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.

Thymic gallium-67 localization in pediatric patients on chemotherapy: concise communication.

Localization of Ga-67 in the thymus has been reported to occur in children. In our control group of 87 patients, 15% of children under 5 yr and 11% of children over 5 yr demonstrated thymic localization. In contrast, in our study group of seven children with acute lymphocytic leukemia or malignant lymphoma, lymphocytic diffuse, treated on a modified non-Hodgkin's lymphoma protocol, Sloan-Kettering LSA2-L2, thymic localization occurred during treatment in five of the seven. We conclude that increased thymic gallium localization in children under chemotherapy for a known malignancy may reflect increased activity of thymic medullary epithelial cells and regeneration of thymic lymphocytes during recovery form involution induced by certain chemotherapeutic agents.

Repair of pectus excavatum in children under 3 years of age: a twelve-year experience.

From 1964 to 1975, 50 children under 36 months of age had operative repair of severely deforming pectus excavatum. No child died or suffered a serious complication from the operation. Most young children needing early repair of progressive pectus excavatum can be identified by 18 months of age. Forty-five patients in this series (90%) have had a totally satisfactory cosmetic and anatomical result on one- to twelve-year follow-up. Early repair of marked pectus excavatum in young children is safe and is efficacious in providing a suitable body contour.

The role of initial cineesophagography in caustic esophageal injury.

The accurate assessment of caustic ingestion requires a vigorous attempt to obtain as much information concerning the type, concentration, and amount of corrosive agent ingested as possible. Although early endoscopy is crucial for assessing the existence of esophageal burns, an accurate prediction of outcome, (for example, stricture) may not be possible from endoscopic study alone. The role of contrast cineesophagography has not been properly emphasized in the surgical literature. Our analysis of the relative accuracy of endoscopy and cineesophagography in esophageal burn evaluation has emphasized that cineesophagography helps in early identification of those patients who will develop strictures. In our experience, cineesophagographically visualized abnormalities, specifically disordered motility, when interpreted within the context of historical facts and physical findings, most accurately prognosticates the outcome of caustic esophageal injuries.

An appropriate negative bronchoscopy rate in suspected foreign body aspiration.

Aspiration of foreign bodies in children can lead to illness and even death if not recognized and treated promptly. Seventy-six patients were referred to our hospital for suspected foreign body aspiration. The following is a retrospective review of their diagnosis and treatment. There was no foreign body found at bronchoscopy in seven patients (9 percent), and there were nine patients (12 percent) with bronchial foreign bodies who had a delay in diagnosis of foreign body aspiration. The delay averaged 35 days. These children, as a result of a prolonged period before diagnosis, were treated unnecessarily for pneumonia and asthma. Once correctly diagnosed, they had a significantly longer hospital stay. We propose that some negative bronchoscopies are necessary in order to prevent the morbidity that occurs from a missed foreign body aspiration.

Pediatric gastroesophageal reflux: age-specific indications for operation.

Pediatric gastroesophageal reflux is common and its complications may be serious. The diagnosis is being suspected and confirmed with increasing frequency in children because of heightened awareness of the symptoms peculiar to pediatric patients. Thirty-one children who underwent Nissen fundoplication for gastroesophageal reflux are reviewed. Diagnosis was obtained by barium meal, isotope scanning, esophagoscopy and pH monitoring. Failure to thrive, recurrent pneumonia, apnea, feeding difficulty and esophageal stricture unresponsive to medical management were the indications for operation. Children with brain damage or previous repair of esophageal atresia are at high risk for gastroesophageal reflux and its complications. A protective fundoplication is a desirable adjunct to feeding gastrostomy in brain-damaged children. Fundoplication eliminated reflux in 30 of 31 patients, relieved symptoms in 28 and improved symptoms in 2. Nissen fundoplication is a safe and effective surgical procedure for correction of gastroesophageal reflux in children.

Nonoperative management of subcapsular hematomas of the liver.

