[Training in laparoscopy and appendicitis]. / Entrenamiento en laparoscopia y apendicitis.

BACKGROUND: In order to improve laparoscopic skills, appendectomy is the most common procedure because of its high frequency and low difficulty. In spite of that, during the learning curve (each surgeon´s first 35 interventions) the incidence of complications may increase, so improvement in training means a bigger risk for some patients. METHODS: We retrospectively reviewed major complications (intra-abdominal abscess, intestinal occlusion, hemorrhage) of 1,710 appendectomies performed at our service between 1997 and 2013. We divided them in three groups: open appendectomy (OA, n= 1,258), laparoscopic appendectomy during the learning curve (LDC, n= 154) and laparoscopic appendectomy after the learning curve (LAC, n= 298). In addition, we distinguish between simple appendicitis (n= 1,233) and peritonitis (n= 477). RESULTS: In the OA group we detected110/1,258 major complications (8.7%), 28/154 major complications (18.2%) in the LDC group and 19/298 (6.4%) in the LAC group (p<0.05 LDC vs OA and LAC). In the simple appendicitis group, we found 13/889 major complications (1.5%) in OA, 3/115 (2.6%) in LDC group and 2/229 (0.9%) in LAC group (p= ns LDC vs OA and LAC). In the peritonitis group, 97/369 (26.3%) major complications were found in OA group, 25/39 (64%) in LDC group and 17/69 (24.6%) in LAC group (p<0.05 LDC vs OA and LAC). CONCLUSIONS: Educational purpose laparoscopic appendectomy must be used in simple appendicitis cases.

INTRODUCCION: Para la formación en laparoscopia, la apendicectomía es la intervención más utilizada, por su alta frecuencia y, habitualmente, escasa dificultad. Sin embargo, durante la curva de aprendizaje (las primeras 35 intervenciones), el número de complicaciones puede aumentar, con lo que el beneficio de la formación se puede convertir en perjuicio para algunos pacientes. Por ello hemos revisado las complicaciones graves de las apendicectomías laparoscópicas realizadas en nuestro Servicio antes y después de la curva de aprendizaje y las hemos comparado entre sí y con las de las apendicectomías abiertas. MATERIAL Y METODOS: Se han revisado las complicaciones graves (abscesos intraabdominales, oclusiones, hemorragias, etc..) de las 1.710 apendicectomías realizadas en nuestro centro desde 1997 hasta 2013, divididas en tres grupos: abiertas (AA, n= 1.258), laparoscópicas durante la curva de aprendizaje (LDC, n= 154) y laparoscópicas tras la curva de aprendizaje (LTC, n= 298). Se han dividido en apendicitis simples (n= 1.233) y peritonitis (n= 477). RESULTADOS: En el grupo AA se detectaron 110/1.258 complicaciones graves (8,7%), en el grupo LDC 28/154 (18,2%) y en el grupo LTC, 19/298 (6,4%) (p<0,05 LDC vs AA y LTC). En las apendicitis simples las complicaciones fueron 13/889 (1,5%), en las AA 3/115 (2,6%) en el grupo LDC, y 2/229 en el grupo LTC (0,9%) (p= ns LDC vs AA y LTC). En las peritonitis las complicaciones fueron 97/369 (26,3%) en las AA, 25/39 (64%) en el grupo LDC y 17/69 (24,6%) en el grupo LTC (p>;0,05 LDC vs AA y LTC). CONCLUSIONES: La apendicectomía laparoscópica con fines formativos debería reservarse a los casos de apendicitis simples.

[Biodegradable catheters for fistula prevention in hypospadias. Experimental preliminary study]. / Sondas biodegradables para la prevención de las fístulas de hipospadias. Estudio preliminar experimental.

