Is the use of cyanoacrylate in intestinal anastomosis a good and reliable alternative?

PURPOSE: The present study aims to compare strength, healing, and operation time of experimental intestinal anastomoses performed by polyglactin 910 (Vicryl; Ethicon, Edinburgh, United Kingdom) sutures with ethyl-2-cyanoacrylate glue (Pattex; Henkel, Dusseldorf, Germany). MATERIAL AND METHODS: Ninety-six Sprague-Dawley rats were divided into 2 (groups E and L). Each group was further subdivided into 6 subgroups (EA1, EA2, EA3, EB1, EB2, EB3, LA1, LA2, LA3, LB1, LB2, LB3), each containing 8 rats. Intestinal anastomosis was performed by polyglactin 910 sutures in A subgroups and with ethyl-2-cyanoacrylate in B subgroups. The anastomosis was end to end in A1 and B1, side to side in A2 and B2, and end to side in A3 and B3. Time for anastomosis performance (AT) was recorded. In group E, bursting pressures and hydroxyproline levels were determined on the second postoperative day, whereas in group L, the same measurements were made on the sixth postoperative day. One-way analysis of variance was used for analyses of variance in the groups. Quantitative data were analyzed with Student's t test. P value was considered significant at less than .05. RESULTS: There was no significant difference between bursting pressures of subgroup pairs on both postoperative days 2 and 6. Hydroxyproline levels and AT were significantly better in B subgroups. CONCLUSION: Better healing, shorter AT, and equal strength were achieved with ethyl-2-cyanoacrylate compared with polyglactin 910 sutures in intestinal anastomosis in the experimental setting.

Management of esophageal perforation secondary to caustic esophageal injury in children.

PURPOSE: To review our management of esophageal perforation in children with caustic esophageal injury. METHOD: We reviewed the medical records of 22 children treated for esophageal perforations that occurred secondary to caustic esophageal injury. RESULTS: There were 18 boys and 4 girls (mean age, 5 years; range, 2-12 years). Three children were treated for perforation during diagnostic endoscopy and 19 were treated for a collective 21 episodes of perforation during balloon dilatation. One child died after undergoing emergency surgery for tracheoesophageal fistula and pneumoperitoneum. Another patient underwent esophagostomy and gastrostomy. Twenty patients were treated conservatively with a nasogastric tube, broad spectrum antibiotics, and tube thoracostomy, 16 of whom responded but 4 required esophagostomy and gastrostomy. Although the perforation healed in 21 patients, 20 were left with a stricture. Two children were lost to follow-up, 8 underwent colonic interposition, and 10 continued to receive periodic balloon dilatations. Two of these 10 patients underwent colonic interposition after a second perforation. The other 8 became resistant to dilatations: 4 were treated by colon interposition; 2, by resection and anastomosis; and 2, by an esophageal stent. CONCLUSIONS: Esophageal perforation can be managed conservatively. Because strictures tend to become resistant to balloon dilatation, resection and anastomosis is preferred if they are up to 1 cm in length, otherwise colonic interposition is indicated.

The missing hazelnut.

This report describes a case of esophageal perforation caused by a hazelnut which became stuck in the upper esophagus but was not detected. We outline the pitfalls in diagnosis, complications and treatment in the pediatric population.

Do patch procedures prevent complications of the Mathieu technique?

PURPOSE: The effects of V-incision sutured (MAVIS) and dartos patch reinforcement techniques in reducing side effects and complications of the Mathieu procedure and improving the appearance of the meatus are evaluated. MATERIALS AND METHODS: A total of 74 patients with distal shaft hypospadias without chordee or with minimal chordee were operated on by a single surgeon using Mathieu's technique. While only the classic Mathieu repair was performed in group 1, MAVIS and dorsal dartos patch reinforcement was included with the procedure in group 2. A silicone urethral catheter and foam silicone dressing were used in both patient groups. RESULTS: There were 32 cases in group 1 and 42 in group 2. Median patient age at operation was 3.2 and 3.4 years in groups 1 and 2, respectively. Mean postoperative period for the silicone catheter was 4.9 days in both groups. Followup ranged from 52 to 128 months (mean 76) for group 1 and 13 to 43 months (25.4) for group 2. Five fistulas and 1 meatal stricture developed in group 1 and all the children in this group required meatal calibration with dilatation in some. Neither fistula nor stricture occurred in group 2 and there was no need for calibration. A slit-like meatus was achieved in all children in group 2 but in only 12 in group 1. CONCLUSIONS: The MAVIS technique and dorsal dartos patch reinforcement may prevent complications of the classic Mathieu procedure. A slit-like meatus was obtained in all cases with this approach.

Neonatal gastric perforation: review of 23 years' experience.

