Symptomatic gastroesophageal reflux following gastrostomy in neurologically impaired patients.

Utilizing the sequence of contrast radiography, gastric technetium scintigraphy, and 24-hour pH probe, 30 of 46 (65%) neurologically impaired patients, referred for feeding gastrostomy, were demonstrated to have gastroesophageal reflux and underwent a Nissen fundoplication and gastrostomy. There was no evidence of reflux in the remaining 16 (35%) and a gastrostomy alone was performed. Four infants (aged 2 to 13 months) subsequently developed progressive vomiting from 2 to 8 months following gastrostomy placement. Repeat evaluation documented postoperative reflux in three. All four underwent a Nissen fundoplication with relief of their symptoms. Gastroesophageal reflux following gastrostomy may have been produced by an alteration in anatomy or progressive neurologic dysfunction. In all likelihood, however, it was present but undetected preoperatively. An antireflux procedure was required following gastrostomy in 25% of neurologically impaired patients with an initial negative reflux evaluation. Additionally, primary fundoplication in this group was associated with 10% incidence of recurrent symptoms. The high incidence of postoperative reflux, as well as the morbidity associated with gastrostomy in face of gastroesophageal reflux, warrants careful follow-up of the brain damaged patient with feeding gastrostomy.

Pyloric stenosis--a timed perspective.

In a review of 90 infants with pyloric stenosis who underwent pyloromyotomy, preoperative nasogastric drainage for more than six hours during the period of fluid resuscitation accompanied by a period of postoperative drainage for more than 12 hours resulted in better acceptance of a graduated feeding protocol with fewer emesis, earlier completion of full feeding, and shortened hospital stay.

The microbiology of neonatal peritonitis.

To review the bacteriology of neonatal intra-abdominal sepsis, we reviewed peritoneal cultures from 86 newborns undergoing operation for necrotizing enterocolitis (NEC) for the type and incidence of microorganism recovered. As a control, we conducted a similar review in 59 children with perforated appendicitis during the same period. Necrotizing enterocolitis was characterized by a lower incidence of polymicrobial contamination (1.7 organisms per patient vs 2.4 organisms per patient, NEC vs appendicitis) and an uncharacteristic pattern of isolates. Although enteric gram-negative bacilli were recovered in 80% of newborns, the incidence of Escherichia coli was only 21% in the NEC group vs 69% in the appendicitis group, while Klebsiella and Enterobacter species represented the most common gram-negative isolates recovered (63% vs 17%). More than 50% of neonatal cultures yielded gram-positive cocci, most frequently coagulase-negative staphylococci (30% vs 0%) and enterococci (17% vs 5%), as compared with more frequent streptococcal isolates in the appendicitis group (50% vs 10%). Anaerobes were seldom recovered in NEC cases (6%), but they were present in 50% of appendicitis cases. Additionally, Candida isolates were recovered in 10% of NEC cases (0% of appendicitis group). These results indicate the unique bacteriology of peritonitis in the critically ill newborn and probably reflect abnormal colonization in the neonatal intensive care unit.

Colostomy complications in children. An analysis of 146 cases.

This report analyzes the course of 146 pediatric patients with colostomies in reference to problems with colostomy formation, management, and subsequent closure. Colostomy was performed predominantly for Hirschsprung's disease (70 cases) and imperforate anus (46 cases). A transverse colostomy was done in 120 patients (82%), and a sigmoid colostomy in the remaining patients. Loop colostomies were five times more frequent than divided colostomies. Early major complications occurred in 24 patients (16%). Stomal complications occurred in 69 patients and were more frequent after loop colostomies. Colostomy revision was required in 24 cases. Sigmoid colostomy had a significantly lower complication rate (P less than .01). One hundred nine patients underwent colostomy closure. Major complications occurred in 16 cases (15%). There were no deaths related to colostomy closure. The use of a sigmoid colostomy when possible and close attention to technical details, principles of stomal care, and proper parental instruction should minimize morbidity.

Giant ectopic ureter presenting as abdominal mass in infant.