INTRODUCTION: Continuous technical innovations are not enough to resolve the high incidence of fistula after hypospadias repair. A urethral catheter-tutor made of reabsorbable polymeric biomaterial (RPB) which could be left in situ long enough could reduce the complications. TARGET: To investigate in an animal model differents RPB to be used in urology. METHODOLOGY: CRL Wistar rats, males, divided into 5 equal groups according to the used polymers: polylactide; lactic-coprolactone copolymer; lactic-glycolic copolymer; simulated; control silicones. Three individuals were sacrificed per group at 4th, 10th and 16th week. In all animals (exceptuating the simulated group), biomaterial was fixed to the bladder wall bylaparotomy. Animals remained in individual housing and kept under daily control of hematuria during the first 15 days and weekly weight and urine control for pH and lactate. After being slaughtered, remaining polymer was collected for chemical analysis and bladder tissue for hystologic study. RESULTS: There was no mortality, hematuria nor other clinical signs. The bladder wall showed a mild foreign body reaction. The values of lactate and pH in urine did not reach toxic levels. Lactic-glycolic was totally reabsorbed by the 10th week and had the lowest degree of calcification. Polylactide and lactic-coprolactone remained intact. CONCLUSION: The model of urinary bladder has proven useful for studying the degradation of bioresorbable polymers. The analyzed polymers have spent long time to be reabsorbed, so we will have to study new others.

[Management of appendicular mass]. / Tratamiento y seguimiento del plastrón apendicular.

BACKGROUND: Management of appendicular mass is still controversial. Some authors plead for an initial non-operative approach followed by a delayed appendectomy. OBJECTIVES: Our aim has been to revise the usefulness of this management and the optimal time to carry out the appendectomy. METHODS: We made a retrospective review of all the appendicular mass cases treated in our hospital during the last 8 years. We analyzed the success rate of the non-operative approach, the interval until the delayed appendectomy was performed, difficulty found at surgery and the occurred complications. RESULTS: Our series includes 19 appendicular mass cases managed initially by a non-operative approach. Intravenous antibiotics were administered to all of them and in 14 cases a peritoneal drainage was placed (the average length of stay was of 11.5 days). In 3 cases (16%) early appendectomy was performed (12, 30 and 40 days after the onset of the symptoms). In 16 (84%) the conservative approach succeeded and the appendectomy was delayed 3-12 months (average: 6.6 months). Four of them were performed by an open approach and 12 by laparoscopy (in 3 of which conversion was needed). The average length of stay was of 1.8 days, with only one complication (wound abscess). Of these 16 delayed appendectomies, 11 were not technically difficult to perform (average wait of 5.5 months) and in 5 cases the procedure was difficult due to multiple adhesions (average wait of 9.4 months). CONCLUSION: Conservative management of appendicular mass is useful, with a success rate of 84% in our series. The appendectomy was less hazardous if performed 3-6 months after the onset of the symptoms.

[Adaptation in the small intestine: Effect of minimal enteral nutrition and probiotics on proliferation and apoptosis in the intestinal wall]. / Adaptación en el intestino corto: efecto de la nutrición enteral mínima y los probióticos sobre la proliferación y la apoptosis en la pared intestinal.

BACKGROUND: The intestinal wall integrity is central to the barrier function and depends on the balance of proliferation/apoptosis. Short bowel (SB) or Parenteral Nutrition (PN) induce high bacterial translocation (BT) probably by the intestinal barrier bug. Probiotics or minimal enteral nutrition (MEN) have reduced BT in animal models. OBJECTIVE: Determine in two BT animal models (SB or PN) the effect of MEN or probiotics on proliferation and apoptosis rates of the intestinal wall. METHODS: Seventy-one Wistar rats, divided into 4 groups: 1) PN (N = 23): parenteral nutrition; 2) PNMEN (N = 16): PN + MEN (2.9 g/100 g/day standard diet); 3) RES (N = 15): 80% bowel resection and standard oral diet; 4) RESPROB (N = 17): RES + probiotics (7 X 10(9) CFU Bifidobacterium lactis). After 10 days in metabolic cages, mesenteryc lymph nodes, portal blood and peripheral blood were cultured. By immunohistochemistry, proliferation and apoptosis index were calculated as well as the proliferation-apoptosis rate. RESULTS: BT: decreased in PNMEN (45%) and RESPROB groups (35%) versus PN (65%) and RES (67%) groups (p<0.05). Proliferation index: was better in PNMEN (12,07) and RESPROB (13,93) groups than PN (7,45) and RES (5,54) groups. (p

[Detection of bacterial translocation by polymerase chain reaction in an experimental short bowel model]. / Diagnóstico de la translocación bacteriana en el intestino corto experimental mediante reacción en cadena de polimerasa.

