Rat jejunal absorptive function after intestinal transplantation. Effects of extrinsic denervation.

Jejunal absorptive function was evaluated following small intestinal transplantation to determine the effects of extrinsic denervation. In particular, water and sodium absorption were measured following transplantation (denervated) and compared to a control group (Thiry-Vella). Water flow was initially secretory two days after transplantation (-41 +/- 27 microliters/min/g dry tissue weight) but became absorptive at day 8 (25 +/- 25). Water flow in the Thiry-Vella group was not significantly different (P > 0.05) from the transplant group at days 8 (17 +/- 7) and 10 (47 +/- 42). Sodium flows were also initially secretory in the transplant group and became absorptive. This study refutes previous claims that small bowel transplants have a deficiency of water absorption due to extrinsic denervation of the bowel and suggests normal absorptive function of water, electrolytes, and protein.

Steroid therapy and duodenal ulcer in infants.

Two infants with acute life-threatening complications of duodenal ulcer following steroid administration are described. Although the possible association between steroid therapy and peptic ulcer disease is well known, the need for ulcer prophylaxis during such therapy in infants is not unanimously accepted. The case for ulcer prophylaxis in this setting is presented.

Arterial trauma of the upper extremity in children.

Thirty children with upper extremity arterial trauma were retrospectively reviewed. Trauma was penetrating in 87% of cases and in 53% injury was caused by broken plate glass. The injured artery was repaired in all but four cases. Nerves were injured in 53% and tendons in 23%. All severed nerves and tendons were repaired primarily. Postoperatively three children with proximal injuries had no palpable pulse in the affected extremity. One patient died of underlying disease and another required amputation during initial surgery due to extensive soft-tissue injury. Followup revealed no dysfunction directly related to vascular insufficiency. Neurologic deficit was found in 33% of the children followed, but only in one was the limb totally nonfunctional. We conclude that the long-term outcome is largely dependent upon neurologic injury. Glass doors and large glass windows should be avoided in the vicinity of children's play areas.

Cervical small bowel transplantation in the rat: a useful tool.

Orthotopic intestinal transplantation in the rat is highly successful, but circumstances may require an extraabdominal graft location. We describe a microsurgical technique for cervical intestinal transplantation in the rat, which has been used to investigate the immune status of hosts already bearing an intraabdominal bowel transplant. A 10 cm segment of donor jejunum is harvested on a pedicle of superior mesenteric artery and superior mesenteric vein. In the recipient, the carotid artery (CA) and external jugular vein (EJV) are isolated. The venous anastomosis is performed end to end to the medial EJV branch, and the arterial anastomosis is completed end to side to the CA. Both anastomoses are performed with interrupted 10-0 nylon. The bowel is placed in a subcutaneous pocket in the neck, with both ends exteriorized. The procedure was performed in 11 donor-recipient pairs planned to elicit rejection, graft-vs.-host disease (GVHD) or graft acceptance. No technical complications were encountered. All rats survived long term, and their grafts were monitored histologically. The expected immune responses were observed, but rejection and GVHD were not fatal to the host with this model. We conclude that this technique is feasible and reliable to monitor the progress of isolated intestinal transplants. The location in the neck does not disrupt normal intestinal function of the recipient and may have multiple applications in the study of intestinal transplant immunology and physiology.

Small-bowel transplantation permits survival in rats with lethal short-gut syndrome.

