Endoscopic treatment of congenital H-Type and recurrent tracheoesophageal fistula with electrocautery and histoacryl glue.

OBJECTIVE: Congenital H-Type tracheoesophageal fistulae (H-Type TEF) and recurrent fistulae after primary repair of esophageal atresia represent a difficult problem in diagnosis and management. The treatment traditionally involved an open technique via a cervical or thoracic route, approaches with high morbidity and mortality rates of up to 50%. Endoscopic closure of fistulae has been reported with various techniques such as tissue adhesives, electrocautery, sclerosants and laser. However, the published case series contain a small number of patients with usually short-term follow-up. The aim of this paper is to present the experience of a decade at Toronto's Hospital for Sick Children, using diathermy and histoacryl tissue adhesive and discuss the indications and limitations of this technique. METHODS: Since 1995, 192 patients have been managed in this institution with tracheoesophageal fistulae of which 10 patients have been treated endoscopically. The fistulae were both of H-Type and recurrent tracheoesophageal fistulae following surgery for esophageal atresia and fistula division. One fistula occurred following trauma. The procedure was undertaken under general anesthesia in the image guided therapy suite under fluoroscopic control. Flexible ball electrocautery and injection of histoacryl glue were used either on their own or in combination. RESULTS: Fistula closure was achieved in 9 out of 10 fistulae. Four patients had a second endoscopic procedure. No major respiratory or other complications were encountered in association with the procedure. Follow-up has been between 3 months and 9 years. CONCLUSION: We conclude, endoscopic treatment of tracheoesophageal fistulae with electrocautery and histoacryl glue has been a safe and successful technique of managing H-Type and recurrent tracheoesophageal fistulae. In this paper, we discuss the indications and the surgical steps of the procedure. We highlight that diathermy should be carefully controlled and applied preferably in the small non-patulous fistulae. A fistula that has not closed after two endoscopic attempts is not suitable for further endoscopic treatment and therefore an external approach should be recommended.

Gastric perforation attributable to liquid nitrogen ingestion.

Despite the widespread use of liquid nitrogen in medicine and industry, there are only a few reports of injuries associated with its use. We report a case of a 13-year-old boy who developed gastric perforation after liquid nitrogen ingestion. This is a previously unreported complication.

Polymer membrane covering of eviscerated bowel in neonate.

When a siliconized nylon pouch prematurely separates leaving incompletely covered bowel, a difficult if not urgent problem develops. To reapply a new pouch is to invite infection and further separation. In two such instances, we have applied a new polymer membrane to the dome of bowel partly covered with some granulations. This method avoids further emergency operations and hastens the formation of a ventral hernia. Within seven to 14 days, the exposed peritoneal contents were covered with granulations. This polymer membrane seems to have all the benefits of a biological dressing under which it aids the more rapid growth of granulations.

Infected thymic cyst: an unusual cause of respiratory distress in a child.

A 15-month-old male developed acute respiratory distress following a prolonged upper respiratory tract infection. Laboratory and radiological investigations suggested tracheal compression by a malignant anterior mediastinal mass. Following a short course of steroid therapy, urgent exploration of the mediastinum and resection of the mass was carried out; resolution of the airway obstruction was obtained. Histological and bacteriological examination of the lesion revealed it to be a thymic cyst infected by Haemophilus Influenzae with abscess formation. The causes of tracheal compression in childhood are discussed.

Traumatic bronchial injuries in children.

Between 1975 and 1981 five children (three girls and two boys) from 3 to 11 years were treated for blunt chest trauma with major tears in two areas of the right main bronchus. All were hit or run over by motor vehicles and were in acute respiratory distress. All suffered right pneumothoraces; three did not respond to a chest tube with suction. Four of five children had subcutaneous emphysema, and two had fractured ribs on the ipsilateral side; three children also had contralateral chest injuries. Four had major extrathoracic injuries. Three children required early repair, while two needed late treatment. All five patients recovered well and have remained healthy from 5 to 10 years after injury. These cases serve as illustrations for a review of a survey of the literature.

Divided loop colostomy that does not prolapse.