BACKGROUND: Bacterial overgrowth occuring after massive bowel resection, facilitates Gram-negative intestinal Bacterial Translocation (TB). Probiotic agents might have beneficial effects on TB. On the other hand, polymerase chain-reaction (PCR) has better sensitivity than conventional methods for bacterial detection and has not been investigated in experimental models of short bowel syndrome and TB. OBJECTIVE: To test the hypothesis that the administration of Bifidobacterium lactis (BL) decreases Escherichia coli Bacterial Translocation (ECTB) in experimental short bowel syndrome and to confirm the better sensitivity of PCR technique to detect ECTB. METHODS: Adult Wistar rats, orally fed with standard rat chow and tap water "ad libitum", were maintained in individual metabolic cages for ten days and divided into three groups: Control (n = 15): non-manipulated animals. RES (n = 15): 80% gut resection. Daily administration 1 ml of sterile water, after orogastric intubation. RES-PRO (n = 18): same resection and daily administration of 7.8 x10(9) Bifidobacterium lactis Colony Forming Units (CFU). At the end of the experiment, mesenteric lymph nodes (MLN), and both peripheral and portal blood samples were recovered and cultured by standard procedures. Also, genomic DNA from E. coli was detected by PCR technique. RESULTS: By conventional cultures ECTB was detected in 0% in the control group, 73% in the RES group and 33% in the RES-PRO group. PCR technique detected ECTB in 47% of the control group, 87% of the RES group and 33% of RES-PRO group, showing higher sensitivity. By both methods, animals receiving BL (RES-PRO group) showed less ECTB. By conventional culture, the relative risk (RR) was 0.45 (95% CI 0,22-0,79) and the number needed to treat (NNT) was 3 (95% CI 0-11). By PCR technique, the RR was 0.38 (95% CI 0.19-0.76), and the NNT 2 (95% CI 0-4). CONCLUSIONS: 1) Administration of Bifidobacterium lactis reduces the incidence of ECTB. 2) PCR technique is a more sensitive method for ECTB detection.

[Laparoscopic appendectomy after the learning curve]. / La apendicectomía laparoscópica más allá de la curva de aprendizaje.

BACKGROUND: Despite its increasing popularity, laparoscopic appendectomy does not put an unanimous end to the answer to the best treatment for appendicitis. Although the postoperative stay is shorter, the wound infection practically does not exist and scars are minimal, some publications question its advantages due to the incidence of intra-abdominal absceses, postoperative analgesia requirements and the recently described "postlaparoscopic appendectomy complication" (PLAC), an intra-abdominal infection, without abscess formation, which develops after laparoscopic appendectomy for non-complicated appendicitis. Some of this series include the "learning curve", wherein they compare results of inexperienced surgeons in laparoscopic techniques with those obtained after with the firmly established open appendectomy (OA) technique. With the aim to clarify this aspects, we reviewed our experience in laparoscopic appendectomy during (LDC) and after (LAC) the "learning curve" and we compared their complications with the open appendectomies' ones. METHODS: We retrospectively reviewed 807 appendectomies: 208 laparoscopic (LA) and 599 open (OA) from January 2001 to December 2007 performed in our hospital. In the laparoscopic group, 83 of them (40%) were done during the learning curve (each surgeon's 35 first interventions, LDC) and 125 (60%) after the learning curve (LAC). We have compared both laparoscopic subgroups to each other and to the open appendectomies group. We analysed the age, sex, length of stay, kind of appendicitis (simple or perforated appendicitis) and five of the most serious complications: intra-abdominal abscess, postoperative intestinal occlusion, intestinal perforation, haemorrhage and PLAC. RESULTS: The mean age (9 years), sex (58% men; 42% women) and the peritonitis rate (30%) were similar among the 3 groups. The mean length of stay was reduced from 5.4 days in OA group to 4.2 days in LA group and 3.6 days in LAC group (p < 0.01). The simple appendicitis cases had the shortest length of stay: 3.41 days in OA group and 2.16 days in LA group (p < 0.0001). There were no differences in stay for the peritonitis group. In the OA group, we detected 56 severe complications (9,3%): 49 abcesses, 2 occlusions, 2 PLAC, 1 haemorrhage, 1 intestinal perforation and 1 liver abscess. Nineteen severe complications were found in LDC group (22,9%): 9 abscesses, 4 occlusions, 4 haemorrhages, 1 intestinal perforation and 1 PLAC (p < 0.01 vs OA group). In the LAC group, we found 13 complications (10,4%): 9 abscesses, 1 occlusion, 1 PLAC and 2 haemorrhages (p = 0.3 vs OA group). CONCLUSIONS: 1. The length of stay was significantly reduced in laparoscopic appendectomies. 2. Severe complications, particularly intestinal occlusions and haemorrhages, increased significantly during the learning curve, with a slight fluctuation for intra-abdominal abscesses and PLAC. 3. After the learning curve, complications' global rate was similar to the OA group's, with an increment of haemorrhages and occlusions, no variation for PLAC and a slight reduction for intra-abdominal abscesses. 4. In our experience, laparoscopic appendectomy after the learning curve is the best therapeutic option for acute appendicitis.

