Thoracoscopic esophagomyotomy for achalasia in a child.
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Adolescent↗
Biomedical subjects
N N Jacir
Publications and source records attributed to N N Jacir.
Transanastomotic feeding tubes in repair of esophageal atresia.
To avoid the need for a gastrostomy and parenteral nutrition during the 7- to 10-day healing period after esophageal anastomosis, the authors modified their technique for esophageal atresia repair to include placement of a transanastomotic feeding tube. A SILASTIC transanastomotic feeding tube and early enteral nutrition was used for 19 of 23 consecutively treated patients after repair of esophageal atresia and tracheoesophageal fistula. One of the 19 patients had recurrent fistula and another had an anastomotic leak. Five patients had significant gastroesophageal reflux (noted on barium esophagram), and four had strictures that required dilatation. Parenteral nutrition was necessary for only two patients. The authors conclude that transanastomotic feeding tubes and early enteral nutrition are safe and effective, reduce costs, and do not appear to increase the incidence of anastomotic leaks, strictures, or gastroesophageal reflux.
Catheters, Indwelling↗
Recurrence of immune thrombocytopenic purpura after splenectomy.
Immune thrombocytopenic purpura (ITP) frequently leads to splenectomy. Accessory spleens maybe found in a variety of locations, and may not be readily apparent. Retained accessory splenic tissue can lead to recurrent ITP, which, this report (involving multiple relapses in a single patient) demonstrates.
Adolescent↗
Modification of the "push" technique for percutaneous endoscopic gastrostomy in infants and children.
BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) by the "push" technique avoids peri-catheter infection, repeated insertion of the endoscope, potential esophageal injury from the catheter, and the possible need for another endoscopy for catheter removal associated with the "pull" technique. In small infants, however, the "push" technique could result in loss of gastric insufflation and pneumoperitoneum during tract dilatation. A simple modification of the "push" technique has eliminated this problem. STUDY DESIGN: During a 16-month period, 22 infants and children underwent PEG insertion using our modified "push" technique. These cases were reviewed for patient characteristics including age, weight, indication for the procedure, duration of the procedure, cost, conversion to open technique, and complications. RESULTS: We have used the modified "push" technique to place PEG tubes in 20 infants and children aged four weeks to 15 years (mean, 13 months), weighing 2.7 to 36 kg (median, 6.0 kg), indicated for failure to thrive due to cystic fibrosis (n=3) or neurologic impairment (n=10). These patients have had follow-up examination from nine to 30 months after the procedure. Operative time averaged 15 minutes. The "push" technique was successful in 95 percent of patients with one failure caused by loss of gastric insufflation when Fogarty balloons failed. All PEGs were used within 24 hours. There were no deaths and no peri-catheter infections. CONCLUSIONS: A simple modification of the "push" technique of PEG insertion eliminated problems with loss of gastric insufflation previously encountered in small infants. The modified "push" technique is safe, simple, and quick, obviating potential risks inherent in the "pull" technique when applied in infants.
Adolescent↗
The natural history of meconium peritonitis diagnosed in utero.
The authors reviewed their experience with meconium peritonitis (MP) diagnosed in utero to define criteria for prenatal and postnatal management. Prenatal diagnosis was made by identifying abdominal calcification on serial ultrasound examinations in nine fetuses, between 18 and 37 weeks' gestation. Cases without associated bowel abnormalities were considered "simple MP" and those with bowel abnormalities were considered "complex MP." Five cases of simple MP were identified at 18, 23, 30, 34, and 37 weeks' gestation. These five fetuses were delivered at term and had normal abdominal examinations. Abdominal radiographs were obtained in three showing normal bowel gas patterns, and abdominal calcifications in only two. All five patients were fed uneventfully. Four cases of complex MP were identified at 26, 26, 31, and 31 weeks' gestation. All four fetuses had dilated loops of bowel. Two of the four had meconium cysts, one of which was associated with ascites and the other with polyhydramnios. Shortly after birth both infants with meconium cysts required ileal resection and ileostomy for ileal atresia and ileal perforation, respectively. The remaining two infants had no evidence of dilated bowel, meconium cyst, or ascites on postnatal radiograph and were fed uneventfully. These data suggest that only 22% of fetuses with a prenatal diagnosis of MP develop complications that require postnatal operation. Gestational age at diagnosis does not correlate with postnatal outcome. Fetuses with complex MP are at increased risk for postnatal bowel obstruction and perforation.