The functional integrity of transplanted bowel would most convincingly be demonstrated if transplantation after an otherwise lethal intestinal resection permitted survival and growth. In this experiment, we proposed to define the extent of bowel resection necessary for lethality and to show that transplantation allows salvage of these animals. Adult Brown-Norway rats (250 g) underwent extensive small-bowel resection (SBR) (ligament of Treitz to ileocecal valve) (n = 5), cecectomy only (CEC) (n = 3), SBR plus CEC (n = 6), or SBR plus CEC and syngeneic transplantation of 25 cm of jejunum (n = 6). All animals with SBR or CEC alone survived and grew; all animals with SBR plus CEC died within 2 weeks (mean, 6.4 days); and 6 of 6 animals with SBR plus CEC and transplant survived and grew. The difference in survival between the lethally resected rats and those with an intestinal transplant was highly significant (P less than 0.01). Dietary intake was similar in all groups. We conclude that in the rat, extensive small-bowel resection alone is not sufficient to be lethal; most of the small bowel and the cecum must be resected to obtain a lethal model. We have also shown that transplantation of small bowel into rats with an otherwise lethal extent of bowel resection will allow the animals to survive and grow. These results suggest the need for caution in correlating survival after intestinal transplantation in the rat with transplant function, since the preservation of too much native gut might permit survival even if the transplant has no nutritional function.

Alteration in gastrointestinal peptide tissue levels in rejecting small bowel transplants.

Gastrointestinal (GI) peptide tissue levels were measured following intestinal transplantation in rats and evaluated as a possible early marker of transplant rejection. Vascularized syngeneic and allogeneic jejunal transplants were performed in rats without immunosuppressive therapy. Serial tissue samples of transplanted intestine were obtained from each group of animals. Baseline levels of peptides were determined in nontransplanted jejunum of the same animals. Results were correlated with histology at all experimental time points. Tissue levels of gut peptides (somatostatin, vasoactive intestinal peptide and substance P) were determined by two methods--immunoperoxidase staining and radioimmunoassay. Normal levels of gut peptides in syngeneic bowel were maintained up to 1 year after transplantation. Allogeneic bowel showed a progressive decline in gut peptide concentrations simultaneously with (or preceding) histologic evidence of rejection. The monitoring of GI peptide tissue levels may prove to be a useful method of detecting small bowel transplant rejection.

Monitoring of intestinal transplant rejection.

Our results show that maltase, sucrase, and lactase activity are present at a normal level in nonrejecting small bowel transplants after an initial postoperative decline. This confirms that the disaccharide absorbing capacity of these grafts is intact. In allogeneic bowel, however, the levels of maltase and sucrase decline as histologic rejection occurs. These results suggest that serial maltase, sucrase, and possibly lactase levels in allogeneic intestinal transplants may serve as a useful adjunct in the monitoring of small bowel transplant rejection.

Leakage of intraluminal low molecular weight polyethylene glycol as a marker of small bowel transplant rejection.

To facilitate early detection of small bowel allograft rejection, we correlated transluminal leakage of low molecular weight polyethylene glycol (PEG) with the development of allograft rejection. Vascularized allogeneic and syngeneic jejunal transplants were performed in rats, without immunosuppression. A control group underwent creation of jejunal Thiry-Vella fistulas of similar length. Jejunal segments were perfused with a physiologic solution containing [3H]-PEG-900. At the end of an equilibrium period, an urinary bladder aspirate was collected and [3H]-PEG-900 measured by scintillation counting. Results are expressed as disintegrations per minute per 100 microL urine. Histologic examinations were performed at all experimental time points. Two days following transplantation, urinary PEG levels were elevated in both allogeneic and syngeneic groups (3943 +/- 935 and 4007 +/- 1164, respectively). Four days after the transplant, syngeneic urine PEG levels decreased to 581 +/- 159, and were not significantly different (P greater than .05) from Thiry-Vella controls (635 +/- 145). Syngeneic levels remained at this low level for the rest of the experiment. The allogeneic group continued to show significantly higher levels (P less than .05) compared with syngeneic and Thiry-Vella groups from day 4 until the end of the experiment. These elevated levels most likely represented the development of rejection, preceding the first significant histologic signs of rejection, which were found at six days post-transplant. Detection of transluminal leakage of low molecular weight PEG may be a useful adjunct in monitoring for small bowel transplant rejection.

Technical aspects of intestinal transplantation in the rat.