[Currarino syndrome]. / Sindrome de Currarino.

The Currarino syndrome is a form of caudal regression syndrome characterized by the classic triad of presacral mass, sacral bone defect and anorectal malformation in which an autosomal dominant inheritance has been described. In case of clinical suspicion it is necessary to search for the classic alterations and to detect other possible associated malformations in order to avoid complications. The management is multidisciplinary and depends on the type of alterations that the patient has. We report a 17-month-old female baby that initially passed unnoticed and was detected during a rectoplasty for reconstruction of a rectal stenosis. The baby presented complications derived from ignorance of the existence of a presacral mass. Early diagnose and adequate treatment is very important.

[Short bowel syndrome in the research setting: 15 years' experience]. / El síndrome de intestino corto en el ambito experimental: experiencia de 15 años.

The fight against infection and liver disease associated with parenteral nutrition (PN) are surely two of the most problematic aspects in the management of paediatric patients with short bowel syndrome (SBS). In the Research Unit of Donostia Hospital, we have spent the past 15 years investigating different ways of reducing these complications in an experimental model of short bowel in the Wistar rat (resection of 80% of the small bowel, with and without PN). All the experiments had a duration of 10 days and 323 animals reached the end of the study period. Nine groups were established in which some type of intervention was performed, and there were 8 control groups. The interventions were: 3 dietary (minimal enteral nutrition [MEN] with low or high dose probiotics); 5 pharmacological (administration of growth hormone [GH], epidermal growth factor [EGF], insulin, cholecystokinin [CCK], and selective intestinal decontamination [SID]); and 1 surgical (resection of the ileocaecal valve). Infection due to bacterial translocation (BT) was detected by culture of mesenteric lymph nodes, portal blood and peripheral blood, and liver damage by the levels of proinflammatory cytokines (IL-1 and TNF-alpha). In summary, our results are: Probiotics, MEN and SID reduce BT. Liver damage was milder in the groups with MEN, SID and CCK. The groups receiving GH, EGF or insulin presented a higher incidence of BT. BT was lower after resection of the ileocaecal valve. In conclusion, the probiotics, MEN and CCK could be useful in the management of children with SBS. These data confirm the utility of this experimental model of short bowel for the investigation of different aspects of SBS.

[Effect of the administration of cholecystokinin on the cholestasis associated with total parenteral nutrition in experimental short bowel]. / Efecto de la administración de colescistoquinina sobre la colestasis asociada a la nutrición parenteral total en el intestino corto experimental.

INTRODUCTION: Total parenteral nutrition (TPN) is not free of complications. One of the most serious is cholestasis; the cause of this complication is unclear but it may be due to a lack of an enteral stimulus for cholecystokinin (CCK) production. CCK is essential for contraction of the gallbladder and also stimulates intrahepatic bile flow. Its absence may contribute to cholestasis. After any hepatic aggression, the Kupffer cells respond and release proinflammatory cytokines, such as interleukin-1 (IL-1) and tumour necrosis factor alpha (TNF-alpha), which increase the hepatic damage. The objective of this experimental study has been to observe the effect that the exogenous administration of CCK could have on hepatic damage in experimental short bowel with and without TPN, determined using the serum levels of IL-1 and TNF-alpha. MATERIAL AND METHODS: A resection of 80% of the small bowel was performed on 53 Wistar rats and a continuous infusion of saline or TPN was initiated. The rats were divided into the following groups: SHAM (N = 14): normal saline infusion and free access to food and water. TPN (N = 15): Standard TPN. SHAM-CCK (N = 14): same as the SHAM group but with a daily dose of CCK. TPN-CCK (N = 10): same as the TPN group but with a daily dose of CCK. At the end of the experiment, the animals were sacrificed and blood samples were obtained to determine the IL-1 and TNF-alpha values by ELISA. RESULTS: The IL-1 and TNF-alpha levels were higher in the TPN group (7.537 and 5.899 pg/mL, respectively) than in the SHAM group (6.509 and 4.989 pg/mL, respectively) (p > 0.05). The TNF-alpha values were higher in the SHAM group (4.989 pg/mL) than in the SHAM-CCK group (4.583 pg/mL) (p < 0.001). The IL-1 and TNF-alpha levels were higher in the TPN group than in the TPN-CCK group (6.709 and 4.794 pg/mL, respectively) (p < 0.001 for TNF-alpha). CONCLUSIONS: 1. There is a rise in the serum levels of the pro-inflammatory cytokines IL-1 and TNF-alpha in animals with short bowel on TPN or enteral nutrition. 2. The administration of CCK causes a fall in the IL-1 and TNF-alpha levels, and could be used such as a further measure to prevent TPN-associated cholestasis.