The liver is the second most common organ injured in blunt abdominal trauma, and with the use of diagnostic techniques such as hepatic scanning, an increasing number of patients with intrahepatic lesions are being identified. Five patients with this type of lesion are presented. A plan of managament, including observation in an intensive care unit, repeated physical examinations, frequent reevaluation of laboratory values, bed rest, gastrointestinal tract decompression and broad spectrum antibiotics, is suggested as the treatment of choice for this type of injury. All patients in the series have done well with no abscess formation, delayed rupture of hemobilia, and all show resolution of the defect on following-up hepatic scanning.

Hemangioendothelioma of the pancreas obstructing the common bile duct and duodenum.

A 6-mo-old male with a hemangioendothelioma of the pancreas obstructing the common bile duct and duodenum required temporary bypass of these structures while awaiting involution of the tumor treated primarily by corticosteroids and radiation therapy.

Antral web in infancy.

Eleven patients have been followed from 1 to 6 yr after diagnosis and treatment during infancy of partially obstructing antral web. Seven had surgical correction, six with web excision and pyloroplasty. Four were treated nonoperatively with antispasmodics and small curd formula. Five of the seven operated infants had continued vomiting postoperatively. All patients in both groups were symptom-free 6 mo posttreatment. Three of four nonoperated patients had follow-up upper gastrointestinal radiography. None had persistence of the antral web. We conclude that partially obstructing antral web in infancy is a self limited disease and that surgical correction is indicated only for severe clinical illness.

Surgery in patients with hemoglobin-S disease.

Sixty-eight patients with sickle cell disease who underwent surgery are reviewed. Fifty-two were homozygous for hemoglobin-S, whereas 16 had heterozygous variants. Associated diseases were common. Both the types of operative procedures and the complications of surgery, in large measure, were determined by these associated diseases. Splenectomy (12 patients) and cholecystectomy (11 patients) were the common major operations; infections (21 patients) were the most common complications. Precise management ensured acceptably low morbidity and mortality (1 death) in this series.

Pyloric stenosis: diagnosis by real time sonography, the pyloric muscle length method.

Real time sonography was performed for identification of pyloric stenosis in 100 infants referred for vomiting. In nine patients, imaging did not identify the pylorus. One of nine had pyloric stenosis. In 91 imaged patients, 40 had pyloric stenosis and 51 did not. Each imaged patient had determinations of the three described diagnostic pyloric muscle measurements: pyloric muscle diameter, pyloric muscle thickness, and pyloric muscle length. The determination of pyloric muscle length was the most accurate (97.8%); it had two false negatives, but no false positive results. Erroneous surgery was thereby avoided. We conclude that real time sonographic determination of pyloric stenosis is reliable and practical, and that pyloric muscle length determination is the most accurate of the currently available techniques.

Neuroradiologic evaluation of sacral abnormalities in imperforate anus complex.

Neurologic impairment and sacral spinal anomalies are a finding in children with imperforate anus. The neurologic deficits previously had been considered static rather than progressive. Recent experience at this institution has documented the frequent association of imperforate anus patients having bony sacral and other spinal deformities with progressive neurologic dysfunction. These deficits are related to underlying spinal cord anomalies, which may be amenable to neurosurgical correction. To investigate the nature and frequency of such lesions, spinal cord imaging was done in these patients. From July 1976 to June 1985, 106 patients with imperforate anus were screened with plain radiographs of the sacral spine; 37 (35%) patients had abnormalities. Of these, 26 have been evaluated with a variety of spinal cord imaging techniques, including magnetic resonance imaging (18), digital metrizamide myelotomography (14), computed tomography (10), metrizamide myelography (5), or ultrasound (4). Four patients were lost to follow-up, and seven have not yet been studied. Fifteen of the 26 patients (53%) had one or more abnormal studies. Thirteen were considered to have progressive dysfunction with operable lesions and have undergone neurosurgical correction. At follow-up, there was improved leg function in five patients and improved bladder function in two patients. No patient had additional neurologic deficits after surgery. Because of the high incidence of progressive but potentially correctable myelodysplasias in patients with coexisting anorectal and sacral anomalies, routine radiographic screening of the spine is recommended, followed by spinal cord imaging and neurosurgical evaluation if warranted.