The microsurgical technique for rat intestinal transplantation used in our laboratory is described. A 25-cm segment of jejunum is harvested from the donor on a pedicle of superior mesenteric artery (SMA) and superior mesenteric vein (SMV). These vessels are then anastomosed end-to-side with 10-0 nylon to the infrarenal aorta and inferior vena cava of the recipient. The bowel ends are placed in isoperistaltic continuity with the host intestine. The procedure was performed in 423 animals with an 86 percent success rate and has been used to investigate all aspects of small bowel transplantation. The technique is described in detail with schematic drawings and intraoperative photographs, with the goal of making the procedure more understandable and accessible to other investigators wishing to study vascularized intestinal transplantation in the rat.

Tracheoesophageal anomalies in Waterston C neonates: a 30-year perspective.

Two hundred and seventy-eight infants with congenital tracheoesophageal anomalies have been managed at the Columbus Children's Hospital since 1955. Fifty-four (20%) have been classified as high risk using Waterston's criteria of birth weight, associated anomalies, and pneumonitis. The infants have been divided into group I (n = 27, 1955 to 1969) and group II (n = 27, 1970 to 1984) to reflect the onset of mechanical ventilation and effective neonatal intensive care. The mean birth weight of infants in group II was significantly less than in group I (1,753 +/- 390 g v 1,950 +/- 505 g, P less than .05). The incidence of prematurity, measured by gestational age, has significantly increased with 9 of 27 (33%) infants in group II and 2 of 27 (7%) infants in group I less than 32 weeks gestation (P less than .05). The presence or severity of associated anomalies was not significantly different in groups I and II. Twenty patients in group I and 22 patients in group II underwent definitive management of their tracheoesophageal anomaly. Operative survival was 30% in group I and 74% in group II (P less than .05). Long-term survival was 15% in group I and 64% in group II (P less than .05). Early postoperative complications included aspiration pneumonitis, anastomotic leak, or stricture. The most frequent complications in long-term follow-up were recurrent pneumonias, which were observed in 9 of 16 children. Esophageal dysmotility or gastroesophageal reflux was documented in five of these children; four were managed successfully with positional or pharmacologic manipulations while one required an antireflux procedure. Thirty percent (5/16) are asymptomatic.(ABSTRACT TRUNCATED AT 250 WORDS)

Improved survival after allogeneic small intestinal transplantation in the rat using cyclosporine immunosuppression.

We investigated the effect of cyclosporine on survival after intestinal transplantation between histoincompatible Brown Norway (AgB3/3) and Lewis (AgB1/1) rats. Intestinal grafts were primarily vascularized (by microsurgical techniques) and interposed isoperistaltically in the recipient's jejunum. All animals were weighed and observed daily. Survival of recipients given cyclosporine 20 mg/kg/d (112 +/- 92 days, n = 10) was significantly longer (P less than .02) than that of recipients given no drug (12 +/- 4 days, n = 8). Six out of ten cyclosporine-treated animals remained alive and well at the conclusion of the experiment. One of these was killed and showed no gross or microscopic evidence of rejection. The described experimental model involves a simple operative technique and minimal postoperative care and should permit systematic investigation of the detection and prevention of rejection.

Esophageal replacement in two siblings with epidermolysis bullosa.

Dystrophic epidermolysis bullosa is an inherited disorder of squamous epithelium that results in dystrophic scarring of the skin after minor trauma. Although severe scarring of the skin is the most common and obvious complication of the disease, esophageal scarring with formation of long strictures may also develop. In two affected siblings, such esophageal strictures occurred and progressed in severity to degrees necessitating esophageal replacement. Each received a preoperative period of total parenteral nutrition, which was continued into the postoperative period. In one, an isoperistaltic segment of right colon was placed substernally in a single stage procedure. In the other, a substernal reversed gastric tube was constructed, also in a single stage. This latter procedure was shorter and technically simpler than the colon interposition. The early postoperative courses in both were complicated by cervical anastomotic leaks, which sealed spontaneously during a period of parenteral nutrition and gastrostomy feedings. Both subsequently developed cervical anastomotic strictures. These were successfully managed by dilatations, and both patients are now tolerating a solid diet. Neither patient experienced problems from endotracheal intubation. Epithelial loss occurred in the skin adjacent to the surgical incision but healed quickly with topical silver sulfadiazine therapy. This report confirms previous reports that esophageal replacement is well tolerated by patients with epidermolysis bullosa and suggests that the reversed gastric tube technique, not previously reported used for this disease, may be preferable to colon esophagoplasty.