Ascites↗
Preoperative chemotherapy in the management of intracaval extension of Wilms' tumor.
Extension of Wilms' tumor into the renal vein and vena cava complicates the operative treatment of a small but significant number of patients. Two children presented with Wilms' tumor and intracaval tumor extension. After biopsy, both children were given chemotherapy. In one case the tumor completely disappeared from the vena cava, and in the other the tumor regressed substantially, and proximal control became possible at the level of the infrahepatic vena cava. Both children then had an uneventful nephrectomy that was greatly simplified. We conclude that preoperative chemotherapy can induce resolution of intravascular tumor, and may be a useful option in cases of extension of Wilms' tumor into the vena cava.
Antineoplastic Combined Chemotherapy Protocols↗
Cystic duodenal duplication: staged management in a premature infant.
Cystic duplication of the duodenum is a rare anomaly of the gastrointestinal tract. Patients may present in early childhood with symptoms of upper intestinal obstruction. Successful, staged management of a cystic duodenal duplication in an 880-g infant is described.
Cysts↗
The desmoplastic round cell tumor: a new solid tumor of childhood.
Three patients with a new, pathologically distinct solid tumor of childhood have been treated recently. The disease is characterized by male predominance, adolescent onset, an extensive abdominal primary tumor, and aggressive metastases to regional lymph nodes, liver, and lung. Two patients presented with vague abdominal pain and the third with testicular pain. All three noted fatigue and malaise of less than two months' duration with minimal associated weight loss. Computed tomography (CT) scans of the abdomen and chest were obtained for initial preoperative staging, and then all three underwent surgical exploration. Widespread disease was found in each case. In no instance was complete tumor extirpation possible because of extensive peritoneal spread and lymphatic and hepatic metastases. Histologically, all three tumors consisted of round blue cells with a dense desmoplastic reaction and focal rhabdoid features. Immunohistochemical markers for epithelial, neural, and muscle elements were positive. Aggressive multidrug chemotherapeutic regimens were used in each case, and all three patients are alive and well but with known residual disease. We conclude that in cases of the desmoplastic round cell tumor of childhood, CT scans underestimate the extent of disease, and exploratory laparotomy is necessary for diagnosis and appropriate staging. Surgery is usually palliative because of extensive spread. Awareness of this newly recognized aggressive solid tumor of childhood is essential to define its natural history and guide the development of effective multidisciplinary therapeutic regimens.
Adolescent↗
Incarceration of inguinal hernia in infants prior to elective repair.
The low morbidity and good results of elective herniorrhaphy in children are adversely affected by incarceration. Since incarceration is a potentially avoidable complication, we reviewed 908 consecutive cases to determine its incidence and consequences in children awaiting elective operation for an inguinal hernia. Eighty-five of the 908 children presented with an incarcerated hernia. Thirty of these 85 patients (35%) were known to have an inguinal hernia prior to incarceration, and 25 of the 30 were awaiting elective hernia repair. The median time from surgical office visit to planned operation was 22 days, but the mean interval from office visit to incarceration was 8 days. Eighty-five percent of the children with incarcerated hernias were infants under 1 year of age. Seventy-one of the 85 patients with an incarcerated hernia (84%) had successful manual reduction. They were all admitted and had a mean hospital stay of 2.5 days. Emergency operation after unsuccessful attempts at reduction was required in the other 14 children, increasing the average length of stay to a mean of 4.0 days. Significant complications, including infarction of the testis or ovary, bowel obstruction, intestinal necrosis, wound infection, and recurrent hernia, occurred in 26 of the 85 children (31%). We conclude that incarceration is a preventable problem. Even patients scheduled for hernia repair are at risk and the operation should be performed soon after the diagnosis is made. Infants are the highest priority group, since 35% of children less than 12 months of age experienced incarceration while awaiting elective surgery.(ABSTRACT TRUNCATED AT 250 WORDS)
Female↗
Simplified "push" technique for percutaneous endoscopic gastrostomy in children.