A case is presented of an abdominal mass created by massive ureteral dilation in an infant with VATER association. Curiously, only the terminal portion of the ureter was dilated.

Management of the newborn with gastrointestinal anomalies and tracheoesophageal fistula.

A standard approach to the otherwise healthy newborn with esophageal atresia and tracheoesophageal fistula has been well established. A significant number of these infants have additional gastrointestinal anomalies that necessitate alteration of the usual operative management. Over 2 1/2 years, nine such newborns have been managed. There were 17 additional gastrointestinal abnormalities, the most frequent being an imperforate anus (5), malrotation (5), and intestinal atresia (4). Management consisted of initial formal laparotomy, thoracotomy, and central line placement. In four infants these procedures were performed at a single sitting. Eight infants survived (89 percent); the single death resulted from intracerebral hemorrhage. Detection of coexisting gastrointestinal anomalies is mandatory in the management of the newborn with esophageal atresia. Standard local gastrostomy and subsequent thoracotomy may delay recognition of these associated anomalies, increase morbidity, and complicate subsequent correction. Preliminary abdominal exploration with correction, diversion, or both followed by thoracotomy, either immediate or staged, is indicated.

Management of congenital nevocellular nevi.

The risk of malignant change in a congenital nevocellular nevus is approximately 10 percent and is the chief indication for early excision. In 90 percent of patients, removal is simple; the remainder present with major cosmetic deformities and are difficult to manage successfully. Seventeen children (newborn to 17 years of age) were treated, including 11 children with localized lesions and 6 children who presented with abnormalities that covered 5 to 50 percent of the total body surface area. In those cases not amenable to primary removal, serial excision was performed at an average of 6 month intervals. Staging was determined by the softening and mobility of the surrounding tissue at follow-up evaluation. No effort was made to provide a cosmetic closure until the final stage. Utilizing this technique, complete removal of congenital nevocellular nevi is possible without the need for disfiguring skin grafts, even for the giant variety. Early excision obviates the risk of malignancy and provides satisfactory cosmetic results.

Bedside monitoring of heparin therapy.

Continuous infusion heparin therapy was monitored in twenty-five patients with simultaneously performed activated partial thromboplastin times and activated clotting times. These data were then compared by means of the coefficient of correlation. Significant correlation is demonstrated between the APTT and ACT in 88 per cent of cases.

Acute abdomen. The teenage girl.

The evaluation of abdominal pain in the adolescent female is a common and often challenging problem. The unique anatomy and biology of the postmenarcheal teenager necessitates the consideration of a broad variety of additional genitourinary problems not encountered in the male. Further complicating this issue, the differential diagnoses involves not only pathological considerations, but normal physiological processes that may, in and of themselves, be symptomatic. One must be skillful enough to avoid unnecessary intervention, while aggressively pursuing significant intraabdominal problems. Occasionally, however, only invasive modalities will enable definitive diagnosis, and facility with these techniques significantly enhances both diagnostic and therapeutic capabilities in these patients.

Sepsis-induced alterations in the erythrocyte membrane.

Sepsis is known to alter red blood cell (RBC) deformability, and this change in flexibility may play a role in the pathophysiology of the hemodynamic alterations characteristic of the septic syndrome. The etiology of this red cell change is unclear. This study evaluates erythrocyte size and cell membrane fluidity during clinical (septic surgical patients) and experimental (endotoxin incubation) sepsis. Membrane lipid viscosity was assessed by fluorescent spectroscopy. Mean corpuscular volume and hemoglobin concentration was determined by automated counter. There was a significant increase in erythrocyte membrane lipid viscosity (P < 0.001) in both the clinical and experimental septic models. No difference was detected, however, in RBC mean corpuscular volume or hemoglobin concentration. These findings suggest that sepsis-induced alterations in erythrocyte deformability are due primarily to an increase in the membrane lipid viscosity and are unrelated to alterations in the cell surface area to volume ratio.

Selective management of pediatric esophageal foreign bodies.

