Surgical treatment of gastroesophageal reflux in children: a combined hospital study of 7467 patients.

OBJECTIVE: To review retrospectively the combined clinical experience with the surgical treatment of persistently symptomatic gastroesophageal reflux (SGER) in childhood from seven large children's surgery centers in the United States. DESIGN: During the past 20 years, 7467 children <18 years of age underwent antireflux operations for SGER at the seven participating hospitals. Fifty-six percent were neurologically normal (NN) and 44% were neurologically impaired (NI). The most frequent diagnostic studies were upper gastrointestinal series (68%), esophageal pH monitoring (54%), gastric emptying study (32%), and esophagoscopy (25%). The age at operation was under 12 months in 40% and 1 to 10 years in 48%. The type of fundoplication was Nissen (64%), Thal (34%), and Toupet (1.5%). A gastric emptying procedure was performed on 11.5% of NN patients and 40% of NI patients. Laparoscopic fundoplication was performed on 2.6% of patients. RESULTS: Good to excellent results were achieved in 95% of NN and 84.6% of NI patients. Major complications occurred in 4.2% of NN and 12.8% of NI patients. The most frequent complications were recurrent reflux attributable to wrap disruption (7.1%), respiratory (4.4%), gas bloat (3.6%), and intestinal obstruction (2.6%). Postoperative death occurred in 0.07% of NN and 0.8% of NI patients. Reoperation was performed in 3.6% of NN and 11.8% of NI patients. The results and complications were similar among the participating hospitals and did not seem related to the type of fundoplication used. CONCLUSION: The excellent results (94% cure) and low morbidity with gastroesophageal fundoplication with or without a gastric emptying procedure from a large combined hospital study indicate that operation should be used early for SGER in NN children and to facilitate enteral feedings and care in NI children.

A combined hospital experience with fundoplication and gastric emptying procedure for gastroesophageal reflux in children.

BACKGROUND: Operative treatment of symptomatic gastroesophageal reflux (GER), often together with neurologic feeding disorders, is very common in infancy and childhood. Delayed gastric emptying (DGE) has been observed frequently in association with GER in children. STUDY DESIGN: A retrospective review was performed on 1,200 consecutive patients 18 years of age and younger operated upon for symptomatic GER or neurologic feeding disorders, or both, at two pediatric surgery centers in widely separated geographic areas in the United States of America, to compare the results after fundoplication with or without a gastric emptying procedure (GEP). RESULTS: Operations included gastroesophageal fundoplication (GEF) alone (871 patients), GEF plus GEP (286 patients), reoperative GEF plus GEP (30 patients), and GEP alone (13 patients). Thus, 27 percent of the total and 40 percent of the last 494 children with reflux had a GEP. Delayed gastric emptying with retention of more than 60 percent of an isotope meal appropriate for age at 90 minutes was present in 241 of the 451 children with reflux studied. Major neurologic disorders were present in 219 (25 percent) of 871 children who underwent GEF alone and in 247 (75 percent) of 329 children who had a GEP. All patients operated upon from both hospitals were relieved of recurrent emesis, and those with failure to thrive showed significant weight gain; pulmonary symptoms were relieved in 94 percent. Recurrent GER developed in 47 (5.2 percent) of 901 children who had GEF alone, but in only four (1.2 percent) of 329 patients who had a GEP. CONCLUSIONS: The excellent clinical results with low morbidity in this largest reported clinical experience with GEP in childhood suggest that a GEP should be combined with GEF for symptomatic children who have both GER and DGE. Minimal investigative studies are necessary for most neurologically impaired children who require a feeding gastrostomy.

Identification and characterization of rabbit buccal mucosal hyaluronidase.

This study establishes the existence of a mammalian buccal mucosal hyaluronidase having properties typical of a lysosomal enzyme. Mucosal hyaluronidase exhibited a distinct substrate preference for hyaluronic acid, generated saturated de-polymerization products by endoglycosidic hydrolysis, and possessed a pH optimum of 3.5 and an isoelectric point of 5.9.

Separation and properties of rabbit buccal mucosal wound hyaluronidase.

This study establishes the existence of a mammalian buccal mucosal wound hyaluronidase (hyaluronate 4-glycohydrolase; EC 3.2.1.35) having properties distinct from those of the endogenous lysosomal hyaluronidase of normal (uninjured) buccal mucosa. A time-dependent change in hyaluronidase activity was measured, with the highest specific activity occurring on post-wound day 4 (7.7 +/- 1.3 units/mg protein), followed by consecutive decreases until activity was no longer discernible by day 21. Mucosal wound hyaluronidase closely resembled a previously described integumentary wound endoglycosidase in terms of a high pH optimum (5.0-6.0), distinct (but non-exclusive) substrate preference for hyaluronic acid, and ability to generate saturated depolymerization products by an endoglycosidic hydrolysis.

