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Biomedical subjects

L Spitz

Publications and source records attributed to L Spitz.

At least 91 records · Page 5Linked to original sources
PubMed1998

Nissen fundoplication may induce gastric myoelectrical disturbance in children.

BACKGROUND: Recurrent vomiting with failure to thrive is a common problem in neurologically impaired children. Many undergo fundoplication to control the underlying gastroesophageal reflux, but the results of surgery are not always satisfactory, and postoperative retching may be a major problem. Retching is part of the emetic reflex and is associated with nausea, which is itself associated with disturbed gastric electrical control activity, resulting in a gastric dysrhythmia. METHODS: By recording gastric electrical control activity before and after Nissen fundoplication using the noninvasive technique of surface electrogastrography, the authors have shown that (1) Neurologically impaired children with gastroesophageal reflux more commonly have a preexisting gastric dysrhythmia (65% neurologically impaired v 20% neurologically normal children with gastroesophageal reflux, P<.05), (2) Children who retch preoperatively are three times more likely to retch postoperatively, and (3) 25% of neurologically impaired children may start to retch postoperatively for the first time. CONCLUSION: The authors propose that in neurologically impaired children, loss of central inhibitory mechanisms may result in inappropriate activation of the emetic reflex, which may be heightened by antireflux surgery.

Child↗
PubMed1998

Neurovascular morbidity from the lithotomy position.

The lithotomy position is used in pediatric surgery when it is necessary to have simultaneous access to the abdomen and perineum. At the authors' institution, after a prolonged period in the lithotomy position, significant lower limb complications developed in four patients. Two patients with Hirschsprung's disease underwent a redo Duhamel procedure, one had an anorectal leiomyoma excised, and one had an ileoanal anastomosis for ulcerative colitis. Sciatic nerve injury developed in two patients and deep venous thrombosis and bilateral compartment syndrome resulting in myonecrosis developed in one each. There is an association between operations that require prolonged lithotomy position and the development of postoperative neurovascular complications. By placing the child in the lithotomy position only when access to the perineum is required, these significant injuries may be avoided.

Adolescent↗
PubMed1998

The ontogeny of innervation of the human pylorus.

PURPOSE: The aim of this study was to document the vagal innervation and expression of neuropeptides, neuronal nitric oxide synthase (nNOS), and neural cell adhesion molecule (NCAM) in the neuromuscular system of the developing human pylorus. METHODS: Specimens of human pylorus (n = 54; age range, 8 weeks' gestation to 6 months postnatal) were studied. Vagal innervation was determined by Dil autofluorescence. A wide range of neuropeptides, NCAM, and the neural isoform of NOS were examined by immunohistochemistry. RESULTS: Vagal innervation was first recognized in the myenteric plexus in the 12-week-old fetus as was vasoactive intestinal polypeptide (VIP) expression. Neuropeptides were present from 8 weeks' gestation and appeared to be expressed progressively from the adventitia toward the mucosa and showed an adultlike profile by 23 weeks' gestation. A craniocaudal pattern of expression was noted for VIP and nNOS. Alpha smooth muscle actin was expressed by muscle fibers of the muscularis propria from 8 weeks and the muscularis mucosae by 14 weeks. All the isoforms of NCAM examined were expressed from 8 weeks in the muscularis propria and by 12 weeks in the submucosa. CONCLUSION: The expression of the antigens studied correlated with the gestational age and development of the pylorus.

Embryonic and Fetal Development↗
PubMed1998

BAPS prize lecture: New insight into mechanisms of parenteral nutrition-associated cholestasis: role of plant sterols. British Association of Paediatric Surgeons.

BACKGROUND PURPOSE: Infants on long-term parenteral nutrition frequently will have progressive cholestatic liver disease, the cause of which remains largely unknown. The aim of this study is to establish a possible role for plant sterols (phytosterols) in the pathogenesis of parenteral nutrition-associated cholestasis (PNAC). METHODS: Two experimental studies were used: (1) A study on neonatal piglets involved the daily injection of plant sterols; measurement of their concentrations in serum, liver, and bile during a 14-day period; and determination of serum bile acid concentrations, bile acid secretion, and bile flow at the end of the 14-day period. (2) Isolated rat hepatocyte couplets were used to study the effects of sterols on canalicular secretion. RESULTS: The daily injection of phytosterols (in amounts similar to those given to infants who receive parenteral nutrition) led to their progressive accumulation in the piglets' serum, liver, and bile. Serum bile acid levels were significantly higher in the sterol-treated piglets. Maximal bile acid excretion was significantly lower in the sterol group. Phytosterols caused a significant inhibition of secretory function in isolated rat hepatocyte couplets. CONCLUSION: Important contaminants of commercial lipid emulsions (phytosterols) have been identified as a possible cause of PNAC.