A loop colostomy in infants and children is usually temporary, made through a small abdominal incision, and frequently prolapses its distal limb within months of its construction. Once this prolapse occurs, its permanent reduction is hardly ever achieved. On the other hand, the colostomy that is made at the time of a major laparotomy and the colostomy whose limbs are brought out through separate abdominal wall openings, rarely prolapse. The advantage of the loop colostomy over the latter two types is that it is easier to make and easier to close. Within the last 3 years, 13 infants and children received a form of loop colostomy that way easy to construct, easy to close, and did not prolapse between these two procedures. The loop colostomy (right transverse in all instances) was brought out through a small right upper quadrant transverse rectus cutting incision, and after the fascia was closed on either side of the colon loop, the latter was divided with the distal stoma tunnelled under the skin about 2.5 cm to the left and sutured to a second skin opening with interrupted 4-0 Dexon sutures. The proximal stoma was sutured to the original skin incision in a similar fashion. Function of this modified loop colostomy was no different, and neither the stomal therapist nor the parents had any trouble caring for this double type of colostomy opening. The closure was not any more difficult. Both stomas were mobilized through one longer than usual transverse incision, trimmed off, and the usual end-to-end colostomy anastomosis was made either extraperitoneal or intraperitoneal.

Residual problems in chest donor sites after microtia reconstruction: a long-term study.

The rib cartilage has been the most popular autogenous tissue for microtia reconstruction. In this study, 88 chest donor sites were evaluated in 80 patients examined in the outpatient clinic at least 1 year after tissue removal. Microtia reconstruction usually was initiated between the ages of 2 and 3 years (42 percent), at which time an axial half of the sixth rib was harvested along with all of the seventh and eighth rib cartilages with their attached perichondrium. During this procedure, there were 19 uneventful pleural perforations (22 percent), and early in the series, 2 patients (2 percent) required a chest tube. Postoperative atelectasis without evidence of pneumothorax occurred in 7 patients (8 percent). Chest scars were classified by impartial observers as excellent (25 percent), good (33 percent), acceptable (28 percent), and poor (14 percent). Better scars were experienced in the cold-knife group than in incision by electrocutting. The younger group and the longer postoperative interval group showed better chest scars. Chest topography deformities were rated as normal (75 percent), mild retrusion (19 percent), and severe retrusion (6 percent). Costal margin contours improved as the postoperative interval lengthened.

A ten-year experience with the pediatric Kock pouch.

In 1981, a five-year experience with the pediatric Kock pouch was reported. This series has now increased to 20 patients with an overall experience of 10 years. There were 12 females and eight males ranging in age from 13 to 19 years. These pouches were all elective: 18 were converted from standard ileostomies, (six with proctectomy or Hartmann procedure), and two had a total proctocolectomy. Three of these conversions were for failed Swenson, Soave, and Duhamel procedures. Sixteen children had ulcerative colitis, three Hirschsprung's disease (one with colon atresia and imperforate anus with rectovaginal fistula), and one colonic polyposis (Gardner's syndrome). None had Crohn's disease. The 100% follow-up shows that 19 of the 20 teenagers have been followed for more than 1 year. The most important conclusions from this 10-year review of 20 teenage Kock pouch patients are (1) this continues to be a difficult operation with a significant potential for complications. (2) After 15 months, there is a very small incidence of nipple valve and outflow tract problems, but the possibility of pouchitis remains between 15 months and 5 years. (3) After 5 years, the chances of any kind of a problem with the Kock pouch are minimal. These children are all well, continent, happy, and back to a virtually normal life that includes marriage and pregnancy. The pediatric Kock pouch continues to be a reasonable alternative for the appropriate teenager, when a standard ileostomy is not desired and/or a pelvic pouch is impossible. It must be done by a surgeon with the necessary interest and experience. Long-term follow-up is essential.

Torsion of an undescended intraabdominal benign testicular teratoma.

A 4-year-old well boy was seen because of an asymptomatic left testicle undescended since birth; the testis was not palpable and the right side was normal. After an episode of left lower quadrant and left hip area pain, with some bladder symptoms and left leg limping, a work-up including a CAT scan showed a calcified retroperitoneal pelvic tumor on the left side. At laparotomy, an infarcted mass was found in the pelvis just above the internal ring. It was a torsion of an undescended intraabdominal testis with a benign testicular teratoma. The tumor was removed and his recovery was uneventful.