The effects of growth factors on Tenon's capsule fibroblasts in serum-free culture.

This study was performed to develop and improve a completely defined in vitro ocular wound-healing model of fibroblast proliferation for glaucoma filtration surgery. This model is essential for the investigation of protein-sensitive drugs and cytokines. Tenon's capsule fibroblasts in their third passage were incubated overnight, washed free of serum, and fed defined media, Aim V or Clonetics FBM serum-free medium containing platelet-derived growth factor, basic fibroblast growth factor, epidermal growth factor, or fibronectin at various dilutions and in combinations at optimum concentrations. Proliferation was measured by 3H-thymidine incorporation at 1, 3, and 7 days. Morphology was compared to controls fed Minimum Essential Medium + 10% serum. Single factors stimulated the greatest amount of thymidine uptake on day 3. Optimum concentrations were epidermal growth factor at 5 ng/ml, basic fibroblast growth factor at 10 ng/ml and platelet-derived growth factor at 20 ng/ml. Identical combinations of factors stimulated nearly twice the thymidine uptake in Clonetics medium as in Aim V. Epidermal growth factor activity was inhibited by either basic fibroblast growth factor or platelet-derived growth factor. Basic fibroblast growth factor and platelet-derived growth factor together produced a less than additive effect. The performance of either serum-free medium may be improved by the addition of basic fibroblast growth factor or platelet-derived growth factor. The optimum serum-free medium (Clonetics FBM) with growth factors was unable to stimulate proliferation as much as Minimum Essential Medium + 10% NBS, but was successful in maintaining viability during the 7 day test period.

Preparation and evaluation of a nonproprietary bilayer skin substitute.

Cross-linked, allogeneic, telopeptide-depleted dermal grafts were lyophilized and laminated with silicone rubber elastomer. Resultant bilayers were studied for incorporation into the wound site and capacity to inhibit cutaneous wound contraction in experimental animals. Bilateral full-thickness skin wounds were made in 20 male New Zealand white rabbits. One side was grafted with the processed graft, while the contralateral side remained ungrafted as a control wound. Over 63 days, wound sites were analyzed at intervals on the basis of the extent and rate of wound contraction and by histologic examination. Cutaneous wounds successfully incorporated graft matrix and were significantly inhibited in their rate and extent of wound contraction. Notably, by day 63, grafted wounds retained 71 percent of their original area, whereas ungrafted control wounds retained only 16 percent of their original area. There were no graft rejections, and the bilayer graft's dermal analogue appeared to function as a biodegradable template that physically conformed neodermis to a preestablished pattern while counteracting contractile forces. This investigation suggests that, in experimental animals, the success of bilayer dermal grafts is less dependent on highly specialized and complex preparative techniques than typically has been presumed and that relatively simple, previously published, nonproprietary techniques, when adapted to a bilayer format, yield acceptable results as defined in terms of biocompatibility, capacity for graft incorporation, and inhibition of wound contraction.

Experience with a variation of the transverse incision in chest wall deformity correction.

This report describes a variation of the transverse chest wall incision to elevate all soft tissue layers of the chest wall in one layer during repair of chest wall deformity in children. This is a report of an experience in 285 cases.

Voiding abnormalities in children: methods of evaluation and results of treatment.

Recent advances in technology have fueled interest in the field of urodynamics and have made possible accurate diagnosis of voiding abnormalities in children. A thorough understanding of the underlying physiology and institution of the appropriate pharmacologic agents and/or teaching techniques results in correction of the underlying problems in 90% of the cases. Symptoms, techniques of diagnosis, therapeutic regimens, and results of therapy are presented.

The 're-do' chest wall deformity correction.

BACKGROUND: A small percentage of patients who undergo surgical correction of a chest wall deformity will have results so unsatisfactory that a second procedure, the so-called "re-do," will be required. CONCLUSIONS: The literature contains very little information regarding the technique and results of these procedures. Based on experience with 18 "re-do" procedures, the authors believe that recurrent deformities should be surgically corrected. Although this is a somewhat diverse group based on age at the first and second procedure, type of original operative procedure, and interval between the procedures, the operative approach is standard, and the results are predictable.

The effect of tube gastrostomy on gastroesophageal reflux in patients with esophageal atresia.

Gastroesophageal reflux (GER) occurs frequently in infants with esophageal atresia (EA). The definitive management is primary repair and often includes tube gastrostomy. The recent finding of lower esophageal sphincter (LES) pressure changes with tube gastrostomy suggests that GER might be related to gastrostomy rather than EA per se. To evaluate this thesis, two populations of patients from different children's hospitals were reviewed: EA with and without routine gastrostomy. The two populations were similar with respect to number of infants, associated anomalies, distribution in the Waterston classification, morbidity, and mortality. One hundred sixteen patients were studied. Of the 66 survivors who underwent gastrostomy and repair of EA, 30 were found to have GER (45.5%) and 12 required fundoplication (18.2%). Of 31 surviving patients who underwent repair of EA without gastrostomy, 11 had GER (35.5%) and four required fundoplication (12.9%). These data suggest that tube gastrostomy does not significantly contribute to the GER associated with EA.

