Appendicitis masquerading as malignancy.
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Adolescent↗
Biomedical subjects
P D Losty
Publications and source records attributed to P D Losty.
After the honeymoon--medium-term outcome of antegrade continence enema procedure.
PURPOSE: The aim of this study was to determine medium-term outcomes of the antegrade continence enema (ACE) procedure. METHODS: A retrospective casenote review plus telephone questionnaire was conducted. The study was performed at a regional paediatric surgical centre. The subjects were consecutive children undergoing the ACE procedure over a 5 year period. Main outcome measures were use of the ACE; reversal rates; complications, ease of use, effectiveness, and satisfaction scores. Data are expressed as median (range). RESULTS: Thirty-two (52%) of 62 children undergoing the ACE procedure were girls. The age at the time of operation was 11.5 (3.8 to 17.6) years. Underlying diagnoses included spina bifida (n = 31), anorectal malformations (n = 15), slow-transit constipation (n = 9), Hirschsprung's disease (n = 2), sacral agenesis (n = 2), and trauma/tumour (n = 2). Median follow-up was 5.4 (3.25 to 8.25) years. Eleven of 62 (18%) children were no longer using the ACE (n = 5) or had it surgically reversed (n = 6; 14.1 +/- 9.3 months postprocedure). Reasons for disuse/reversal were lack of effectiveness (n = 4), complications (n = 2), noncompliance (n = 3), independent continence (n = 1), and pain (n = 1). Five (8%) children currently have a colostomy. Gender (P =.31; Fisher's Exact), age (Pearson), and underlying diagnoses (P =.07, Chi2) were not predictors of failure. Overall, stomal stenosis was the most common complication, affecting 26 of 62 (41%) children. Of 32 questionnaire respondents to linear scores, ease of use was rated as 2 (0 to 8, 0, very easy; 10, very difficult), discomfort on use as 3 (0 to 9; 0, no pain; 10, very painful), overall satisfaction as 9 (0 to 10; 0, completely dissatisfied; 10, completely satisfied). Eighty-four percent were completely continent or had soiling less than once a month. There was a significant correlation between the level of continence and satisfaction with the procedure (P =.04; Pearson). CONCLUSIONS: The ACE procedure offers significant benefits to some children with incontinence or intractable constipation. However, it is not universally successful, and other continence promoting strategies may need to be considered.
Adolescent↗
Perforated duodenal ulcer disclosing medium chain acyl-CoA dehydrogenase deficiency.
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Acute Disease↗
Occult intraspinal glass injury.
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Accidental Falls↗
Magnetic resonance venography in assessing venous patency after multiple venous catheters.
BACKGROUND/PURPOSE: Venous thrombosis is a well-recognised complication of central venous catheters (CVC). The aim of the study was to assess the value of magnetic resonance venography (MRV) in assessing venous patency in children with suspected venous thrombosis. METHODS: Contrast studies through the CVC (linogram) and Doppler ultrasonography were the initial investigations performed in children with suspected CVC-related thrombosis. Two-dimensional gated inflow and phase contrast MRV also was performed to assess the extent of venous thrombosis and to locate patent veins for replacement CVC. When the MRV identified a suitable patent vein, the CVC was reinserted by direct venous cut down or the percutaneous method under a general anaesthetic. RESULTS: A total of 25 children (median age, 5 years; range, 2 months to 17 years) who had multiple CVC insertions (median, 3; range, 1-9), underwent MRV for suspected venous thrombosis. Of 10 patients in whom the catheter was completely occluded, MRV identified extensive thrombosis of the central veins in 6. In 7 other children the linogram showed adherent thrombus at the tip of the CVC only. In 5 of these 7 children MRV showed extensive thrombosis of the vein in which the catheters were placed. Doppler ultrasonography diagnosed thrombotic occlusion of the neck veins in 7 children. The MRV studies showed more extensive thrombosis in 4 of these 7 patients. Additionally, MRV showed thrombosis of the intrathoracic veins in 11 patients who had patent neck veins on ultrasound scan. MRV identified a patent vein for reinsertion of CVC in 22 of 25 children. At operation, venous patency was confirmed in 20 patients (91%). CONCLUSION: MRV in children with suspected CVC-related thrombosis is more accurate than Doppler ultrasonography, and contrast studies for defining the extent of venous thrombosis. MRV correctly shows venous anatomy and patency for reinsertion of CVC.