Gastric emptying in children with gastroesophageal reflux. I. An estimate of effective gastric emptying.

The association of gastroesophageal reflux (GER) and gastric emptying has been observed, but its importance is poorly understood. We compared 18- to 24-hour esophageal pH recordings with gastric emptying of radionuclide in apple juice in 109 children (2 weeks to 16 years old) referred for an evaluation of GER. A pH score and the pattern of GER (type I, II, and III) were obtained by esophageal pH monitoring. Gastric emptying was measured at 30 minutes (%GE30) and at 60 minutes (%GE60). The measured gastric emptying of apple juice was similar for the normal child and for those with GER regardless of pattern type. An inverse linear correlation between postcibal reflex and measured gastric emptying was demonstrated only by the eight asymptomatic children with a normal pH score (%GE30, r = -.9603, P less than .001; and %GE60, r = -.8263, P less than .05). If the contribution of postcibal reflux on gastric emptying was eliminated, then the effective gastric emptying was increased in many children with the type I (44%, P less than .05), type II (46%, P less than .05), or type III (60%, P less than .05) pattern of GER as compared with children with a normal reflux pattern (7%). In conclusion, measured gastric emptying of clear liquids is not necessarily decreased in most children with GER. Furthermore, many children with GER demonstrate an increased effective gastric emptying even though measured gastric emptying may not appear increased.

Intravenous vasopressin and gastrointestinal hemorrhage in children.

Intravenous (IV) vasopressin has been used to control human upper gastrointestinal (GI) hemorrhage for over 30 years. Although the use of vasopressin has been studied extensively in adults, no study has evaluated its use in children. Vasopressin was used therapeutically in 15 episodes of esophageal variceal hemorrhage and two episodes of bleeding peptic ulcer. Nine of 17 episodes were controlled with vasopressin alone (53%). Balloon tamponade and variceal sclerosis were required for control in the remainder. Blood requirements averaged 53 mL/kg prior to control of hemorrhage. Metabolic complications occurred in 65% of the episodes. There were two groups of patients identified: those receiving greater or those receiving less than .01 units/kg/min of IV vasopressin. All of the complications identified occurred when greater than .01 U/kg/min of vasopressin were used (P less than .05). Control of bleeding was not improved with higher doses of vasopressin. These data suggest that the use of IV vasopressin at doses greater than .01 U/kg/min to control GI bleeding will increase the incidence of complications without improving control of hemorrhage.

Real-time echocardiography: a new technique to facilitate Swan-Ganz catheter insertion.

Real-time echocardiography was used to position a pulmonary artery catheter in a septic child in whom the usual placement methods were not successful. This technique to facilitate pulmonary artery catheter placement avoids radiation, is portable and allows direct visualization of intracardiac catheter orientation. When smaller children and infants undergo pulmonary artery catheterization at the bedside, real-time echocardiography may allow catheter insertion when the usual techniques have failed.

Hepatoportal sclerosis in childhood: a mimic of extrahepatic portal vein obstruction.

In the absence of cirrhosis, most children with portal hypertension and bleeding esophageal varices have extrahepatic portal vein occlusion. In the past 2 yr this clinical picture has been mimicked by two children with hepatoportal sclerosis causing their variceal hemorrhage. Hepatoportal sclerosis has been well described in adults. It is manifested by splenomegaly, portal hypertension, and variable ascites and hepatomegaly. Liver histology is initially normal but subsequently shows periportal fibrosis without cirrhosis. Hepatic manometrics indicate a presinusoidal block, but angiography demonstrates a patient portal vein. Typically there is abrupt narrowing of the intrahepatic portal branches, giving a "withered tree" appearance. These findings are illustrated by two children who presented with esophageal variceal bleeding at 21 and 20 mo of age, respectively. They are the youngest reported cases of hepatoportal sclerosis. The etiology of hepatoportal sclerosis is uncertain, but the disease appears to be only slowly progressive. Control of variceal bleeding by central portosystemic shunts in this condition is associated with a 50% incidence of hepatic encephalopathy. Therefore alternate methods of therapy need be considered. Endoscopic injection sclerotherapy successfully controlled variceal bleeding in one child reported here. Hepatoportal sclerosis is a distinct entity and must be considered in the differential diagnosis of portal hypertension in infants and children.