Burn care in children: special considerations.

Burn injuries are common in children. In this article, the epidemiology, initial resuscitation, nutritional management, and wound management of pediatric burn injuries are reviewed with emphasis on the special problems of children.

Broviac catheter sepsis: the natural history of an iatrogenic infection.

Between January 1982 and December 1983, 335 Broviac catheters placed in 270 infants and children were prospectively evaluated. The average duration of catheter life was 99.7 days, yielding a total accumulated experience of 33,394 catheter days. Blood culture-proven bacteremia occurred on 77 occasions (23%), an average of one spetic episode for every 434 days of catheter use. Temperature elevation was the only consistent clinical sign of infection occurring in 91% of the children. White blood cell counts remained within the normal range in the majority of patients. The differential counts were most helpful, however, documenting a significant increase in the number of immature neutrophils. The rise in band forms was frequently observed 24 to 48 hours before the onset of clinically evident sepsis. Platelet counts did not change significantly. Eighty-eight microorganisms were identified on blood culture. Eighty-three bacterial isolates were recovered (94%) and five fungi. The vast majority of patients (86%) had a single organism on blood culture but polymicrobial sepsis was observed on 11 occasions. Staphylococcus sp (38%) and Streptococcus sp (25%) species were most common. Of particular importance, 48% of coagulase negative staphylococci were nafcillin-resistant. Of the gram negative bacteria, Klebsiella (10%) and Pseudomonas (6%) species were most frequent. In 53 patients, antibiotic therapy was administered in an attempt to salvage the catheter. Bacteremia was controlled successfully in 39 (74%), and in the other 14 children, persistent sepsis dictated catheter removal. One patient (0.4%) died as a result of catheter-related sepsis.

The effectiveness of Nissen fundoplication in neurologically impaired children with gastroesophageal reflux.

Fifty-seven of 101 Nissen fundoplications during the 4-year period, July 1979 to July 1983, were performed on neurologically impaired children. Mean age at the time of surgery was 5.9 years (range 1 month to 22 years). Indications for operation included: persistent vomiting, 57 patients (100%); failure to thrive, 49 patients (86%); repeated episodes of pneumonia, 49 patients (86%); esophagitis, 18 patients (32%); hiatal hernia, 14 patients (25%); episodes of apnea, 10 patients (18%); and esophageal stricture, six patients (10%). Forty-six of the 57 patients had previously failed a standard trial of nonsurgical management. Gastroesophageal reflux was documented by barium esophagograms in 51/56 patients (91%), chalasia scans in 28/32 patients (88%), esophagitis or stricture at endoscopy in 21/23 patients (91%), and acid reflux on pH monitoring in 13/16 patients (80%). Operative management included gastrostomy in 55 of the 57 patients and this was permanent in 50. Gastrostomies had previously been performed in nine patients but had failed to provide a reliable method of enteral feeding because of chronic reflux and aspiration. The surgical complication rate was 12%. Intraoperative esophageal perforation occurred in two patients, splenic tear in one, hepatic vein laceration in one, and a tight wrap in one. After surgery, bowel obstruction from adhesions developed in one patient and a midgut volvulus in another. Five of the children have died, none from causes related to the surgical procedure. Clinical and radiologic follow-up evaluations of all survivors have been done, with a mean follow-up of 3 years. In four patients the repair was felt to be inadequate. One patient had an esophageal stricture and three had recurring episodes of pneumonia. Three children showed radiologic evidence of persistent reflux, but only two were symptomatic. Two patients required a second antireflux procedure for reflux and are now free of symptoms. Nissen fundoplication appears to be a safe and beneficial procedure in neurological impaired children. Long-term follow-up evaluation of these patients showed satisfactory growth as well as a significant decrease in pulmonary disease associated with aspiration.