Adolescent↗
Trends in the management and outcome of jejuno-ileal atresia.
The aim of this study was to evaluate contemporary patterns of presentation and trends in the management and outcome of newborn infants with jejuno-ileal atresia at a regional paediatric surgical centre in the United Kingdom. The hospital neonatal surgical registry was used to identify patients with jejuno-ileal atresia (n = 83) admitted between 1976 - 1998, excluding those associated with gastroschisis. The clinical records were reviewed and antenatal information, patient demographics, associated anomalies, operative treatment, post-operative management and outcomes were analysed in three time periods to identify trends in management and survival: Group 1 1976 - 1982 (n = 32), Group 2 1983 - 1990 (n = 21), and Group 3 1991 - 1998 (n = 30). Overall survival was 90 %. The number of patients with associated anomalies were Group 1, 10 (31 %); Group 2, 7 (33 %); and Group 3, 11 (37 %). Cystic fibrosis was encountered in 4 (13 %), 1 (5 %) and 4 (13 %) patients, respectively. Resection with primary anastomosis was the definitive management in most of patients: Group 1, 25 (78 %); Group 2, 17 (81 %); and Group 3, 27 (90 %). Initial stoma followed by delayed primary anastomosis was performed in 14 infants; eight patients had divided stomas while 6 had Bishop-Koop stoma. Tapering was used in 10 patients (12 %) with proximal jejuno-ileal atresia. Parenteral nutrition was increasingly utilised over the three time periods studied. There were no deaths in Group 3 compared to 6 deaths in Group 1 and 2 in Group 2 (P = 0.02). Most of the deaths were due to overwhelming sepsis. Mortality did not correlate significantly with the TYPE of atresia, presence of associated anomalies or the need for long-term total parenteral nutrition. The overall complication rate in survivors was 18 %. In the infants undergoing Bishop-Koop operation the complication rate was 50 %. This study has shown a significant reduction in mortality from jejuno-ileal atresia, which may be attributed primarily to advances in perioperative management, including parenteral nutrition. Generous resection of the atretic segment with primary anastomosis is more frequently employed in preference to initial stoma formation. Cystic fibrosis remains an important co-morbid condition that must be excluded promptly in all newborns.
Case-Control Studies↗
Outcome of hypospadias fistula repair.
Objectives To examine the long-term results of hypospadias fistula repair, the factors involved in recurrence and the outcome in cases where this has occurred. Patients and methods The study comprised 113 children undergoing urethrocutaneous fistula repair between 1984 and 1996. Most of the fistulae were closed in two to three layers, with or without a transpositional skin flap. Tunica vaginalis or a scrotal dartos flap was used in patients with inadequate vascularized tissue adjacent to the fistula. Success rates were calculated for each attempt at fistula repair until the patient was cured. Results The median (range) age at primary fistula repair was 40 (18-169) months and the median follow-up after the most recent repair 7.5 (2.3-17) years. The overall success rate of primary fistula repair was 71%. Fistulae which were >2 mm (11 of 21, 52%) were more likely to recur than were those < or = 2 mm (22 of 92, 24%). Recurrence did not relate to the initial form of hypospadias repair, to the means of skin closure nor, with the exception of multiple lesions, to the location of the fistula. The success rates of subsequent repairs were 70% at the second and 50% at the third, fourth and fifth repairs. One child was cured at the sixth attempt. The use of tunica vaginalis or scrotal dartos as a 'waterproofing' layer was limited to the third or subsequent repairs and was successful in five of six cases. Conclusion A simple layered closure with or with no transpositional skin flap is effective in 71% of repairs. For recurrent fistulae, tissues from an unscarred area (tunica vaginalis or scrotal dartos layer) should be used to cover the fistula.