Animals↗
PubMed1998

Primitive neuroectodermal tumours: anatomic location, extent of surgery, and outcome.

BACKGROUND/PURPOSE: Primitive neuroectodermal tumours (PNET) are rare tumours sharing similar histology, immunohistochemistry, and cytogenetics to Ewing's sarcomas. The aim of the study was to document the effect of site of origin and the completeness of surgical excision on the outcome in infants and children with PNET. METHODS: All patients (n = 26) with PNET treated in our hospital during the last 6 years were included in the study. The diagnosis was based on the histopathologic findings and a positive MIC2 antibody test. The tumours were classified according to the Intergroup Rhabdomyosarcoma Study III, and were treated according to the UKEESG protocol for Ewing's Sarcoma. RESULTS: Complete remission (CR) was achieved in 52% of the patients completing their chemotherapy. Overall, survival was 42% (11 of 26). Tumours from the paraspinal and scapula areas responded relatively well (CR, 83%), whereas abdominal PNET did not respond to treatment. Tumours arising from the head, neck, or chest had an intermediate prognosis (37% survival). Three of the 10 patients who had a complete excision of the tumour died of progressive disease. CONCLUSIONS: Complete surgical excision reduced the risk of local recurrence but did not prevent metastatic spread. These data indicate that PNET have a worse prognosis and different favourable sites than other sarcomas. New treatment strategies are necessary for these rare tumours.

Abdominal Neoplasms↗
PubMed1998

The failure rate of surgery for gastro-oesophageal reflux.

PURPOSE: The aim of this study was to document the presenting symptomatology and radiological findings of failed fundoplication, to determine the risk factors involved in recurrent gastro-oesophageal reflux, and to assess the results of revisional surgery. METHODS: Sixty-six patients requiring redo fundoplication during the past 15 years were studied. Sixty children had their initial fundoplication performed at our institution. RESULTS: The median time from initial fundoplication to the diagnosis of failure was 1.5 years. The main presenting symptoms were severe retching (n = 33), recurrent vomiting and aspiration (n = 26) and intolerable gas bloat (n = 7). Severe dysphagia occurred in two children with tight Nissen fundoplications. Contrast radiographic studies demonstrated fundoplication failure and correlated with the operative findings in 85% of cases. Risk factors for failure comprised hypertonic cerebral palsy, severe learning difficulties, oesophageal atresia, CHARGE syndrome, and tracheomalacia. The cause for the fundoplication failure included herniation of the fundoplication into the posterior mediastinum (failed crural repair, n = 30), disruption of the wrap (n = 10), combination of herniation and disruption (n = 22), and a tight wrap (n = 4). After revisional surgery, 13 children had persisting symptoms, five of whom underwent a third antireflux procedure. CONCLUSIONS: The predominant cause of fundoplication failure is herniation into the posterior mediastinum, which occurred most frequently in children with hypertonic cerebral palsy. This may be prevented by meticulous attention to accurate apposition of the crura at initial procedure. Redo fundoplication failed to resolve the preoperative symptoms in 20%, with five children requiring a third fundoplication.

Child↗
PubMed1998

Percutaneous endoscopic gastrostomy in paediatric practice: complications and outcome.

PURPOSE: The aim of this study was to establish the morbidity and mortality of percutaneous endoscopic gastrostomy (PEG) in a tertiary referral paediatric practice and to identify risk factors for developing complications after a PEG. METHODS: The medical records of all patients who had a percutaneous endoscopic gastrostomy attempted over a 5-year period (1990 to 1995) were reviewed. RESULTS: One hundred thirty percutaneous gastrostomies were placed in 120 paediatric patients. Indications for insertion were inability to swallow (n = 74, of which, 52 were neurologically impaired), inadequate calorie intake (n = 30), special feeding requirements (n = 12), continuous enteral feeding in short gut (n = 2), and malabsorption (n = 2). All the children had complex medical problems, and 80% of the patients were rated as "high risk" for general anaesthesia (> or = ASA grade 3). Major complications developed in 21 children (17.5%) and minor complications in 27 (22.5%). Of the 17 children in whom gastroesophageal reflux (GOR) became symptomatic, 10 required a Nissen fundoplication. Nine of these 10 children were neurologically impaired (19% of the neurologically impaired children). One postrenal transplant patient on immunosuppression died 54 days after the procedure of intraabdominal sepsis. Thirty-one patients required secondary surgical procedures. CONCLUSIONS: PEG is associated with significant morbidity. Neurologically impaired children are at risk of acquiring symptomatic GOR, but the risk does not warrant routine fundoplication. Major complications are common and need urgent surgical consultation with many requiring secondary surgical procedures. PEG in paediatric patients should be considered a major surgical undertaking.