A multi-state survey of videotaping practices for major trauma resuscitations.

The objective of this study was to determine the prevalence and problems, both perceived and actual, associated with videotaping major trauma resuscitations. A cross-sectional two-part survey of trauma centers was conducted. Part 1 determined demographic information and videotaping status. Part 2 asked trauma centers that were not doing videotaping (NVTCs) about their plans, past experience, and perceived problems. Videotaping trauma centers (VTCs) were asked about mechanics, responsibility, utilization, and problems. A total of 221 centers were surveyed; 20% VTCs, 70% NVTCs, and 10% NVTCs that had videotaped in the past (PVTC). Among VTCs, 53% reported problems with videotaping including lack of personnel (40%) and time (40%) to administer the program. Videotaping, however, was found to be an effective quality improvement tool in 95% of the VTCs. Of the NVTCs, 70% perceived problems with implementing a videotaping program; these included medicolegal (34%) and patient confidentiality (22%) concerns. Of the PVTCs, 90% stated that they had problems with videotaping including lack of staff support (33%) and lack of personnel to assist with the program (24%). In conclusion, staff participation and adequate personnel outweigh medicolegal concerns as actual videotaping problems. Videotaping is perceived to be an effective performance improvement tool.

Chest wall deformities in children.

Pectus excavatum and pectus carinatum deformities are not uncommon. Pectus excavatum is associated with definite demonstrable adverse physiologic effects. The psychologic impact of these deformities on the patient can be truly devastating. The clinician must realize the impact and importance of the advice given to patients and their families. Although correction of these deformities is a major surgical undertaking, it is well tolerated, safe, and usually produces a satisfactory result.

A noninvasive method for recording the electrical activity of the human uterus in vivo.

Development of an electrohysterograph (EHG) for recording the electrical activity of the uterus in vivo has been blocked for 60 years by problems with artifacts and extraneous/reactive electrical activity. This study reevaluates a method of cervical recording that does not appear to have these limitations. A set of cervical electrode cups was used to record uterine activity of 33 normal subjects and patients who had dysmenorrhea, endometriosis, or chronic pelvic pain. The electrode cups were atraumatic, able to be fitted to all subjects, and showed exceptional positional stability. Unipolar and bipolar recordings from the cervix showed the same infrequent spikes and spike bursts reported from other studies along with continuous, mildly irregular, undulating slow-wave activity, which was present throughout the recordings. The frequencies and amplitudes of these slow waves changed in relation to exogenous estrogen, diagnosis, intrauterine catheters, and the intensity of the subject's pain. Spikes and spike bursts were common only during menses and at midcycle. The cervical electrode cups proved easy to use and were well accepted by the subjects. The findings indicated that the spikes and slow waves were probably uterine in origin and not artifact or extraneous/reactive activity. There were also direct and indirect indications that the slow waves may represent the ionic propagation of uterine electrophysiologic activity through a network of uterine intercellular ionic channels (gap junctions). The limited but fairly consistent evidence from a number of perspectives indicates that recording spike and slow-wave activity from the cervix is a viable and practical EHG method.

Chest wall deformities.

Chest wall deformities are principally depression deformities, the most common being pectus excavatum (funnel chest). The most common protrusion deformity is pectus carinatum (pigeon breast). Pectus carinatum is a cosmetic problem, but its presence can be psychologically devastating to the patient. Pectus excavatum is definitely a physiologic problem, the effects of which may be reversible by surgical correction. Surgery is safe, complications are minimal, and results are usually satisfactory.

Lightweight remotely actuated switching valve for rebreathing exercise studies.

A new type of switching valve used in rebreathing studies for estimating cardiac output is described. This valve employs a unique deformable elastic element, actuated by low-pressure compressed air, to effect switching. The capability for remote operation (via a compressed air line) and the light weight of the valve (110 g) make the valve especially well suited to exercise stress testing studies. Two valves of this type have been satisfactorily used in graded exercise stress tests in a clinical setting for over 2 yr.

New respiratory gas valve support for graded exercise studies.

We describe a new support structure for respiratory gas valves for use in exercise studies. Use of this structure largely avoids problems of large inertial reactions and feelings of confinement on the part of the subject which have characterized previous systems. The support mechanism consists of a spring-reacted, pivoted boom carried on the end of a counterbalanced swinging beam. This device was designed for use on an adjustable slope motor-driven treadmill, but may be adapted to a variety of other experimental arrangements.