PURPOSE: To review our experience of treating 13 neonates with gastric perforation (GP) over the past 23 years. METHODS: The records of all 13 patients were reviewed, noting gender, weight, gestational age, age at admission, associated anomalies, site of perforation, type of operation, and clinical outcome. RESULTS: There were 11 boys and 2 girls, with a mean body weight of 2 375 g, including 4 (45%) preterm infants. The mean age at admission was 3.2 days. Three (23%) infants had associated anomalies. Perforation occurred in the lesser curvature and anterior wall in 3 (23%) infants, at the greater curvature and anterior wall in 2 (15.4%), in necrosis of anterior wall in 1 (7.7%), at the esophageal junction and posterior wall in 2 (15.4%), at the lesser curvature and posterior wall in 1 (7.7%), at the lesser curvature and esophageal junction in 1 (7.7%), and the site was not specified in 3 (23%). Twelve patients were treated with gastrorrhaphy and drainage, and 1 was treated with gastrorrhaphy alone. Three patients required additional gastrostomy. Mortality was 53.8% (n = 7). Early diagnosis and management before clinical deterioration of the metabolic status improved the prognosis. CONCLUSION: The pattern of presentation and surgical findings should be investigated comparatively in premature and full-term neonates, as the etiology of this condition is likely to differ in these two gestational groups.

Hepatobiliary mucinous cystadenoma in a child.

The authors present a 4-year-old boy who had a large mucin-hypersecreting hepatobiliary cystadenoma. The tumor caused a hepato-colo-cutaneous fistula, which produced a large amount of external fluid loss. Total excision and the repair of the fistula could be possible after shrinkage of the tumor with the use of selective embolization of the feeding artery by interventional radiology.

Intestinal rotation anomalies in childhood: review of 22 years' experience.

PURPOSE: We review our experience of treating intestinal rotation anomalies in infants and children in the 22-year period between 1978 and 2000. METHODS: The type of operation performed, postoperative complications, and mortality were compared in three age groups. Group 1 consisted of neonates <1 month old, Group 2 consisted of infants aged <1 year old, and Group 3 consisted of children aged >1 year old. RESULTS: There were 101 infants and children, with a female : male ratio of 2 : 1. Of the 101 patients, 72 (71%) were neonates, with a mean age of 11.8 days (range 1-28 days); 20 (19.8%) were under the age of 1 year, with a mean age of 6.7 months (range 1-12 months); and 9 (8.9%) were >1 year of age, with a mean age of 6 years (range 1-9 years). Eighty-five (84%) patients underwent emergency procedures. Ladd's operation was performed in all patients, with various additional procedures. The most frequent postoperative complications were adhesive intestinal obstruction, stoma necrosis, evisceration, and short bowel syndrome. The mortality rate was 36% in Group 1, 20% in Group 2, and 0% in Group 3. CONCLUSIONS: In this series surgery was usually performed as an emergency procedure, with higher morbidity and mortality in newborns than in older infants and children.

Management of portal hypertension in children: a retrospective study with long-term follow-up.

OBJECTIVES: Data regarding the management of the portal hypertensive haemorrhage in the paediatric patients have yielded conflicting results. The purpose of this study was to evaluate the efficacy of beta-blocker (propranolol) alone, sclerotherapy alone and beta-blocker + sclerotherapy combination in the management of portal hypertension in the paediatric population. METHODS: Medical information was retrieved from the records of 62 children with portal hypertension who were under treatment during at least two years of follow-up period. Data collected included diagnosis, type of portal hypertension, age at initiation of therapy, bleeding episodes before and during therapy. RESULTS: Sixteen of 62 patients were diagnosed as extrahepatic portal hypertension, 46 as intrahepatic portal hypertension. The mean age of study population was 7.6 +/- 4.2 years, 45 percent being females. The mean duration of follow-up under therapy was 5.2 +/- 2.5 years. Among the patients with intrahepatic portal hypertension, 29 received propranolol + sclerotherapy, 12 received only propranolol and 5 received only sclerotherapy. There was no significant decrease in bleeding episodes during propranolol or sclerotherapy. However patients under propranolol + sclerotherapy, showed significant decrease in bleeding episodes during therapy (23/29 before therapy, 15/29 during therapy, p < 0.05). Rebleeding index in patients with IHPH was significantly long in the group treated by propranolol + sclerotherapy (p = 0.0001) compared with before therapy. Because the numbers of patients in the groups are small, Kaplan Meier estimation suggest that propranol treatment is more effective. But there isn't significant difference when the results were compared with those of before therapy, except in the combined treatment group. CONCLUSION: The monotherapy is not sufficient for longterm follow-up of portal hypertensive patients. The combination therapy with propranolol + sclerotherapy appears more encouraging in the prevention of portal hypertensive haemorrhage, but this needs to be assessed in randomized trials.

Pyloric atresia: 15-year review from a single institution.