Adolescent↗
Does the developing liver inhibit early lung growth in congenital diaphragmatic hernia?
It has been hypothesised that the liver induces lung hypoplasia in congenital diaphragmatic hernia (CDH) by non-compressive intrathoracic growth rather than traditional mass herniation. Utilising a co-culture system, we tested the capacity of liver cells to inhibit lung growth by contact rather than compression. Heart, liver, and lungs were microdissected from normal rat embryos (n > 20 from at least three litters) on day 13.5 of gestation. Monolayer cultures of enzymatically dispersed livers and hearts were established at the same cell density. Lung primordia were cultured in direct contact with hepatic cells or partitioned from them by a permeable polytetrafluoroethylene membrane. This permits the contributions of diffusable factors and cell contact to be distinguished. Lungs were similarly cultured in direct contact with or partitioned from cardiac cells. Lungs cultured in isolation served as further controls. Daily inspection permitted assessment of in-vitro lung growth. Growth of lungs in direct contact with hepatic cells was equivalent to that of lungs partitioned from liver cells. Lungs in direct contact with cardiac cells and lungs partitioned from cardiac cells were also not inhibited compared to lungs cultured in isolation. Early lung development is thus not inhibited by humoral or contact-mediated interactions with embryonic liver cells. Lung hypoplasia in CDH is therefore unlikely to originate from contact inhibition with the developing liver. An intrinsic pulmonary defect may better explain hypoplastic lung development in CDH.
Animals↗
Classification and risk-factor analysis of infections in a surgical neonatal unit.
BACKGROUND/PURPOSE: Nosocomial infection may result in significant morbidity in surgical neonates. Traditionally, nosocomial infections are classified using time cut-off points. Gastrointestinal carriage of microorganisms has not been used as a criterion for classifying infection in surgical neonates. The aims of the study were to (1) determine the overall infection rate, (2) distinguish between nosocomial and community acquired infections using a 48-hour postadmission cutoff and the carrier state criterion, and (3) determine risk factors for clinical infection. METHODS: A 1-year prospective observational cohort study was undertaken in a regional neonatal surgical unit between 1997 and 1998. All infants residing for >/=3 days in the unit were included in the study (n = 167). Patient demographics, including illness severity (PRISM score), were recorded for all infants. Surveillance throat and rectal swabs were obtained on admission and twice weekly thereafter to determine carrier status. Carriage was defined as isolation of the same microorganism from at least 2 consecutive surveillance samples. Infective episodes were diagnosed if a clinical diagnosis of local or general inflammation was microbiologically proven. RESULTS: A total of 167 infants responsible for 174 admissions were studied. Median gestational age was 38 weeks (range, 24 to 42), median birth weight was 3 kg (range, 1 to 3.6), median age on admission was 8 days (range, 0 to 142), median length of hospital stay was 8 days (range, 3 to 95). The diagnoses were gastrointestinal disorders (n = 96), abdominal wall defects (n = 22), neural tube defects and hydrocephalus (n = 17), thoracic disorders (n = 16), urologic disorders (n = 12), and abdominal tumours (n = 4). Twenty-five infants had 33 episodes of infection giving an overall infection rate of 14.9%. The predominant infecting organism was Stapylococcus aureus (n = 11); others were enterococcus, coagulase negative staphylococcus, Candida spp, Gram-negative bacilli, and anaerobes. A total of 27 of 33 infective episodes were caused by microorganisms carried by the infants on admission (primary endogenous). Only 6 children had "true" nosocomial infections. Using a traditional 48 hour cutoff, 87% of the infections were classed as nosocomial. Birth weight, presence of central venous line, PRISM score, and length of stay were identified as significant risk factors for developing clinical infection. CONCLUSIONS: (1) Carriage allowed us to identify the true nosocomial infection rate (microorganisms acquired in the unit), which was only 18%. In contrast, using a traditional 48 hour cutoff, 87% of the infections would have been classed as nosocomial and warranted unnecessary cross-infection investigations. (2) The results of this study confirm that birth weight, illness severity (PRISM score), presence of central venous catheter, and length of hospital stay were independent risk factors associated with clinical infection in surgical neonates.