[Selective intestinal decontamination and parenteral nutrition related liver disease. Experimental study]. / Descontaminación intestinal selectiva y hepatopatía asociada a nutrición parenteral: estudio experimental.

Selective intestinal decontamination (SID) has been useful restraining Bacterial translocation (BT) in both animal models and human clinics. The not well known parenteral nutrition-related liver disease is a serious problem associated to short bowel and long-term parenteral nutrition (PN) use, and BT is also frequent in those patients. Germs reach liver through portal vein and activate Kupffer cells, which release cytokines as IL-1 or TNF-alpha. The aim of this study was to test the use of SID restraining BT in a PN undergoing experimental short bowel model, and its possible favourable consequences on hepatic injury determined by IL-1 and TNF-alpha levels. Twenty-five 240-280 g Wistar rats were divided into two groups and maintained in individual metabolic cages for ten days: Resection-PN group (n=15): animals with a bowel resection of the 80% and a continuous PN infusion. Resection-PN-SID (n=10) group: similar to previous group and a daily oral administration of Tobramycine (20mg/kg/day) and Polymyxine-E (25mg/kg/day). Animals were sacrificed and mesenteric lymph nodes (MLN), and both peripheral and portal blood samples were recovered for TB determination in bacterial culture. Determination of both IL-l and TNF-alpha seric levels were carried out by ELISA. Bacterial translocation incidence was higher in RES-NPT group (66.6%) than RES-NPT-SID group (30%) (P>0,05). The relative risk was 2.22 (IC 95% 0,81-6,11) and the number needed to treat was 3 (IC 95% 2-235). Seric levels of IL-1 and TNF-alpha were also higher in RES-NPT group (7,537 and 5,399 pg/ml, respectively) than in RES-NPT-SID group (6,397 and 5,032 pg/ml respectively) (p<0,001). 1. SID reduces TB in a PN undergoing experimental short bowel resection murine model. 2. Parenteral nutrition-related liver disease decreases in DIS receiving animals.

[Necrotizing enterocolitis and bacterial translocation: role of minimal enteral nutrition]. / Enterocolitis necrosante y traslocación bacteriana: papel de la nutrición enteral mínima.

INTRODUCTION: Both necrotizing enterocolitis (NEC) and bacterial translocation (BT) have in common that bacterial overgrowth, a decrease in immunity and intestinal mucosal damage, followed by a barrier failure, can act as trigger factors. The main objectives in NEC treatment are to reduce mortality due to sepsis and to promote feeding tolerance. To achieve that, Minimal Enteral Nutrition (MEN) (less than 25% of the calories provided by enteral route) is a more and more used technique in newborns who receive Parenteral Nutrition (PN) to slow down fasting related villi atrophy and to attenuate its consequences. AIM: To test the hypothesis that MEN decreases BT in an experimental model of PN. METHODS: Twenty-four adult Wistar male rats received a continuous infusion of all-in-one PN solution through a jugular vein catheter. The animals were randomly divided in two groups and maintained in individual metabolic cages for ten days. * Control group (N= 1): fasting rats receiving, standard PN (300 mL/kg/ 24 h, 280 kcall kg/24 h). * MEN group (N=13): standard PN and rat chow (15 g /24 h, 3,1 kcal/g). At the end of the experiment animals were sacrificed and mesenteric lymph nodes (MLN), and both peripheral and portal blood samples were recovered and cultured. Bacterial identification in blood was carried out by conventional methods and MLN culture was considered positive with a growth over 100 Colony Forming Units/g. RESULTS: Weight curve was better in MEN group and BT was also significantly reduced. Translocation was found in 45% of control group and 8% of MEN group (p < 0,05). The relative risk (RR) was 5,9 (IC 95% 0,81-43,71) and the number needed to treat (NNT) was 3 (95% CI 2-20). CONCLUSIONS: 1. MEN reduces the incidence of BT in an experimental model of parenteral nutrition. 2. BT reduction could decrease NEC-related sepsis risk.

