Bedside peritoneal drainage in very low birth weight infants.

BACKGROUND: Bedside peritoneal drainage is emerging as a useful therapy for premature infants with intestinal perforation in the newborn period. Some authors recommend that bedside drainage be primary therapy for very low birth weight neonates. Surprisingly, some series report up to 70% of neonates so treated never require further or definitive surgery. METHODS: This is a retrospective chart review of all premature newborns with a diagnosis of either necrotizing enterocolitis or bowel perforation between November 1996 and May 2000. RESULTS: Sixty-seven patients were identified, of whom 27 were treated medically only and not considered here. Thirty-two neonates were treated with laparotomy primarily, with 26 survivors. Eight neonates were treated first with bedside peritoneal drainage. Of these, 4 survived, 6 required secondary surgery for obstruction or infection, and 2 died before any further intervention. CONCLUSIONS: Bedside peritoneal drainage is a useful adjunct in the approach to treating the very sick, very low birth weight neonate with evidence of intestinal perforation. Our experience does not support drainage as definitive therapy.

Follow-up studies on patients undergoing Nissen fundoplication utilizing intraoperative manometry.

Intraoperative esophageal manometry has been developed for use in children as a guide to optimizing the surgical results of Nissen fundoplication. Eighty-two Nissen fundoplication operations were performed using intraoperative manometry. Follow-up manometry was performed within 6 wk postoperatively in 45 patients and later than 6 wk postoperatively in 33 patients. The mean preoperative lower esophageal sphincter pressure (LESP) was 13 mm Hg. The mean postoperative LESP was 42 mm Hg. LESP was found to drop in the early postoperative period nearly 40%. There was minimal further decline in LESP between the early and late follow-up determinations. Lower esophageal sphincter length (LESL) was measured both pre- and postoperatively in 56 patients with an average increase of 1.4 cm. There was a very mild decline in LESL in the late follow-up period. The clinical course of these patients was correlated with manometric findings. The routine use of gastrostomy has been found to be unnecessary.

Muscle thickness in hypertrophic pyloric stenosis: sonographic determination.

Abdominal sonography was performed in 169 infants with vomiting. The hypertrophied circular muscle of the pylorus and distal antrum could be seen as a thick, hypoechoic cylinder in all cases of hypertrophic pyloric stenosis. The thickness of each wall of this cylinder was 4 mm or more in 86 of 93 patients subsequently shown to have hypertrophic pyloric stenosis at surgery. None of the patients without stenosis displayed this finding on sonography. Although technically demanding, sonographic imaging with a high-frequency system (7 MHz or more) can be an accurate initial examination for hypertrophic phyloric stenosis.

Prospective evaluation of angiography in the diagnosis and management of patients suspected of having pancreatic cancer.

One hundred three patients suspected of having pancreatic cancer underwent celiac and superior mesenteric arteriography which was reported 'blind.' Final diagnosis, operative findings, and resectability of pancreatic cancers were correlated with angiography reports. Forty patients had pancreatic cancer. Thirty-seven of these underwent laparotomy, and 14 (37%) had resectable lesions. Sensitivity and specificity of arteriogrphy for pancreatic cancer were 72% (29/40) and 71% (45/63) respectively. Resectability was unrelated to the angiographic diagnosis. Nonresectability was related to an angiographic finding of definite tumor vessel (4/4), large-vessel encasement (14/7), and major venous pathology (8/11). Only the first of these was unique to pancreatic cancer. Hepatic metastases were detected in only six of 13 patients. Small-artery encasement, arterial occlusion, vessel displacement, and gallbladder distention were not indicators of diagnosis or extent of disease. Major anatomic anomaly of foregut vasulature was revealed in 25% of angiographic studies. Prior knowledge of such anomalies has important bearing on the operative approach to pancreatic resection. We conclude that angiography should be performed prior to laparotomy whenever a resectable pancreatic cancer is suspected from other investigations. When used prospectively, angiography is not a reliable diagnostic or prognostic tool for pancreatic cancer.