Carrier State↗
Use of the gonadal vein in children with difficult central venous access: a novel technique.
In children who require multiple central venous catheterization, the commonly used veins can become thrombosed making central venous access a challenging problem. The authors report on a patient with a rare metabolic disorder who had extensive thrombosis of the superior vena cava and iliofemoral veins, in whom the right ovarian vein was cannulated using a retroperitoneal approach for the placement of a SILASTIC((R)) (Dow Corning, Midland, MI) catheter with an implantable port. This is a useful and reliable technique in children who have difficult venous access.
Catheterization, Central Venous↗
Phenotypic presentation and outcome of esophageal atresia in the era of the Spitz classification.
PURPOSE: The aim of this study was to investigate contemporary patterns of presentation and outcome in newborns with esophageal atresia with or without tracheoesophageal fistula (OA) using modern prognostic criteria to appraise survival. METHODS: Over a 12-year period (1986 through 1997), 134 patients with OA were admitted to a single institution. Patient demographics, the presence of cardiac defects, other associated abnormalities (VACTERL), surgical intervention, and patient outcome were recorded. To identify and evaluate changes in the pattern of clinical presentation, frequency of associated anomalies and outcome, patients were analyzed during 4 consecutive time periods, 1986 to 1988, 1989 to 1991, 1992 to 1994, and 1995 to 1997. RESULTS: A primary repair or delayed primary repair was performed in 113 (84%) patients, with a staged procedure in 19 (14%). Two babies with trisomy 18 did not undergo surgery. Thirty-eight newborns (28%) had a major cardiac malformation (excluding patent ductus arteriosus, unless needing ligation), and 25 (19%) had recognized VACTERL associations. There was a significant increase in the proportion of infants with major cardiac defects diagnosed over the study period, 5 of 34 patients between 1986 and 1988 to 19 of 41 patients between 1995 and 1997 (chi(2) test, P <.001), but the incidence of VACTERL associations remained unchanged. Overall survival rate was 86% in those who underwent surgery. The relative risk of mortality in patients with major cardiac disease and VACTERL associations was 3.47 (95% CI; 1.51 to 7.96) and 2.54 (95% CI; 1.14 to 4.86), respectively. Birth weight was significantly higher in infants who survived (2.68 kg) compared with those who died (2.16 kg, P =.003). Thirty percent of infants with more than one system abnormality died compared with 8% of infants with 1, system abnormality (P =.004). CONCLUSIONS: This study has found a significant increase in the frequency of cardiac abnormalities encountered in a cohort of OA patients during the period under review. Cardiac disease and multiple abnormalities carried a substantial increased risk of mortality. In the era of the Spitz classification, the phenotypic presentation is important to accurately assess caseload severity and prognosis.
Abnormalities, Multiple↗
Umbilical pyloromyotomy--an alternative to laparoscopy?
AIMS: To evaluate the utility of umbilical pyloromyotomy for infantile hypertrophic pyloric stenosis (IHPS) compared to published series promoting laparoscopy. METHODS: Eighty-six babies with IHPS had pyloromyotomy using an umbilical skin fold incision. Operating times, post-operative hospital stay and cosmetic appearance of the umbilical wound were studied. Data extracted from recent series promoting laparoscopy were identified using a MEDLINE search strategy and used for comparative analysis. RESULTS: Mean operating time for umbilical pyloromyotomy was 30 min (range 15-50 min). All patients went home at an average period of 58 h (range 48-72 h) following surgery. The umbilical scar was barely visible in the post-operative period. Laparoscopic pyloromyotomy operating times ranging from 18-41 min (mean overall 30 min) are recorded in the literature. Post-operative stay following laparoscopy has been variable (23-91 h), where reported. In contrast with umbilical pyloromyotomy, "pox" marks observed following port insertions for laparoscopy can give an unsightly scar. CONCLUSIONS: This study has found that umbilical pyloromyotomy can be performed with minimal morbidity and equivalent operating times to laparoscopy. The shorter hospital stay reported in some series promoting laparoscopy must be balanced against local practice influencing hospital stay, the financial implications of offering a laparoscopic service, the skills needed for laparoscopy, and the short learning curve required by paediatric surgical trainees to become proficient at umbilical pyloromyotomy. The cosmesis of the umbilical incision is excellent. These findings suggest that umbilical pyloromyotomy is a reliable alternative to laparoscopy.