Gastric tubes in children with caustic esophageal injury: a 32-year review.

PURPOSE: Caustic injury to the upper aerodigestive system with scarring of the pharynx, hypopharynx, and esophagus is a challenging reconstructive problem. The author has used the gastric tube for this purpose for three decades. METHODS: During the last 32 years (1965 to 1996 inclusive) the author treated 11 patients who required esophageal replacement with a gastric tube conduit, which was anastomosed to the cervical esophagus. At the time of injury, ages ranged from 2 months to 13 years (mean, 3 years) in seven boys and four girls. Time from injury to esophageal replacement was 12 months to 14 years (mean, 5 years). All 11 had multiple dilations before the replacement. Two had injury and scarring of the epiglottis and larynx that required pharyngeal reconstruction and tracheostomy before replacement. Nine patients underwent reconstruction with a gastric tube anastomosed to the cervical esophagus, and the other two had an interposition with an intrathoracic anastomosis. Eight tubes were antiperistaltic and three isoperistaltic. Seven tubes were placed in the retrosternal space, three were transthoracic, and one was subcutaneous. Six tubes were completed in two stages and five in a single stage. RESULTS: Nontube complications were wound infection (n = 2), perforation (n = 2), paralyzed hemidiaphragm (n = 1), and recurrent laryngeal nerve injury requiring tracheostomy (n = 1). Tube complications were anastomotic leak (n = 9), stricture (n = 8), anastomotic resection (n = 3), ulcer (n = 1), and perforation (n = 1). Six required posttube multiple dilations for several years including self-bouginage (n = 2). All learned to swallow and eat initially with minimal aspiration; only one remains on tube feed supplements. Long-term follow-up (3 to 30 years) includes nine eating normally and not requiring dilations (the tracheostomy boy has chronic lung disease), one lost to follow-up after 1 year, and one death from tube hemorrhage 2 months after operation. CONCLUSION: Children with caustic injury to the upper aerodigestive system can undergo gastric tube replacement with good results. The majority of the problems relate to the esophagogastric tube anastomosis.

Leading points in childhood intussusception.

Children whose intussusception is caused by a specific pathologic lesion are harder to diagnose and have a higher morbidity than those with the idiopathic variety. We have collected and analyzed 31 such cases found in a series of over 500 intussusceptions. The average age of these children was greater than is usually found in most cases, and the duration of the signs and symptoms was also longer than is usually seen. Almost 50% presented with a picture of advanced small bowel obstruction. Fewer barium enemas were done (50%) and none was successful in reducing the intussusception. There was a higher number of ileo-ideal intussusceptions in this group. The commonest leading points were Meckel's diverticula, polyps, and duplications. All patients with leading points required operation; three-fourths had a bowel resection performed. This study of 569 cases suggests that older children with intussusception and children with recurrent intussusception do not necessarily have leading points causing their intussusceptions.

Recurrent intussusception in children.

Twenty-eight children with 35 recurrent intussusceptions were collected and analyzed from a series of 600 intussusceptions over 17 yr. The overall recurrence rate in the entire series was 5% with 11% recurring after hydrostatic barium enema reduction, and 3% after operative reduction. Twenty-three children had one recurrence each, four children had two recurrences, and one child had four recurrent intussusceptions. More than two-thirds of the patients had a recurrence within 6 mo of their first intussusception, and half of these presented earlier and with fewer signs and symptoms than the previous attack had manifested. Twenty-one of 30 recurrences were reduced with barium enema. Sixteen were operated on, reducing nine manually and resecting four others. Only two leading points were found, and in both instances resection was required. All but two of the intussusceptions were ileocolic. The previous mode of reduction of each intussusception did not set a trend for future treatment of recurrent intussusceptions in the same child. While operative reduction diminishes the chances of a recurrent intussusception and ileocolic resection eliminates it, there does not seem to be any indication for surgery as long as barium enema reduction is successful. We have never observed the hydrostatic reduction of an intussusception caused by a leading point.

