. A retrosternal isoperistaltic ileocolic segment is our preference for complete esophageal replacement. Forty-eight patients underwent esophageal reconstruction with this procedure. The esophagus damaged by caustic ingestion was left in place in all patients, without any subsequent problem. The authors have not used the distal esophagus for anastomosis in patients with atresia, because this segment may be abnormal; and, in any case, an isoperistaltic cologastric anastomosis does not reflux. The right or left colon or jejunum was used in the other cases. Three children lost an interposed intestinal segment from necrosis even though the bowel appeared to be well vascularized at the end of the operation. Each patient had successful reconstruction using another type of interposition. An intrathoracic leak occurred in one infant. A cervical anastomotic leak developed in 11 children, and a stricture in 13. Strictures were more common in patients who had caustic burns. Three patients required surgery for adhesive intestinal obstruction. A redundant colon transplant with ulceration, and the herniation of an ileal segment into the pleural cavity with obstruction prompted reoperation in two other patients. There were two deaths early in the series, one of which was secondary to postoperative respiratory arrest. The other death occurred in a child who had a caustic pharyngeal burn and chronic aspiration. All patients were seen in our office recently, or they or their parents were interviewed by phone. All of them are taking all of their nutrition by mouth. Forty-three of the 61 survivors have had no difficulty with swallowing. One required reoperation to enlarge the thoracic inlet. Seventeen other have mild dysphagia that does not require treatment. The patients with esophageal atresia or atresia and fistula consistently have not grown as well as those who required replacement for an acquired condition or injury.

The spectrum of meconium disease in infancy.

Meconium diseases in infancy cannot be neatly separated into discrete categories of meconium plug syndrome, meconium ileus, and meconium peritonitis; nor can the therapy of each condition. A patient with any of the three may or may not have cystic fibrosis. All babies with any form of meconium obstruction or atresia must have a sweat chloride test to confirm or rule out this diagnosis. Repeated gastrografin enemas can decrease the need for operative intervention in all babies with meconium plug syndrome and in selected babies with meconium ileus. Babies with meconium diseases can now be managed with a low perinatal mortality.

Pneumonectomy in infants and children: The use of a prosthesis to prevent mediastinal shift and its complications*

Twenty cases of pneumonectomy in infants and children performed over a 35-yr period have been reviewed. Pneumonectomy may be necessary for inflammatory, congenital, neoplastic, and traumatic conditions. The postoperative complications of progressive mediastinal shift can be minimized by the use of a pleural prosthesis.

Circular esophagomyotomy for primary repair of long-gap esophageal atresia

Twelve of forty patients (30%) treated for esophageal atresia at the Childrens Memorial Hospital in Chicago between June 1976 and May 1980 required a circular esophagomyotomy with or without upper pouch bougienage to achieve an anatomical repair. Ten patients had a distal tracheoesophageal fistula; 1 had a proximal fistula as well; and 2 had no fistula. Over 40% of the patients were small for gestational age. One half had severe associated anomalies including congenital heart disease in 1/3 and the VATER association in 1/4. Three patients died, all from congenital heart disease. Immediate complications in 6 patients included anastomotic leaks (3), tracheal injuries (2), and mucosal entry at the myotomy site (1). Late complications included symptomatic gastroesophageal reflux (60%), anastomotic strictures (40%), and severe tracheomalacia requiring long-term tracheotomy (20%). Altered esophageal motility (77%) contributed to poor weight gain (less than 3rd percentile) in most patients. In spite of these complications, satisfactory results were achieved in 8 of the 9 long-term survivors. The ninth patient had a turbulent neonatal period and has persistent swallowing difficulties at 36 mo follow-up. Although an anatomical repair can now be achieved in all patients with esophageal atresia utilizing bougienage and myotomy, some ill neonates may be better served by traditional staging techniques.

Caval catheterization in the intensive care nursery: A useful means for providing parenteral nutrition to the extremely low birth-weight infant

We provided parenteral nutrition to 40 very low birth-weight premature infants (birth weight 815 +/- 17 grams, gestational age 27 +/- 2 weeks) with a superior vena cava catheter. To avoid the risk of transport, catheterization was performed under sterile conditions in the intensive care nursery. The central venous catheter facilitated administration of calories to sustain growth, especially in infants whose catheters remained in place for 3 weeks or longer. The overall incidence of catheter related sepsis was high (30%) but the majority of cases were due to Staphylococcus epidermidis and resolved without incident. Other complications of parenteral nutrition were minimal. This approach is a safe and effective means of providing nutrition to the very low birth-weight infant.

The Valved Conduit Prevents Ascending Cholangitis: A Follow-up

Reflux of bacteria-laden intestinal contents into the biliary tree can be prevented by an intussuscepted valve in an isolated segment of jejunum interposed between the porta hepatis and the duodenum. This method of bile duct reconstruction was adopted in 1979 and since then has been used in 17 children with biliary atresia and 9 with choledochal duct cysts. Those with choledochal duct cysts are well. Follow-up HIDA scans demonstrate normal bile flow, and ultrasound examinations have not revealed dilated bile ducts. Bile flow was established in 13 infants with biliary atresia and was persistent in 8. Two expired because of unrelated problems between 2 to 6 months postoperatively. One of these children developed cholangitis, but at autopsy the nipple valve was incompetent. Six children currently have normal serum bilirubin levels and are clinically well. The average postoperative stay for these patients was 7.5 days. Three were rehospitalized for brief periods for suspected cholangitis which was not proven. Bile flow was never established in 4 babies and was present only briefly in 5. Five of these children died of progressive liver failure and one from unrelated causes. Two have had liver transplants, and a third is awaiting transplantation.