Humans↗
Double blind randomised controlled trial of topical glyceryl trinitrate in anal fissure.
AIMS: To determine the effectiveness and safety of topical glyceryl trinitrate (GTN) in the management of acute anal fissure in children. METHODS: Individual children were randomised to receive GTN paste or placebo for six weeks in addition to oral senna and lactulose. Patients took laxatives alone for a further 10 weeks. Each week a research nurse telephoned families to assess pain scores and give advice. Main outcome measures were validated standardised pain scores and time to painless defaecation. RESULTS: Forty subjects were recruited from 46 eligible children; 31 children completed the trial (13 in the GTN group and 18 in the placebo group). No differences in the proportion of those achieving pain free defaecation with relation to time were seen between the two groups. Similarly, there were no significant differences in pain scores between the two groups over the 16 week study period. However, in both groups pain scores had decreased significantly. There were no differences in the incidence of rectal bleeding, faecal soiling, presence of visible fissure, skin tag, or faecal loading at outpatient review at the time of recruitment, or at 6 weeks and 16 weeks. No serious adverse effects were observed. CONCLUSIONS: This study suggests that 0.2% GTN paste is ineffective in the treatment of acute anal fissures in childhood. However the overall fissure healing rate is high (84%) with associated reduction in pain scores, suggesting that a nurse based treatment programme can achieve a high rate of fissure healing.
Acute Disease↗
Heparin and in-vitro experimental lung hypoplasia.
Pulmonary hypoplasia (PH) is a leading contributor to the lethality of congenital diaphragmatic hernia (CDH). Studies now suggest that PH arises prior to visceral herniation. Growth factors (GF) are pivotal to this embryonic lung growth. With striking in-vitro effects on lung morphogenesis, GF are under investigation as therapies for PH. Heparin modulates the kinetics of heparan-sulphate binding ligands that drive lung development. We hypothesised that heparin may rescue PH by favourable alteration of endogenous pulmonary GF activity. Normal and hypoplastic lung primordia were microdissected on day 13.5 of gestation and cultured for up to 78 h in plain media with and without heparin. In-vitro morphological development was studied by serial measurements of terminal bud count, lung area, and lung perimeter. Nitrofen-exposed lungs cultured with heparin showed no significant improvements in terminal bud count, lung area, and lung perimeter at 30, 54, and 78 h compared to untreated hypoplastic lungs maintained in vitro. In normal lungs heparin demonstrated no sustained significant morphological effects compared to untreated control lungs. In this study, heparin did not stimulate branching morphogenesis of normal or hypoplastic lungs in our organ culture system. Known at higher concentrations to inhibit smooth-muscle proliferation, heparin may ameliorate pulmonary vascular hypermuscularisation with the prospect of benefiting CDH infants on extracorporeal membrane oxygenation. Future studies will address the impact of exogenous GF on hypoplastic lung development in organ culture.
Animals↗
Early lung malformations in congenital diaphragmatic hernia.