BACKGROUND: Pyloric atresia (PA) is a rare pathology. Calder presented the first pyloric atresia case in 1749 and Touroff, Sussman, Meltz, and their colleagues presented the first successful operation in 1940. PA has 3 types of anatomic variations: (1) type A, pyloric membrane or web; (2) type B, the pyloric channel is a solid cord; and (3) type C, in which there is a gap between the stomach and duodenum. Associated anomalies also have been described. Epidermolysis bullosa (EB) and intestinal anomalies occur most often with this condition. METHODS: Charts of 16 cases of congenital PA, aged 1 to 30 days and admitted to our department between 1986 and 2001, were studied retrospectively in regard to sex, prenatal diagnosis, presence of polyhydramnios, time of admission, pathology, type of operation, associated anomalies, and mortality rate. RESULTS: In the study group, the male to female ratio was 5:3, the mean birth weight was 2,312 g and the mean age of admission was 6.5 days. The distribution of the anatomic variations was type A in 9 (56.3%) and type B in 7 (43.7%) of cases. Associated anomalies were present in 7 cases (43.8%). Familial occurrence was a prominent feature of our series. Seven of 16 cases occurred in 3 families. We performed 9 web excisions together with Heineke Mikulicz (H-M) pyloroplasty, 5 atresia excisions and gastro-duodenostomy, and 2 H-M pyloroplasties alone. Stamm gastrostomy was supplemented in 3 cases. The overall mortality rate (n = 9) was 56.3%. CONCLUSIONS: Pyloric atresia can be managed successfully if it is diagnosed early. In this group of patients, congenital anomalies or septicemia are the main causes of mortality.

Nonsurgical diagnosis and management of an inflammatory pseudotumor of the spleen in a child.

Primary splenic tumors in children are rare and usually benign. We report the case of a 7-year-old boy with a splenic mass that initially resembled an infectious process. Histopathologic examination of a specimen obtained using sonographically guided Tru-cut needle biopsy, performed after angiography, revealed an inflammatory pseudotumor of the spleen, an extremely rare benign lesion. The lesion has been managed conservatively with clinical and sonographic follow-up. This case shows that benign lesions of the spleen can easily be diagnosed using current radiologic and histopathologic techniques without the need for surgery, thus allowing total or even partial splenectomy to be reserved for patients in whom a mass cannot be diagnosed or in whom clinical progression is evident.

Arterial carbon dioxide markedly increases during diagnostic laparoscopy in portal hypertensive children.

UNLABELLED: Several factors are responsible for hypercarbia during laparoscopic procedures. This study was undertaken because we observed a sudden increase in PaCO(2) in children with portal hypertension (PHT), which was unusual in healthy children undergoing laparoscopic procedures. Fifty-seven children underwent laparoscopic procedures under general anesthesia and were mechanically ventilated. Arterial blood samples were obtained 5 min after intubation (T(0)), 15 min and 30 min after CO(2) pneumoperitoneum (T(15) and T(30)), 5 min after desufflation (T(end)), and 10 min after extubation (T(ext)) for blood gas analysis. The changes in PaCO(2), pH, and ETCO(2) were statistically significant during the study periods in both groups (P < 0.05). The percentage of PaCO(2) increase between T(0) and T(15) was 11.5% and 20.1%, respectively, in the control group and the PHT group (P < 0.05). This increase reached 36.8% at T(30) in the PHT group, whereas the control group had a 17.2% increase (P < 0.05). ETCO(2) presented similar changes. The variability in base excess, bicarbonate, PaO(2), arterial oxygen saturation, and SpO(2) was not significant in either group (P > 0.05). The PaCO(2) increased remarkably in children with PHT undergoing laparoscopy, with no difference in intrahepatic or extrahepatic origin. Limiting the duration of CO(2) pneumoperitoneum and intraabdominal pressure and adjusting ventilatory variables to accommodate hypercarbia are of the utmost importance for such cases. IMPLICATIONS: We compared children with portal hypertension with systemically healthy children during laparoscopy. The increase in arterial and end-tidal CO(2) was remarkable in children with portal hypertension, regardless of bicarbonate changes. Managing ventilation to accommodate hypercarbia is of the utmost importance for such cases.

Esophageal variceal bleeding secondary to portal hypertension: endoscopic sclerotherapy as the first-step treatment.

BACKGROUND: Variceal bleeding from the esophagus is an important cause of mortality and morbidity in children with portal hypertension (PHT). PATIENTS AND METHODS: A series of 69 PHT cases (41 intrahepatic, 28 extrahepatic) have been evaluated in our department since 1990. According to the Child-Pugh classification, 49 cases were in class A, 16 cases were in class B, and 4 cases were in class C at admission. In our protocol, endoscopic sclerotherapy is performed in all patients, and the diagnosis is achieved directly by diagnostic laparoscopy and fine-needle liver biopsy. The procedure is applied under general anesthesia, and 1% aethoxysclerol (polidocanol) is injected paravariceally and intravariceally with the use of a flexible endoscope. RESULTS: The Sugiura procedure was performed in nine patients who presented with recurrent bleeding episodes despite the strict sclerotherapy protocol. Liver transplantation was performed in two patients who were in Child class C. The total mortality rate in this series was 7% (5/69). CONCLUSION: Endoscopic sclerotherapy, as presented herein, decreases the need for additional surgical interventions in children with PHT.