Laparoscopic gastrostomy in infants and children.

Gastrostomy is a common procedure in children. Percutaneous endoscopic gastrostomy (PEG) is less traumatic than open surgery, but carries a higher risk in small children. We report our experience with laparoscopic gastrostomy, which appears to combine the advantages of the PEG and the safety of an open operation. Operative technique. An umbilical port (5 or 10 mm, depending on the patient's weight) and a left subcostal cannula (site of the future gastrostomy) are used. The stomach is pulled to the abdominal wall with two T-anchors, and the gastrostomy is performed using the Seldinger technique. A 17-Fr peel-away sheath is placed, through which a 5 mm endoscope is introduced to confirm its intragastric position. A 14-Fr balloon gastrostomy tube or button is then introduced. Results. Fifty-one children, aged 0 to 19 years (mean 4.4 +/- 6.4 years), underwent a total of 54 laparoscopic gastrostomies in a 42-month period. Thirty-three patients were younger than 2 years, and 22 weighed less than 5 kg. Thirty-three children had failure-to-thrive, 12 suffered from cerebral palsy and 8 from cystic fibrosis. Operative time was 33.6 +/- 14.3 minutes; in 18 cases, a concomitant Nissen fundoplication was performed (total operative time 76.5 +/- 58.7 minutes). In all cases, gastrostomy feedings were started the following day, and hospital stay in the gastrostomy-only group was 3.3 +/- 0.6 days. There were two (recognized) perforations of the back wall of the stomach, which were repaired laparoscopically, and two tube dislodgments, at 24 hours and at 4 months, requiring reoperation. Conclusions. Laparoscopy allows a quick and simple technique of gastrostomy placement under direct vision in even the smallest newborn and infant. It carries minimal operative risks and allows initiation of feedings within 24 hours.

Cystic fibrosis. Gastrointestinal complications and gene therapy.

The gastrointestinal and nutritional complications of cystic fibrosis are diverse. As longevity improves in patients with cystic fibrosis, management of these complications is becoming increasingly important . This article provides overviews of the molecular aspects of the pathogenesis of cystic fibrosis, the current status of gene therapy, and a review of the gastrointestinal manifestations and nutritional care.

Analysis of the peripheral blood T-cell receptor (TCR) repertoire in monozygotic twins discordant for Crohn's disease.

T cell involvement in the inflammatory process of Crohn's Disease (CD) is evident by an increase in activated T cells and their cytokines in actively inflamed CD tissue. It has been suggested that CD may involve a superantigen based on the observation that a significant proportion of CD patients express elevated levels of V beta 8+ T cells in their peripheral blood compared to normal controls. In order to determine whether a superantigen might play a role in the pathogenesis of CD we have compared the TCR repertoires of four pairs of monozygotic twins discordant for CD. By using monozygotic twins, we could rule out the effects of HLA and other genes on the TCR repertoire. The TCR repertoires were analyzed by using a panel of V-segment-specific mAb and by quantitative polymerase chain reaction (qPCR) using V beta-specific oligonucleotide primers. In all cases the TCR repertoires of the affected and unaffected sibs were strikingly similar. We did not observe any TCR segment that was consistently altered in frequency or expression levels in all of the affected sibs compared to their identical twin. Furthermore, we did not see an increase in V beta 8+T cells in the peripheral blood of the CD sibs relative to their normal counterpart. These studies suggest that the presence of CD does not alter the TCR repertoire of peripheral blood in any obvious way and argue against the role of a superantigen in the etiology of pathogenesis of CD.

Evidence for an altered T-cell receptor repertoire in Crohn's disease.

We have compared the frequencies of T cells expressing each of four different T cell receptor (TCR) V beta segments in lamina propria and peripheral blood lymphocytes of 12 Crohn's disease (CD), six ulcerative colitis (UC), and 10 control patients in an attempt to identify disease-specific changes. The frequencies of CD4+ and CD8+ cells reacting with each of four fluoresceinated TCR-specific monoclonal antibodies directed against V beta 5, V beta 6.7a, V beta 8, and V beta 12 were determined by flow cytometry. There was no difference among the groups in the average frequency of any single V beta segment in either the CD4+ or CD8+ subpopulations. However, when the sum of the differences in V beta frequencies (delta score) between peripheral blood lymphocytes (PBL) and lamina propria lymphocytes (LPL) were determined for each individual, significant differences were observed between the CD4+ and CD8+ populations and among the patient groups. In all three patient groups, there were significant individual differences between LPL and PBL in the frequencies of CD8+ and CD4+ cells reacting with the four V beta-specific mAb. In Controls and UC, this difference was, on average, two-fold greater in CD8+ cells than in CD4+. In CD, however, this difference was, on average, the same for CD8+ and CD4+ cells. These observations suggest that (1) the human colonic LPL TCR repertoire is normally different from that of PBL, especially in the CD8+ population and (2) there is an alteration in the LPL TCR repertoire in CD which is not observed in Controls or UC.