Five years of the pediatric Kock pouch.

Since 1976, 16 teenagers at the Hospital for Sick Children, Toronto, have had a Kock pouch constructed. This group consists of 10 females and 6 males ranging in age from 13 to 19 yr. These were all elective pouches: 9 were converted from standard ileostomies, 5 were converted along with proctectomy or Hartmann procedure, and 2 had total colectomies along with a Kock pouch. Two of these conversions were for failed Swenson and Soave procedures. The complications directly related to the Kock pouch were stoma stricture, prolapsed nipple valve, long outflow tract, fecal fistula, salt loss, slipped nipple valve, chronic small bowel obstruction, and "pouchitis." These 8 complications required a total of 16 operations to correct (1.4 operations per patient). The 100% follow-up shows all but 3 followed for more than 1 yr. They are all well, continent, happy, and back to a virtually normal life that includes marriage in 3. The Kock pouch should be an elective procedure and must be done only when the total colon has been removed. There must be rigid selection of pediatric patients for this operation and no children younger than teenage should receive this pouch. Moreover, it may even by worthwhile letting such a child have a standard ileostomy for a while until his or her general condition (both physical and mental) is best able to cope with a Kock pouch.

A new nonoperative treatment of large omphaloceles with a polymer membrane.

The management of a huge omphalocele that cannot be primarily closed presents many difficulties. When surgery is technically impossible, the application of a Silon pouch carries a serious risk of infection and painting the sac with tinctures has its own peculiar problems. A newborn baby with a large unruptured omphalocele was successfully treated by covering the sac with a skin-like polymer membrane that is flexible, elastic, and impervious to bacteria and water. The covering did not adhere to the underlying tissues and did not interfere with gastrointestinal function. Infection was not a problem. This material was wrapped around the trunk and covered with a dry sterile dressing. The entire dressing was removed after 3 wk, revealing a small residual area of granulations that subsequently healed at home. This baby was not operated upon. We have also used this technique in a second newborn in whom the sac had ruptured. The rent was repaired and the membrane applied. This method does not eliminate later closure of the large ventral hernia, but ccertainly eliminates the necessity for surgery in the newborn period.

Gastroschisis: primary closure or Silon pouch.

There has been a substantial increase in the incidence of gastroschisis in the last few years, and total parenteral nutrition has enabled many of these neonates to survive the long post-operative course. From 1969 to 1976 inclusive, 44 neonates with gastroschisis were treated with either primary closure or the application of a Silon pouch. Fifteen neonates were managed by primary closure. Three of these neonates developed clinical sepsis, but no other intraabdominal complications ensued. There were two deaths (13%) in the early postoperative period, due to CNS hemorrhage and aspiration. This gorup of 15 babies had 17 abdominal operations and the survivors averaged 32 days of parenteral intravenous nutrition before complete oral alimentation could be successfully started. Two ventral hernias required late repair. Twenty-nine neonates were managed primarily with a Silon pouch. Eighteen of these newborns developed sepsis, three Silon sacs had to be removed because of necrotic bowel within, and two other infants developed small bowel fistulae. There were 12 deaths (35%). These 12 infants had prolonged intestinal malfunction that lasted an average of 67 days. This group of 29 babies had 64 abdominal operations and the survivors averaged 46 days of parenteral intravenous nutrition prior to full oral feeds. Four ventral hernias required later repair. The comparison of results in these two groups of newborns reveals a striking difference in their post-operative course and survival. Although the Silon sac has until now become the accepted surgical procedure for gastroschisis, these results conclusively indicate the advantage of primary reduction and closure of the abdominal wall defect.

The unusual presentation of pancreatitis in infancy.

Two infants with acute pancreatitis are described. It appears that acute pancreatitis in infancy presents in one of two ways: part of a severe generalized illness, or as ascites. The outlook for the former depends on the prognosis of the generalized illness. If pancreatitis can be recognized as the cause of the ascites, then adequate treatment will result in survival. Although the cause in some infants is said to be idiopathic, exploration should be performed, the lesser sac investigated and if the child is in reasonable condition, appropriate study of the biliary tree and pancreatic ductile system should be considered. If a pseudocyst is present, adequate drainage is mandatory. Early diagnosis and appropriate treatment will be possible only if this rare disorder is suspected. The eventual prognosis is excellent and the chance of recurrent attacks is minimal.