Percutaneous endoscopic gastrostomy (PEG) by the "pull" technique is the standard method in pediatric patients. Modifications have been reported for adults but few in children. Problems with the "pull" technique including pericatheter infection due to contamination of the tube tract with oral flora, repeated insertion of the endoscope, potential esophageal injury from the catheter, and the possible need for another endoscopy for catheter removal, prompted our interest in a simpler technique. The "push" technique requires insertion of the endoscope only once to insufflate and visualize the insertion site. A modified Seldinger technique is used to insert a 14F acrylic Foley catheter. We have used this technique to place PEG tubes in 8 children age 6 weeks to 17 years (mean, 6 years), for failure to thrive due to cystic fibrosis (3), neurological impairment (4), and undetermined cause (1). Operative time averaged 15 minutes. All PEGs were used within 24 hours. This "push" technique of PEG insertion is safe, simple, quick, and obviates many of the potential risks inherent in the "pull" technique. The "push" technique deserves a more widespread application in children.
Adolescent↗
Experimental volume replacement through lower extremity veins.
Hypovolemic shock was produced in anesthetized pigs by removal of 40% of blood volume over 10 minutes. Following blood loss, the inferior vena cava (IVC) was occluded below the renal veins to simulate the hemodynamics of emergency surgical treatment. Control animals were not treated. Experimental animals received intravenous lactated Ringer's solution equal to three times the blood loss given through catheters either in the IVC or the superior vena cava (SVC) to determine if lower extremity access would be efficacious in this model. To define the path taken by the resuscitation fluids, an additional group of animals received technetium-99m-labelled crystalloid through lower extremity catheters with continuous recording of isotope counts in the IVC and right atrium. The treated animals in all experimental groups had significant improvements in mean arterial pressure, cardiac output, and pH compared with controls. There was no significant difference in hemodynamic response in animals receiving volume replacement through the IVC compared with the SVC. When fluid was infused below a clamped IVC, the arrival of isotope in the right atrium was delayed only 1.5 seconds. We conclude that in a model simulating emergency control of potentially lethal hemorrhage, the beneficial effects of fluid resuscitation are unrelated to the site of venous access. Lower extremity veins provide a valuable site for volume replacement even with IVC occlusion. These findings should have direct application to resuscitation and surgical care of seriously injured patients.
Animals↗
Sutureless hemisplenectomy.
Splenic salvage following blunt injury can fail when parenchymal bleeding is uncontrollable. To define the usefulness of an argon beam coagulator for hemostasis, we used the instrument in a laboratory trial of partial splenic resection. New Zealand white rabbits, weighing 4 to 5 kg, had sharp excision of the lower half of the spleen. No sutures were used to control hemorrhage from the cut splenic surface or the hilar vessels. Hemostasis was achieved with 2 to 4 seconds of electrocoagulation delivered by a beam of argon gas. All animals survived the procedure and were in good health when killed between the fourth and sixth week following the procedure. At necropsy, the spleen was viable in all animals with no abscess or hematoma. Minimal adhesions from the treated splenic surface to the omentum were found. The scar at the cut surface was 1 mm in depth, and the histology of the remainder of the spleen was normal. In this simulated splenic injury model, argon beam coagulation was uniformly successful in achieving hemostasis. Minimal tissue destruction and lack of infection were noted. The argon beam coagulator may be useful in patients with severe splenic injuries and other situations requiring partial splenectomy.
Animals↗
Surgical restraint in Burkitt's lymphoma in children.
Burkitt's lymphoma is a disease of unique cytokinetics that account for the bulky tumors, variety of presenting symptoms, and sensitivity to chemotherapy. A need to ascertain the role of surgery in the treatment of this illness prompted this review. Of nine children 5 to 12 years of age with Burkitt's lymphoma, eight had abdominal involvement. Two of the eight patients also had oral lesions and staging was done by biopsy of the oral lesion and noninvasive imaging of the abdominal tumors. The other six patients presented with abdominal complaints. One of these had diagnostic paracentesis, another had only gastroscopy, and four underwent exploratory laparotomy. The four children in whom the diagnosis was established either by biopsy of an oral lesion, biopsy of an abdominal mass, or resection of an abdominal tumor are alive without evidence of disease 6 months to 6 years after treatment. Each of these children had rapid initiation of chemotherapy. Of the other four who died, two had delayed induction of drug therapy following cytoreduction or gastroscopic biopsy. The best outcomes were associated with prompt chemotherapy. We conclude that except in rare instances in which a solitary lesion lends itself to total or near-total resection, the proper role of surgery is a simple, safe procedure to obtain enough viable tumor for accurate diagnosis and prompt chemotherapy.