Esophageal foreign body is a relatively common consultation from the Pediatric Emergency Room. This study evaluates optimal selective management of esophageal foreign bodies in the pediatric patient. Eighty-six children have been referred for esophageal foreign body. Fifteen had been symptomatic for 48 or more hours before being seen. In eight, there was a known history of previous repair for esophageal atresia. In 88%, the foreign body was opaque, most frequently a coin. The most common nonopaque foreign body was retained food. Upon diagnosis, 72 children were taken to radiology, where balloon extraction under fluoroscopic control was attempted. Fourteen children went directly to the operating room for endoscopy and foreign body removal. Balloon extraction was successful in 62 cases (86%), and the children were discharged directly from the Emergency Department. The foreign body was successfully removed at esophagoscopy in the 10 cases that failed attempts at balloon extraction. Since 1990, successful extraction has been accomplished in 100% of cases (29/29). Neither balloon extraction nor endoscopy was associated with morbidity or mortality. Endoscopy was, however, associated with total hospital charges approximately 400% higher than balloon extraction. Fluoroscopically guided balloon extraction of appropriate esophageal foreign bodies is a safe and cost-effective alternative to endoscopy. Failure of nonoperative management does not complicate subsequent endoscopic removal. Patients with symptoms > 48 hours, a history of prior esophageal atresia, and/or nonopaque esophageal foreign bodies do not preclude attempt at balloon extraction.

Nitric oxide synthase inhibition negates septic-induced alterations in cytoplasmic calcium homeostasis and membrane dynamics.

This study was undertaken to evaluate the role of nitric oxide (NO) in the sepsis-induced disruption of intracellular calcium homeostasis and membrane dynamics. Anticoagulated whole blood was obtained from 10 healthy volunteers. Equal aliquots were incubated with saline (control), 2 microg/mL Escherichia coli endotoxin (lipopolysaccharide), 8 microg/mL NO inhibitor, N-monomethyl arginine (NMA), and endotoxin plus NO inhibitor (lipopolysaccharide/NMA). Erythrocytes were harvested, washed, and loaded with the calcium chelator, FURA-2AM, and the fluorescent membrane probe TMA-DPH. Cells were evaluated for both intracellular calcium concentration and membrane viscosity (anisotropy) by fluorescent spectrophotometry. Endotoxin induced a significant increase in both intracellular calcium concentration and anisotropy. NMA had no intrinsic affect on either of these cellular characteristics. NMA was, however, effective in preventing the endotoxin-induced changes. These results suggest that NO may play a role in the disruption of intracellular calcium homeostasis and erythrocyte membrane deformability noted in sepsis.

The effect of initial operative repair on the recovery of intestinal function in gastroschisis.

Recent reports concerning the treatment of gastroschisis suggest that primary closure results in more rapid return of gastrointestinal function, a shortened hospitalization, diminished perinatal complications, and improved long-term survival. A 4-year retrospective review of infants treated for gastroschisis at the University of Florida yielded 30 infants requiring repair of this abdominal wall defect. The series included 19 males and 11 females, and the average abdominal wall defect measured 4 cm in its greatest dimension. Nine infants (mean weight, 2,275 gm) were repaired using a staged closure using a silastic (six) or cutaneous (three) silo. Complete fascial closure was accomplished in an average of 8 days in the silastic group and 15 days in the infants with skin flaps. Mean age at start of enteral feeds was 23 days, with complete oral feedings at 43 days. Twenty-one infants (mean weight, 2,127 gm) underwent primary fascial closure. Three deaths occurred in the perioperative period: one from acute renal failure and two from sepsis secondary to a segment of necrotic intestine. An additional infant developed postoperative necrotizing entercolitis but recovered. Two infants in this group also had jejuno-ileal atresia requiring extensive small bowel resection. In the remaining 15 infants, oral alimentation was initiated for an average of 23 days, with full oral alimentation at 46 days. The data suggest that the recovery of the gastrointestinal system, adequate enough to support total oral alimentation, is unrelated to the initial surgical procedure chosen to obtain fascial closure in the newborn with gastroschisis. In addition, vigorous attempts at primary fascial closure may jeopardize intestinal viability, diminish ventilatory function, and result in unnecessary morbidity and mortality.