Child↗
PubMed1998

Elective partial splenectomy in childhood.

BACKGROUND & PURPOSE: The indications and results of elective partial splenectomy in children remain uncertain. The aim of this study was to determine (1) the indications for elective partial splenectomy (EPS), (2) the extent of splenic resection, and (3) the complications of EPS. METHODS: Patients who underwent EPS from three centers over a 10-year period (1986 through 1996) were studied. Variables analyzed included clinical presentation and indications for EPS, extent of resection performed, perioperative transfusions, and complications. Postoperatively, splenic viability was determined by regular Doppler ultrasound scan and splenic function on peripheral blood film analysis. RESULTS: EPS was attempted in 12 children for various conditions: giant epithelial cyst (n = 6), hypersplenism and metabolic disease (n = 4), pseudotumor (n = 1), and abscess (n = 1). One procedure was converted to total splenectomy because of thin splenic tissue around an infected giant cyst. No child required transfusion for splenic bleeding. There were no postoperative complications or deaths. Only 7 of the 12 children received prophylactic preoperative immunisation. In the 11 successful cases splenic remnant viability remains confirmed by ultrasound scan and normal blood film. There has been no significant splenic regrowth or recurrent hypersplenism in the four children with metabolic disorders. CONCLUSIONS: EPS is suitable for benign splenic conditions and can be performed without major blood loss. Preoperative vaccination is advisable. Up to 95% of the spleen can be safely removed, basing the blood supply of the residual spleen tissue on peripheral polar vessels, with adequate postoperative function.

Adolescent↗
PubMed1998

Urological problems in conjoined twins.

OBJECTIVES: To review the urological abnormalities in conjoined twins, a rare congenital abnormality arising from an incomplete separation of a pair of monozygotic twins, and who can be joined from the head to the pelvis with varying degrees of union. PATIENTS AND METHODS: The records and urological anomalies of conjoined twins presenting from 1985 to 1995 were reviewed retrospectively and the management and surgical reconstruction described. RESULTS: Seven of 11 sets of conjoined twins underwent surgical exploration. Complex urological problems occurred in all twins with omphalo-ischiopagus. The urological anomalies were: Set 1; both twins had one lateral crossed fused renal ectopia with uncrossed ureters draining into a single bladder with one urethra. They had one set of genitalia. Each twin received one crossed fused ectopic kidney, half the bladder and genitalia, with one retaining the urethra and one a vesicostomy. Set 2; these twins had four kidneys (two lateral and two central that were fused), four ureters (two of which crossed) and these drained into two sagittal bladders that emptied by one urethra associated with a single set of external genitalia containing three corpora cavernosa. At separation, the crossed ureters were re-routed, each received a bladder and the genitalia were split. Set 3; there were four kidneys with two crossed ureters draining into two collateral bladders, there was a partial duplication of the urethra and a single hypospadiac penis. After separation, each had kidneys draining into a bladder, one received the urethra and external genitalia, and one a urostomy. CONCLUSION: Complex urological problems occur in conjoined twins, although restricted to those with pelvic fusion (ischiopagus). Assessment and treatment needs to be individualised and overseen by a surgeon with experience in complex urology.

Child, Preschool↗
PubMed1998

Peritonitis following percutaneous gastrostomy in children: management guidelines.

BACKGROUND: To establish the incidence, timing and outcome of peritonitis following percutaneous gastrostomy (PEG) insertion in children. METHODS: Patients developing peritonitis after PEG insertion during a 5-year period (1990-95) were identified. Variables analysed included clinical presentation, management, operative findings and outcome. RESULTS: One hundred and twenty paediatric patients received 130 PEG in the 5-year period. Eight children developed peritonitis: 4 within 24 h of PEG insertion and 4 following routine PEG tube change (3-18 months later). All four patients developing early peritonitis underwent laparotomy in whom three had sustained major damage to adjacent viscera. The fourth patient had a negative laparotomy, but died from continued overwhelming sepsis. All four patients who developed peritonitis after a routine tube change underwent a tube contrast study. In two children a gastrocolic fistula was identified and surgically repaired. Contrast studies in two patients detected an intraperitoneal leak. This problem resolved with conservative management in both cases. CONCLUSIONS: Peritonitis immediately following PEG insertion is rarely due to the air leakage during insertion (benign pneumoperitoneum) and warrants early laparotomy to identify and correct the likely associated visceral trauma. Following PEG tube change peritonitis may result from stomal separation or tube malposition and an urgent study is indicated to identify the cause.