Normal intestinal rotation with non-fixation: a cause of chronic abdominal pain.

The majority of clinically significant gastrointestinal rotational anomalies involve:(1) an arrest of rotation about the superior mesenteric vessels, (2) abnormal peritoneal bands, and (3) obstruction with or without volvulus. Between 1973 and 1978, six children had chronic intermittent volvulus secondary to a nonfixed but normally-rotated intestine; this is 10% of all infants and children treated for malrotation in our hospital during the same period. Barium studies showed normal duodenojejunal configuration and a colon that was normally situated on at least one study. All were labeled as functional complainers by their pediatricians. One died of a volvulus because her complaints were appreciated too late. At laparotomy, evidence of chronic intermittent volulus secondary to nonfixation from the ligament of Treitz to the transverse colon was found in all patients. A Ladd procedure with appendectomy was performed and immediate resolution of symptoms was noted in each surviving child. Children with a story of chronic abdominal pain deserve a carefully interpreted history and radiographic examination before being labeled as chronic complainers.

Pure esophageal atresia: a 50-year review.

This review encompasses 50 years (1942 through 1991) and 69 newborns (43 boys, 26 girls). Half the babies were premature (weighing less than 2.5 kg), and about one third had other anomalies. The procedures used in this series were late primary anastomosis (17), gastric tube reconstruction (16), staging esophagostomy and gastrostomy (13), gastric pull-up (13), early primary anastomosis (4), and colon replacement (3). Four neonates received no treatment. The most common repair in the 1940s and 1950s was the gastric pull-up; the gastric tube was the most popular in the 1960s and 1970s. Delayed primary anastomosis has been the operation of choice since the 1980s. Over the last decade, it has become apparent that primary repair is successful in three quarters of such infants if the wait is 3 months and/or the newborn weight has at least doubled. This repair appears to provide the best functional result, unless there is an anastomotic stricture. Before the 1970s, the survival rate was below 40%, but since the 1980s the rate has more than doubled, to 90% in our series, regardless of the type of repair used.

A 24-year follow-up of a large omphalocele: from Silon pouch to pregnancy.

In 1970, this patient was first reported after her massive ventral hernia was repaired. Her large omphalocele was initially covered with skin flaps as a newborn, and at 3 years of age the resulting ventral hernia was completely repaired using the staging technique described by Schuster, and modified by Plzak and Gross. Silon sheeting was used as a temporary prosthesis. She remained well until 1988 (age 23 years) when she became pregnant with the expected date of confinement January 10, 1989. The first two trimesters were uneventful with sonograms showing a normal male fetus who was gaining weight appropriately. By the third trimester the abdominal girth did not increase coincident with the baby's size, vomiting prevented adequate caloric intake, and pelvic pressure from the baby's head caused increasing discomfort. She spent 7 weeks in the hospital on intravenous therapy, including peripheral total parenteral nutrition, and delivered vaginally, with the aid of forceps, a 2.9-kg normal boy 5 weeks prematurely. This is the first reported case of a large omphalocele patient conceiving and delivering a normal fetus. It also demonstrates the potential problems related to multiple surgical procedures to close a large congenital abdominal wall defect.

The late nonfunctioning duodenal atresia repair.

Since 1979, three newborn males had duodenoduodenostomies for duodenal atresia, and all babies had smooth uncomplicated postoperative courses. There were no other anomalies. Between 6 and 18 months postoperatively, each infant developed an obstruction at the anastomosis that was initially treated with prolonged nasogastric suction. Because conservative management did not relieve the obstruction, the first two babies were operated on several times with revision of the anastomosis and bypass procedures, all of which were slow to function and required prolonged intravenous alimentation. It then became apparent that the duodenoduodenostomy was functionally obstructed. Therefore, the third infant was successfully treated with plication only of the dilated atonic proximal duodenum. All three children are now thriving more than 2 years after their surgery.