Role of the leukocyte in endotoxin-induced alterations of the red cell membrane. Second place winner of the Conrad Jobst Award in the Gold Medal paper competition.

Sepsis and endotoxemia are known to be associated with alterations in the red cell membrane that result in diminished flexibility. This decreased flexibility may be responsible, in part, for the microcirculatory abnormalities accompanying sepsis. The etiology of these sepsis-associated changes remains unclear. This study evaluates the role of the white blood cell in these abnormalities. Specimens were obtained from 44 volunteers and divided into two treatment groups. Group I specimens were incubated with Escherichia coli endotoxin (2 micrograms/ml) followed by removal of the white blood cells. The white blood cells were removed from group II specimens before endotoxin incubation. Paired, saline-incubated samples served as controls. After incubation, washed erythrocytes were evaluated for deformability and membrane viscosity. Deformability was assessed by filtration through 4.7-microns membranes. Red cell deformability was expressed as filtration rate (volume of cells per second per square centimeter). Membrane viscosity was assessed by fluorescent spectroscopy of cells into which the membrane probe 1(4-(trimethylamino)-phenyl)-6-phenyl-1,3,5-hexatriene had been incorporated. Results were expressed as anisotropy. Endotoxin resulted in a significant increase in erythrocyte membrane viscosity (experimental, 0.296 +/- 0.002 vs. control, 0.284 +/- 0.002, P < 0.001). This was reflected by a significant decrease in cellular deformability (experimental, 142.55 +/- 6.55 vs. control, 157.86 +/- 8.63, P < 0.01). However, these alterations are not a direct effect of endotoxin, but require the presence and participation of the white blood cell and/or its mediators (experimental, 0.301 +/- 0.002 vs. control, 0.300 +/- 0.001, P = NS).

Impact of emergency room laboratory studies on the ultimate triage and disposition of the injured child.

One hundred sixty six surviving pediatric trauma patients were retrospectively studied to assess the contribution of initial laboratory evaluations to clinical decision making in the emergency department (ED). All laboratory tests ordered, the results of those tests and the number of test results available before patient disposition from the ED were reviewed. A total of 626 laboratory studies were ordered in 166 patients. Results from only 68.5 per cent of the laboratory tests were available in the ED prior to the patient's transfer from the ED. Only 6.4 per cent of these results were abnormal. This low incidence of abnormal test results and preadmission availability questions the utility of extensive initial routine laboratory evaluations of the pediatric trauma patient. Based on this data, the current protocol has been revised to include hemoglobin/hematocrit determinations, type and screen, and urinalysis. Additional blood is obtained and appropriately labeled so that further studies can be performed if the patient's management should require baseline laboratory evaluations. This approach is more efficient, cost-effective, and no less sensitive in the initial evaluation and management of the injured child.

Blunt hepatic injury in adolescents: age makes a difference.

This analysis of mortality from blunt hepatic injury was performed to define outcome in the adolescent age group in relation to that recorded for children and adults. Children (age 0-10 years) were selected from a multi-institutional trauma registry, adults (age > or = 21 years) from the registry of a Level I trauma center, and adolescents (age 11-20 years) from both. Groups were compared by injury frequency, proportion of severe hepatic injuries (code 864.03 or 864.04 in the International Classification of Diseases, Adapted for Use in the United States 9-CM), immediate laparotomy, mortality, and cause of death. Children had the lowest proportion of severe injury and overall mortality. Torso trauma was the primary cause of death in only three children. Adolescent injury patterns were similar to those of adults in the proportion of severe visceral disruption and incidence of fatal torso trauma. Immediate laparotomy was employed almost twice as commonly in adults as in adolescents. The 64 per cent of adolescents who did not undergo laparotomy had a lower mortality than those who did. Conversely, the 36 per cent of adults without exploration had a significantly higher mortality, which usually occurred before laparotomy could be initiated. Increasing hepatic injury severity brought increasing mortality; however, the cause of death differed with age. Although the incidence of severe liver injury did not differ between adolescents and adults, management and outcome did. These data indicate that individualized management based on overall patient status remains the best approach to care of these injuries.