BACKGROUND/PURPOSE: Lung hypoplasia, a leading contributor to the lethality of congenital diaphragmatic hernia (CDH), has been attributed to compression of the fetal lung by herniated abdominal viscera. Contested findings in experimental CDH suggest that lung malformation may precede diaphragmatic hernia. To address this unresolved question, we studied the pattern and progress of embryonic lung development in vivo and in vitro before diaphragmatic herniation in the nitrofen CDH model. METHODS: Sprague-Dawley rats were fed nitrofen on day 9.5 of pregnancy to induce pulmonary hypoplasia and CDH in newborns (term, day 22). Control rats received olive oil. Embryonic lungs were microdissected on day 13.5 gestation, 24 hours after lung primordia bud from the foregut (normal diaphragmatic closure, day 16.5). In vivo airway branching was measured by counting terminal lung buds at this stage. Lungs were cultured for up to 78 hours and longitudinal in vitro development studied by serial measurements of terminal bud count, area, and perimeter. RESULTS: At 13.5 days of gestation in vivo, nearly 99% of normal lungs (n = 130) had > or = 6 terminal lung buds. In contrast, 36% of the nitrofen-exposed lungs (n = 170) fell short of this developmental milestone with less than 6 terminal buds (P < .001). In vitro, the nitrofen lungs had reduced area compared with controls after 6, 30, and 54 hours (P = .001, P < .001, and P = .001, respectively). Bud count and epithelial perimeter were reduced in the nitrofen lungs after 6 and 30 hours in vitro (P < .001 and P = .01 v normal terminal bud count; P < .001 and P= .002 v normal perimeter). CONCLUSIONS: Before diaphragmatic herniation, nitrofen-exposed embryos in vivo have a 36% frequency of reduced airway branching that strikingly parallels the 30% to 40% term incidence of CDH in this model. The authors propose that this early lung anomaly is restricted to a subset of nitrofen-exposed embryos in which it is integral to an emerging CDH phenotype. In vitro data confirm that nitrofen-induced pulmonary hypoplasia precedes visceral herniation and persists to allow experimental manipulation in culture. The developmental biology underlying lung hypoplasia in CDH may now be addressed using this organ culture system.
Animals↗
Cell proliferation and apoptosis in experimental lung hypoplasia.
BACKGROUND/PURPOSE: Current treatment for lethal pulmonary hypoplasia in congenital diaphragmatic hernia (CDH) may be hampered by uncertainty over its origin. Herniation of abdominal organs into the chest was thought to produce lung hypoplasia by compression. Experimental CDH models suggest that disturbed lung growth precedes these events. Mammalian development comprises cell differentiation, proliferation and programmed cell death or apoptosis. Could lung hypoplasia in CDH result from alterations in these processes well before visceral herniation takes place? The aim of this study was to compare cell proliferation and apoptosis in normal and hypoplastic embryonic lungs before normal diaphragmatic closure using a CDH model. METHODS: Sprague-Dawley rats were given 100 mg of nitrofen on day 9.5 of pregnancy to create lung hypoplasia and CDH in newborns (term, 22 days). Control rats received olive oil. Cell proliferation in embryonic lung specimens was measured by bromodeoxyuridine (BrdU) incorporation at 13.5 to 15.5 days' gestation, before normal diaphragmatic closure in this species (day 16.5). Apoptosis was measured by the in situ end-nick labelling (TUNEL) method in lung sections obtained from rat embryos of 13.5 to 16.5 days' gestation. RESULTS: High levels of cell proliferation were seen in both normal control and nitrofen-exposed lungs. However, 24 hours before normal diaphragmatic closure, nitrofen-exposed lungs had significant reductions in cell proliferation on day 15.5 of gestation (P = .009 v controls). Apoptosis occurred at low levels throughout the developmental stages examined (< 0.3%) without significant differences encountered between the study groups. CONCLUSIONS: These findings have shown high rates of cell division during normal lung development before diaphragmatic closure. Decreased levels over this critical period in gestation may contribute to early lung anomalies in the nitrofen CDH model. Strategies to promote cell proliferation in the fetal lung may therefore hold future promise in human CDH. Apoptosis appears not to play a major role in hypoplastic lung development. Therapies to inhibit apoptosis would seem unlikely to improve this early lung growth.
Animals↗
In vitro effects of growth factors on lung hypoplasia in a model of congenital diaphragmatic hernia.