Child↗
PubMed1997

Surface electrogastrography in children with esophageal atresia.

Surface electrogastrography was performed in 18 patients with esophageal atresia (EA) and 10 normal controls to investigate the possible role of a congenital enteric nerve defect as a cause of gastroesophageal reflux (GER), which is common after repair of EA. The means of the dominant frequencies and ranges of the frequency distribution were compared. The dominant frequencies (0.047+/-0.007 Hz) in the EA group did not differ significantly from those of the controls (0.050+/-0.007 Hz, P >0.1), although 2 patients had bradygastria and 2 had tachygastria in the EA group. The range of the frequency distribution was significantly wider in the EA group compared with normal children (P = 0.002). The wide frequency distribution in children with EA suggests disturbed electrical activity of the stomach, which could be associated with poor electromechanical coupling and, hence abnormal gastric contraction.

Child↗
PubMed1997

Separation of thoraco-omphalopagus conjoined twins with complex hepato-biliary anatomy.

This report describes separation of thoraco-omphalopagus conjoined twins and management of the hepatobiliary complications that ensued. The livers were fused and, although both infants had gallbladders, the extrahepatic biliary trees were fused. After separation, obstructive jaundice developed in one twin and she required a biliary diversion. The other twin had an external biliary fistula that only closed after resection of a segment of liver with no connection to the ipsilateral biliary tree. Closure of the abdominal wall defects with biodegradable patches proved very satisfactory and eliminated the problems with persistent wound sinuses related to nonabsorbable mesh.

Abdomen↗
PubMed1997

Idiopathic constipation in childhood is associated with thickening of the internal anal sphincter.

This study was undertaken to search for a rational basis for the use of anal dilatation and internal sphincterotomy as the treatment for chronic intractable constipation in children. Sixteen children, age 5 months to 13 years, who had constipation resistant to conservative treatment were compared with 39 age-matched controls. History and current symptoms were assessed using a standard questionnaire. Internal and external and sphincter morphology was assessed on clinical examination and by anal endosonography, using a 10-MHz rotating endoprobe to provide accurate measurement of the various components of the anal canal. The control group showed a linear correlation between the thickness of the internal anal sphincter and both age and weight, increasing from 0.4 mm in infancy to 0.9 mm in adolescence. Children who had constipation displayed significant thickening of the internal sphincter (range, 0.5 to 1.9 mm, P = .005) which was independent of the length of the history (P = .103). There was no difference in the morphology of the external anal sphincters between the groups. The finding of a hypertrophied internal anal sphincter could provide a rational basis for anal dilatation and internal sphincterotomy as treatment for idiopathic constipation.

Adolescent↗
PubMed1997

Abnormalities of neuropeptides and neural markers in the esophagus of fetal rats with adriamycin-induced esophageal atresia.

BACKGROUND/PURPOSE: To investigate the distribution of neural markers and neuropeptides in esophageal atresia (EA). METHODS: A fetal rat model with Adriamycin-induced EA was used. The animals were divided into four groups: (1) control group, (2) saline-injected group, (3) Adriamycin administered but without the development of EA, and (4) Adriamycin-induced EA group. Specimens of the distal esophagus from each group were immunostained using antibodies to S100, protein gene product 9.5 (PGP), somatostatin, vasoactive intestine peptide (VIP), bombesin, galanin, substance P, neuropeptide Y (NPY), calcitonin gene-related product (CGRP), met-encephalin, nitric oxide synthase, and tyrosine hydroxylase. RESULTS: The total cross-sectional area of the distal atretic esophagus was significantly smaller than controls (P = .01), the submucosa being the component most affected (0.0465 v 0.0234 mm). Immunoreactivity for S100 and galanin were significantly elevated in the atresia group (0.0288 v 0.0079 and .001 v 0.000). In addition, there was also an increase in CGRP and Substance P in the atretic group. CONCLUSION: The elevated levels of S100 and galanin could explain the disordered motility observed in patients who had esophageal atresia.

Animals↗