Abdominal complications of ventriculoperitoneal shunts. Case reports and review of the literature.

Ventriculoperitoneal (VP) shunting of cerebrospinal fluid (CSF) is the standard therapy for the management of hydrocephalus. Before the advent of silastic, early abdominal complications were frequent and finally led to the abandonment of this technique for management of hydrocephalus. With the use of silastic shunt tubing, VP shunts have once again gained favor as the procedure of choice. Although there are now considerably fewer complications from VP shunts, the presence of an intraperitoneal catheter can still initiate various complications. Abdominal complications of VP shunts are reported to be from 10-30 per cent, thus remaining clinically important for early recognition and treatment in patient management. An awareness of these complications is necessary in creating an index of suspicion for the primary physician whose patients harbor a VP shunt and present with abdominal symptoms. This report presents five cases of children with abdominal complications of VP shunts (four pseudocysts and one umbilical granuloma with spontaneous drainage of CSF). Additional abdominal complications of VP shunts are discussed, as well as diagnostic and therapeutic alternatives in order to improve and expedite accuracy in diagnosis and provide simplicity and efficiency in treatment.

Perinatal nonimmune hydrops: diagnostic ultrasonography and related aspects of management.

Nonimmune hydrops fetalis may become the commonest form of hydrops seen in Western countries during the perinatal period, and it has at least a 50% mortality. This report describes five infants with nonimmune hydrops associated with maternal hydramnios and with congenital fetal lesions or disorders, ie, mediastinal teratoma, pulmonary leiomyosarcoma, Beckwith-Weidemann syndrome with omphalocele, fetal tachycardia, and Down's syndrome. Three of the infants survived the neonatal period and two of these underwent surgery for resection of their tumors early in the neonatal period. The third had an omphalocele repaired at 6 hours of age. The literature is reviewed with respect to the pathophysiology of nonimmune hydrops. Its diagnosis and treatment are discussed, with special emphasis on the role of ultrasound in its early diagnosis and optimal prenatal and postnatal management, and on the morbidity seen in survivors.

The role of pentoxifylline in endotoxin-induced alterations of red cell deformability and whole blood viscosity in the neonate.

Endotoxin induces alterations in the neonatal red cell membrane that result in decreased deformability and an increase in whole blood viscosity. These rheologic alterations are detrimental to flow in the microcirculation. Pentoxifylline (PTX), a methyl xanthine derivation, increases red cell deformability presumably through its effect on intracellular adenosine 5-triphosphate. The purpose of this study was to evaluate the effect of PTX on endotoxin-induced alterations in the neonatal red blood cell. Anticoagulated whole blood specimens obtained from the cord of 12 neonates at birth were used to study the effects of Escherichia coli endotoxin (LPS) with and without PTX (50 micrograms/mL) on red cell deformability and whole blood viscosity. LPS resulted in a significant (P less than .001) decrease in deformability compared with controls. PTX reversed these endotoxin-induced alterations (P less than .01), normalizing deformability to control values (P = NS). LPS resulted in a significant increase (P less than .005) in blood viscosity that was reversed by PTX (P = NS). Pentoxifylline reverses the detrimental rheologic effect of endotoxin in the neonate. This activity may be helpful in sustaining normal microcirculation in neonatal sepsis.

Percutaneous placement of a venous access port in a pediatric patient population.

Venous access for administration of therapeutic agents and blood sampling has been difficult in the pediatric age group. A subcutaneous injection venous access port, the Infuse-A-Port (Infusaid Corp, Norwood, Mass) has been placed by percutaneous means in 29 patients aged 2 to 24 years. Placement has been under general (16) and local (13) anesthesia. There have been five problems (extravasation 2, suspected sepsis 1, and hematoma 2) during a total of 2,927 days of exposure. The convenience, reliability, safety, and patient acceptance of this venous access port makes this method the preferred choice for prolonged venous access in the pediatric age group.