Gastroesophageal reflux following percutaneous endoscopic gastrostomy in children.

The frequency and clinical significance of gastroesophageal reflux (GER) in patients after percutaneous endoscopic gastrostomy (PEG) was determined. Ten children, aged 11 months to 15 years, who had normal preoperative extended esophageal pH monitoring were restudied after PEG. Of the ten patients, six developed GER with a pH score significantly higher than their initial one (40.5 +/- 3.3 pre-PEG v 129.5 +/- 24.2 post-PEG, P less than .005). Similarly, the mean post-PEG pH score was higher in patients with GER than in those without a change in score (129.5 +/- 24.2 v 33.8 +/- 2.8, P less than .005). None of these patients was symptomatic for GER immediately after the PEG, but within 10 months of surgery, three of six (50%) developed reflux-related symptoms. These data indicate that clinically significant GER is associated with PEG.

Hypoalbuminemia may predispose infants to necrotizing enterocolitis.

Numerous risk factors for necrotizing enterocolitis (NEC) including prematurity, bowel ischemia, pathogenic bacteria, and hyperosmolar feedings have been proposed. Recent studies have demonstrated feeding intolerance and bowel dysfunction in children with hypoalbuminemia. No association between hypoalbuminemia and NEC has been suggested. The records of 45 patients with NEC and complete documentation of prenatal and birth histories were reviewed. A control (CONT) group of 90 children matched for maternal age (+/- 1 year), parity, gestational age (+/- 1 week), birth weight (+/- 20 g), type of delivery, sex, race, type of initial feeding, and perinatal stress was compiled. While all other measured parameters were similar in the two groups, premorbid albumin was significantly lower in the patients who subsequently developed NEC (P less than .001). These data suggest that newborns with hypoalbuminemia may have an increased risk of developing NEC.

Outpatient bowel preparation in children.

A polyethylene glycol electrolyte solution was evaluated as a mechanical bowel preparation prior to surgery in an outpatient setting. Twelve children underwent outpatient bowel preparation (OPBP) prior to a variety of surgical procedures. The technique was well tolerated and consistently produced a well-prepared intestinal tract. This technique will decrease the overall cost of hospitalization, and it enhances patient and parental acceptance of mechanical bowel preparation.

The mean duration of gastroesophageal reflux during sleep as an indicator of respiratory symptoms from gastroesophageal reflux in children.

The coexistence of gastroesophageal reflux (GER) and respiratory symptoms has been reported in children, but identifying a reliable indicator of reflux-induced respiratory symptoms has been difficult. The mean duration of reflux episodes during sleep (ZMD), extracted from a 18- to 24-hour esophageal pH recording, has been presented previously as a reliable correlate of respiratory symptoms caused by GER in infants. To reexamine the accuracy of the ZMD we report 519 consecutive children with respiratory symptoms (aged 1 week to 15 years) who were referred for documentation of GER by 18- to 24-hour esophageal pH monitoring. Follow-up information was obtained on 388 patients 1 to 115 months later (mean, 23 months). From the follow-up information, 259 children could be reliably classified; 128 as having reflux-related and 131 as having reflux-unrelated respiratory symptoms. None of the 131 children with reflux-unrelated respiratory symptoms had a prolonged ZMD (greater than 3.8 minutes). In comparison, 119 of the 128 children (93%) with reflux-related respiratory symptoms had a prolonged ZMD (P less than .001). The nine children who had a normal ZMD and improvement in their respiratory symptoms with the successful control of GER had advanced esophagitis (n = 4), central apnea (n = 3), or associated disorders in which respiratory symptoms improved with the avoidance of oral feedings (n = 2). In conclusion, the ZMD was confirmed to correlate directly with both the presence and absence of respiratory symptoms caused by GER in children.