Predicting preoperatively the outcome of respiratory symptoms of gastroesophageal reflux.

The fact that bronchopulmonary symptoms remain unchanged in about 15% of patients after successful operation for gastroesophageal reflux (GER) with respiratory tract disease (RTD) makes surgical indications uncertain and warrants further research into preoperative prognostic predictors. This problem has been addressed in infants by demonstrating that those most likely to be cured by antireflux procedures have long nocturnal episodes of GER and/or temporal coincidence between drops in pH levels and respiratory episodes. In an attempt to validate these predictors and, at the same time, to search for other reliable ones, we have retrospectively studied the charts, manometric studies, pH tracings, and pathology reports of 55 patients aged 48 +/- 36 months (range, 2 to 170) who had Nissen funduplication for GER with RTD in the last 10 years. Forty-five children were cured or improved of their RTD symptoms after operation, but in 10 (18%) they were unchanged in spite of the control of GER. Patients with a former history of vomiting (n = 38) had better results than those (n = 17) without it (95% of RTD cure v 53%, P less than .001). The success rate in children with recurrent obstructive airway disease (n = 20) was definitely lower than in those without it (n = 35) (70% v 89%, P less than .05). Neither esophageal manometry nor mucosal biopsy provided any predictive clue, but pH studies confirmed that the mean duration of nocturnal episodes of reflux (ZMD) was definitely longer in patients responding favourably to surgical cure of GER than in those in whom this failed (12.2 +/- 9.6 v 3.9 +/- 2.8 minutes, P less than .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Simultaneous gastroesophageal pH monitoring and the diagnosis of alkaline reflux.

The diagnosis of alkaline gastroesophageal reflux (AGER) by esophageal pH-monitoring is elusive because several other causes may raise esophageal pH above 7. This study approaches the issue by simultaneously recording esophageal and gastric pH with a 2.1 mm assembly of two antimony electrodes in refluxing (n = 69) and nonrefluxing (n = 40) children. On the basis of the information gathered, patients were divided into four groups: acid refluxers (GER, n = 40 or 57%), alkaline refluxers (AGER, n = 8 or 11%), alkalacid refluxers (AAGER, n = 15 or 22%), and silent refluxers or false negatives (SGER, n = 6 or 9%). Children with AGER could not be differentiated from other refluxers nor from controls by esophageal pH information alone. Prolonged gastric buffering or alkalinization could be documented in both AGER and AAGER children, indicating extended duodenogastric reflux (DGR) in them. The incidence of esophagitis was not significantly different between the groups of refluxers: 75% for AGER and AAGER, 73% for GER, and 67% for SGER. AGER, a disorder involving both pyloric and gastroesophageal barriers, is as significant a problem in children as in adults and may lead to severe complications even in the absence of excessive acid exposure. Monitoring esophageal pH alone is insufficient for making the diagnosis of AGER. The diagnosis can be made with little more expense and similar patient discomfort using the two-probe test. We suggest the need for a critical reassessment of the current antacid and prokinetic GER treatments and of antireflux operations which leave DGR intact while correcting GER.

The area under pH curve: a single-figure parameter representative of esophageal acid exposure.