Biopsy↗
Pediatric blunt liver injury and coagulopathy managed with packs and a silo: case report.
Packing the abdomen can be lifesaving when severe hepatic trauma is complicated by refractory hypothermia, coagulopathy, and continuing hemorrhage requiring large-volume transfusion. This report describes the successful use of abdominal packs and a modified silo in a child following blunt liver injury.
Accidents, Traffic↗
The development of pyloric stenosis during transpyloric feedings.
Three infants, ages 3 to 4 months, had nasojejunal feeding tubes placed for recurrent aspiration and/or feeding intolerance after upper gastrointestinal cineradiographs (ugi) had documented gastroesophageal reflux (GER) with normal pyloric channels and prompt gastric emptying. The tubes had been in place for 3 and 4 weeks, respectively, in the first two infants when classic hypertrophic pyloric stenosis (HPS) was found during fundoplication and gastrostomy tube placement. The last child had a failed attempt at nasogastric tube feedings following 3 months of nasojejunal tube feedings. A repeat ugi suggested HPS, which was confirmed by pyloric ultrasound. This infant underwent pyloromyotomy alone. The late presentation of HPS in these infants suggests that transpyloric tubes might cause the development of HPS and exacerbate the symptoms of preexisting GER. In infants who are expected to eat by mouth, pyloromyotomy alone might allow the reinstitution of orogastric feedings without the perioperative morbidity of fundoplication and gastrostomy tube placement.
Enteral Nutrition↗
An antireflux procedure for use with the reversed gastric tube.
A study was undertaken to determine whether reflux could be reduced or prevented by creation of a nipple valve at the distal end of a reversed gastric tube. The gastric tube was constructed in standard fashion in six adult dogs. The tube was placed through a substernal tunnel to a cutaneous ostomy in the neck. An antireflux valve was then created by invaginating the lower end of the tube into the gastric remnant. The following observations were made before and after creation of the valve: (1) gastric distending pressure required to produce efflux of saline from the ostomy; (2) manometric pressure at the stomach-tube junction; and (3) 2-hour pH monitoring within the tube after acid infusion into the stomach. The valve shortened the gastric tube by 2.0 to 2.5 cm. It did not obstruct antegrade flow of saline. Prior to creation of the valve, reflux of saline out of the cutaneous ostomy occurred at an average pressure of 62 cm H2O (range 25 to 80). The antireflux procedure prevented reflux with distending pressures up to 200 cm H2O. Manometry revealed an average pressure of 18 cm H2O (range 5 to 25) at the lower end of the tube before creation of the valve. The antireflux procedure raised this high pressure zone to 60 cm H2O (Range 50 to 65) (P less than 0.05). Spontaneous reflux was rarely observed in the anesthetized dog when acid was infused into the stomach and the pH was monitored in the gastric tube. Acid reflux could easily be produced by application of minimal manual pressure to the closed abdomen.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Cholelithiasis in infancy: resolution of gallstones in three of four infants.
Cholelithiasis in infancy is believed to be a rare finding. It is also held that all cholelithiasis in infancy has a predisposing factor such as hemolysis, prolonged fasting, congenital abnormality of the biliary tree, or the administration of TPN and is associated with severe morbidity and mortality. In the last three years, four infants at our hospital have been found on real-time ultrasonography to have gallstones. Their ages ranged from 3 weeks to 6 months. One patient had a hemolytic disease but the finding of cholelithiasis in the other three patients was incidental. A repeat sonogram in the infant with hemolysis three months after initial recognition and one day before scheduled cholecystectomy revealed spontaneous resolution of the gallstones. This led us to a conservative approach in the other three patients. Two more infants had spontaneous resolution of their gallstones and one child, now aged 16 months, is thriving with a persistent asymptomatic gallstone visible on sonogram.
Cholelithiasis↗