Irrigation of the peritoneal cavity for appendicitis in children: A double-blind study

INTRAPERITONEAL ANTIBIOTICS have been used for over 30 Deyr. spite numerous experimental and clinical investigations, their role in clinical peritonitis has not been clarified. A number of retrospective studies have included patients of varying ages with peritonitis of diverse origins. Appendicitis, with generalized peritonitis in children is still a major clinical problem. The benefits of systemic antibiotics in these cases remains controversial and the use of intraperitoneal antibiotics has not been widely reported. At the Childrens Memorial Hospital we have carried out a double-blind controlled study of the effects of intraperitoneal and wound irrigation with kanamycin in cases of perforated appendicitis. METHODS Children with perforated appendicitis and established peritonitis undergoing operation from April 1969 to July 1974 were included in this study. Cultures of peritoneal fluid or pus were obtained on each patient. The use of systemic antibiotics and ~.eritoneal or wound drainage was left to the discretion of the surgeon. Kanamycin and placebo solutions were supplied in numerically coded vials, previously randomized by Bristol Laboratories. These were added to identically coded 500 ml bottles of normal saline by the hospital pharmacy prior to use. Before closure of the peritoneum the peritoneal cavity and the wound were irrigated with either a 0.25% solution of kanamycin or with normal saline. No attempt was made to suction all of the irrigant. A volume of 20 ml/kg of body weight was used up to a maximum of 500 ml. Irrigation with the kanamycin solution delivered 50 mg of drug/kg body weight. Each patient was specifically observed during the intraoperative and postoperative periods for signs of respiratory depression. None exhibited any sign of depression or other evidence of drug toxicity. The postoperative courses of 79 patients with perforated appendicitis were analyzed. This patient population included 37 boys and 42 girls. Nineteen were black, 59 white, and one oriental. Forty-eight per cent were between six and 10 yr of age; 24% were 13 mo to 5 yr; and 28%, 11-16 yr. Wound infections that necessitated the drainage of a primarily closed wound or prevented a planned delayed primary closure were distinguished from wounds showing only prolonged or purulent drainage at sites of peritoneal or wound drains. Localized intra-abdominal abscesses requiring operative drainage have been listed separately from presumed pelvic phlegmons that resolved spontaneously.

Endodermal sinus tumor: a clinical and pathological correlation.

Endodermal sinus tumors occur in the gonads and in a variety of extragonadal locations, particularly as the malignant component of sacral teratomas. Light and electron microscopic studies as well as the presence of alpha fetoprotein support the concept that these lesions arise from germ cells that migrate from the extraembryonic yolk sac. These tumors in all locations are highly malignant and metastasize to lymph nodes, lung, liver and bone. Peritoneal implants are seen from tumors in the ovary, testis, and following ventriculoperitoneal shunts for yolk sac tumors of the pineal gland. There is no satisfactory therapy for the endodermal sinus tumor, regardless of location, when there are distant metastases at the time of diagnosis; however, we have documented complete regression of metastases in one child following therapy with vinblastine, bleomycin, and cis-platinum. Nine of 13 boys with endodermal sinus tumors of the testis survived in this series of patients. All survivors were treated with orchiectomy and lymph node excision. Surgical excision combined with chemotherapy and radiation led to survivors in children with large extragonadal pelvic and retroperitoneal tumors. We recommend vigorous multimodal therapy with surgery and chemotherapy. Radiation is given to the primary lesion when it is too extensive for initial resection or to eradicate residual disease following chemotherapy. Alpha fetoprotein is a valuable tumor marker.

The evolution of a valved hepatoduodenal intestinal conduit

Ascending cholangitis remains among the most serious complications following operations for biliary disorders. The bacterial count of refluxing intestinal contents can be reduced by using an enteric conduit from the biliary tract to the relatively sterile duodenum. A valvular conduit prohibits reflux of intestinal contents and permits unobstructed antegrade flow of bile. This can be created by intussuscepting approximately 1 cm of intestine in the midportion of the conduit. During the last 3 yr, valvular conduits were created in 11 patients. Seven of these children were treated for biliary atresia, and 4 had operations for choledochal duct cysts. There have been no deaths or morbidity resulting from the use of the valvular conduits. The postoperative courses in these patients indicate that the use of an intussusception valve may be beneficial in the prevention of ascending cholangitis.

Transfusion requirements in conservative nonoperative management of blunt splenic and hepatic injuries during childhood

Nonoperative management of splenic and hepatic injuries in children is safe, and the majority of those with isolated injuries do not require blood transfusion. Thirty-seven children were treated for blunt splenic or hepatic trauma from November 1983 to September 1989. There was one death in a patient with a lethal head injury. No operations were performed on those with isolated splenic or hepatic injuries. Three of those with multiple injuries underwent delayed laparotomy. Two had perirenal and retroperitoneal hematomas without active bleeding, and one had a bowel obstruction secondary to an intramural jejunal hematoma. There were no late complications related to the splenic or hepatic injuries. Eight children (22%) required surgery for other injuries. Twelve children were not transfused, including the majority (8/11) of those with isolated splenic or hepatic injury. The hematocrit of four of these children fell to below 28% and this anemia was well-tolerated. Two children with bleeding disorders (factor VIII [antihemophilic factor] and factor XII [Hageman factor] deficiency) did not require packed red blood cells transfusion. Two clinically distinct groups of children received blood transfusions: (1) eight patients with multiple injuries were transfused during initial resuscitation when unstable or during early operation for other system trauma (mean, 62.0 mL blood/kg body weight); and (2) three hemodynamically stable patients with isolated injuries and 14 stable patients with multiple injuries were transfused empirically after initial resuscitation solely because of decreasing blood counts. They received an average of 16.5 and 21.1 mL blood/kg body weight, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)