BACKGROUND/PURPOSE: Pulmonary hypoplasia, a leading contributor to the lethality of congenital diaphragmatic hernia (CDH), precedes diaphragmatic malformation in the nitrofen model and persists to allow experimental manipulations in organ culture. Fibroblast growth factors (FGFs) are crucial to early lung development. Acidic FGF (FGF-1) binds to all FGF receptors and enhances in vitro branching morphogenesis. Basic FGF (FGF-2) is localized to developing airway epithelium, basement membrane, and extracellular matrix. Heparin (HEP) modulates FGF kinetics and inhibits smooth muscle proliferation in lung primordia. The aim of this study was to examine the morphological effects of fibroblast growth factors and heparin on lung hypoplasia in an organ culture model. METHODS: Sprague-Dawley rats were fed nitrofen on day 9.5 of pregnancy to induce lung hypoplasia and CDH in newborns. Control rats received olive oil. Normal and hypoplastic lung primordia were microdissected on day 13.5 of gestation and cultured up to 78 hours in plain media with or without FGF-1 or FGF-2, with or without HEP. In vitro morphological development was studied by serial measurements of terminal bud count, lung area, and lung perimeter. RESULTS: Over 120 fetal lung specimens were studied (n > or = 4 per group). Significant increases in area, perimeter, and bud count were seen in normal lungs cultured with FGF-1 plus HEP compared with control media (P < .05). In the nitrofen lungs, FGF1 plus HEP yielded reductions in all parameters compared with those in control media (P < .05), whereas FGF-2 produced significant expansion in lung area but marked reductions in bud count and lung perimeter divided by square root of area (P < .05). Heparin did not produce substantial or sustained alteration of morphology in normal or hypoplastic lungs. CONCLUSIONS: These observations may indicate an intrinsic abnormality of FGF processing in the hypoplastic nitrofen lung before diaphragmatic malformation. Heparin did not rescue abnormal lung development. Mechanisms underlying the differential effects of these agents now need to be explored to target fetal lung growth and improve the dismal prognosis of human CDH.
Animals↗
Transanal endorectal coloanal surgery for Hirschsprung's disease: experience in two centers.
BACKGROUND/PURPOSE: Transanal mucosal proctectomy with low coloanal anastomosis has been used widely in the treatment of rectal malignancies, ulcerative colitis, and familial polyposis. The use of this technique for Hirschsprung's disease is a relatively new concept. The aim of this study was to evaluate and compare the results of transanal endorectal coloanal anastomosis (TECA) for Hirschsprung's disease from 2 centers. METHODS: All children who underwent TECA for Hirschsprung's disease at Alder Hey Children's Hospital, Liverpool, England from January 1995 to December 1998 (n = 41) and the Children's Hospital, Helsinki, Finland from June 1988 to December 1998 (n = 95) were evaluated. Patient demographics, age at diagnosis, initial management, length of aganglionic segment, and age at operation were documented. Postoperative complications and functional outcome were analyzed. RESULTS: Patient demographics were similar in the 2 centers. Age at diagnosis was less than 1 month in 71% of children at Liverpool, compared with 53% at Helsinki. Sixteen (39%) patients in Liverpool and 75 (79%) patients in Helsinki underwent primary TECA without colostomy. Postoperative enterocolitis occurred in 14 of 136 patients (10%). An ischemic stricture of the colon was documented in 4 children in the Liverpool series, 2 of whom had TECA as a salvage procedure after a previously failed Duhamel pull-through operation. Frequency of bowel movements, seen in the immediate postoperative period in most patients gradually improved with time from a median of 5 (range, 2 to 12) bowel movements a day at 3 months after TECA to 2 (range, 1 to 6) bowel movements a day at 2 years' follow-up. Assessment of continence was possible in 51 of 136 patients (37%) over the age of 4 years. Thirty-nine children had normal bowel function giving an overall success rate of 76%. CONCLUSIONS: Transanal endorectal coloanal anastomosis is a good technique for treatment of Hirschsprung's disease with few operation-related complications. Based on the data emerging from these 2 centers the functional outcome is highly satisfactory and comparable with other established procedures.
Anastomosis, Surgical↗