This investigation aims at providing simpler methods for reading esophageal extended pH-metering tracings. Because the currently used parameters only quantify frequency and duration of acid exposure, we have measured the area between the pH curve and the pH 4 line (area under curve [AUC]) in an attempt to include in the evaluation the severity of acid exposure as well. We compared 20 control and 63 children with gastroesophageal reflux (GER). Extended pH metering curves were read according to currently accepted methods. In addition, we measured planimetrically total 24-hour AUC, AUC during daytime, AUC during sleep time, and total AUC excluding 2-hour postprandial periods. In spite of the very significant differences found between means of controls and GER patients for all variables considered, values overlapped widely. Receiver-operating characteristic (ROC) analysis indicated the best threshold values for differentiation of controls and GER patients and tested the diagnostic efficiency for each variable. We found that 24-hour AUC was the best comprehensive value (sensitivity = 1, specificity = 1) and that there was probably no use for fractional evaluation during selected periods of time. The optimum 24-hour AUC threshold value in the present conditions of measurement (paper speed, 0.25 cm/min; 1 pH unit, 2.5 cm) was 20 cm2. In order to facilitate comparison we propose using a pH-surface unit (pHSU) equal to recording speed (in cm/min) multiplied by vertical shift per 1 pH unit (in centimeters) (in this case, 0.25 x 2.5 = 0.625 cm2). A threshold value of 20 cm2 thus becomes 32 pHSU. A similar transformation will be adequate for any other recording conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

Continuous positive airway pressure and gastroesophageal reflux: an experimental study.

Gastroesophageal reflux (GER) often occurs in babies receiving respiratory assistance for neonatal distress. The authors examined the lower esophageal sphincter and the thoracic and abdominal pressure conditions in rats under progressively higher continuous positive airway pressure (CPAP) to test the efficacy of the antireflux barrier under such conditions. Intrathoracic and intraabdominal pressures were recorded within the esophagus and within the inferior vena cava in 10 anaesthesized 250-g male rats. Pull-through techniques were used for lower esophageal sphincter pressure (LESP) and length (LESL) studies, and the length of the intraabdominal segment of the esophagus (LIASE) was also determined. Measurements were performed in baseline conditions and at CPAP levels of 0, 1, 3, 5, and 7 cm H2O. The respiratory effort progressively increased with prolonged expiration and decreased frequency. LESP and LESL did not change significantly, but the antireflux barrier was weakened by a progressive shortening of LIASE. Successive CPAP increases led to increasingly negative thoracic pressures during inspiration, and increasingly positive abdominal pressures during expiration yielded progressively greater transdiaphragmatic pressure gradients. The authors suggest that CPAP weakens the antireflux barrier and, at the same time, increases the gastroesophageal pressure gradient, thus increasing the risk of GER. Although transpolation of experimental data to the clinical setting is always hazardous, the authors believe this issue should be investigated in infants.

Airway obstruction and gastroesophageal reflux: an experimental study on the pathogenesis of this association.

Gastroesophageal reflux (GER) frequently complicates the clinical course of children suffering from conditions leading to upper airway obstruction (UAO) (choanal atresia, tracheomalacia, esophageal atresia, vascular rings, etc). In an attempt to explore whether partial airway obstruction causes changes in the normal thoracoabdominal pressure gradients, we measured end-inspiratory intrathoracic and intraabdominal pressures in anesthetized rats under spontaneous breathing conditions, after tracheostomy, and under upper airway obstruction induced by tracheal intubation with three progressively narrower cannulae (inner diameters 1.0 mm, 0.5 mm, and 0.2 mm). We also measured the lower esophageal sphincter pressure (LESP) and length (LESL) and calculated the thoracoabdominal end-inspiratory pressure gradient (TAEIPG). Neither LESP nor LESL changed significantly before or after maximal tracheal obstruction (14.3 +/- 6.2 v 18 +/- 7.6 cm H2O [P > .05] and 0.34 +/- 0.09 v 0.41 +/- 0.1 cm H2O [P > .05] respectively) but TAEIPG significantly increased from 5.58 +/- 1.34 cm H2O to 17.62 +/- 4.27 cm H2O (P < .01) under the same conditions, mainly as a result of progressively increasing negative intrathoracic pressures during inspiration. These experiments prove that the powerful thoracoabdominal pressure gradients developed after partial UAO may contribute to the pathogenesis of GER by overcoming the antireflux barrier function. This study points out the convenience of routinely screening for GER all children with airway obstructive conditions, bearing in mind that the reestablishment of normal respiratory conditions should be the primary goal of treatment.

Peutz-Jeghers syndrome in children: report of two cases and review of the literature.

In this article, we report two new cases of Peutz-Jeghers syndrome in children and review the literature over the past twenty years. This series of 70 cases demonstrates that the clinical pictures observed in children are similar to those of adults. Rectal prolapse or extrusion of polyps can be the clue to the diagnosis at an early age, even in the absence of pigmentation, which can appear later. Gastroduodenal polyps were strikingly frequent in the less than or equal to 16-yr-old group (62%) a circumstance that can create operative difficulties. Five out of the 70 patients (7.14%) had tumors during childhood (two gastrointestinal adenocarcinomas, two ovarian and one testicular neoplasms). A higher risk of tumor development in these patients does exist either as a result of degeneration of the polyps or of a genetic predisposition. Whenever operation becomes necessary, a very cautious approach must be advised in order to preserve as much intestinal length as possible in these patients, who have a lifelong disease which may require repeated operations.

Giant spontaneous duodenal hematoma in hemophilia A.

A 12-year-old hemophilic boy was admitted because of acute abdomen with intraabdominal bleeding. The cause was a giant intramural duodenal hematoma that resolved after 16 days of parenteral nutrition. This condition is a rare complication of coagulation disorders, but it should be suspected in cases with internal blood loss. Abdominal ultrasonography, computed tomography scans, and contrast x-ray studies are diagnostic procedures for such cases.

Lymphocyte subpopulations after extensive small bowel resection in the rat.

The increased risk of infection after massive intestinal resection (MIR) may be attributable to impaired nutrition, loss of intestinal lymphoid tissue, or both. This study examines whether MIR itself changes the immune cell populations in laboratory animals when nutritional status is preserved. The authors studied cellular immunity (lymphocyte subsets T4 and T8 and the T4:T8 ratio) and humoral immunity (IgG, IgM, IgA, and B lymphocytes) in the blood, spleen, and mesenteric lymph nodes of unresected Wistar rats (control group, n = 6) and of animals that underwent 80% bowel resection followed by 7 days of either oral feeding (resection-oral group, n = 6) or parenteral nutrition (resection-TPN group, n = 6). The increase in body weight was similar among all groups, and the levels of total protein, albumin, prealbumin, and immunoglobulin remained unchanged. All resected animals, irrespective of their feeding route, had significantly lower proportions of T4 and B lymphocytes and T4:T8 ratio in blood, T4 and T8 in mesenteric lymph nodes, and T4 and T4:T8 ratio in the spleen. The author's results suggest that removal of large amounts of lymphoid tissue along with the bowel during MIR might lead to inadequate immune response even when the nutritional status is preserved.

Effect of growth hormone, epidermal growth factor, and insulin on bacterial translocation in experimental short bowel syndrome.

BACKGROUND/PURPOSE: An adaptive process starts in the remaining intestine after massive resection, and several trophic factors including growth hormone (GH), epidermal growth factor (EGF), and insulin (INS) have been shown to have a positive effect on it. Bacterial translocation (BT) is frequent after extensive small bowel resection, but the effects of GH, EGF, or INS have not been investigated in experimental short bowel syndrome (SBS). This study tests the hypothesis that GH, EGF, or INS decrease BT in SBS in rats with parenteral nutrition (PN). METHODS: Thirty-eight adult Wistar rats underwent central venous cannulation and were assigned randomly to 1 of 4 groups receiving for 10 days 4 treatment regimes: (1) PN group (n = 10): fasting, all-in-one PN solution (300 mL/kg/24 h, 280 kcal/kg/24 h), 80% gut resection including ileo-cecal valve; (2) GH group (n = 9): fasting, same PN regime and resection, GH (1 mg/kg/d, subcutaneously); (3) EGF group (n = 9): fasting, PN, resection, EGF (150 microg/24 h intravenously); (4) INS group (n = 9): fasting, PN, resection, INS (1 UI/100 g/24 h subcutaneously). At the end of the experiment they were killed, and mesenteric lymph nodes (MLN) and peripheral and portal blood samples were recovered and cultured. Several fragments of intestine were taken to determine cell proliferation (PCNA index) and morphometric parameters (villous height, crypt depth). RESULTS: GH, EGF, and INS groups showed a 28%, 29%, and 30% increase in gut mucosal thickness, and PCNA index rose 21%, 20%, and 25%, respectively in comparison with PN controls. Bacterial translocation to peripheral blood was detected in 0% of PN animals and in 44%, 40%, and 28% of GH, EGF, or INS rats, respectively (P < .05). No differences were found in BT in MLN or portal blood among groups. CONCLUSION: Administration of GH, EGF, or INS improves gut mucosal structure in rats with SBS under PN, but, surprisingly, the incidence of BT detected in peripheral blood was increased rather than decreased in animals receiving these treatments.