Gastrin, somatostatin and infantile hypertrophic pyloric stenosis.

UNLABELLED: Despite multiple and often contradictory research, no firm conclusions regarding the role of hypergastrinaemia in infantile hypertrophic pyloric stenosis (IHPS) have been established. Evaluation of somatostatin, the main physiological antagonist of gastrin, has not been assessed in previous studies. Long-term evaluation following pyloromyotomy suggests persistent abnormalities in gastrin and somatostatin in IHPS. The objective of this case-controlled study was to compare fasting serum gastrin and somatostatin levels in IHPS. Serum sample were collected from 39 children with IHPS at the time of pyloromyotomy and 20 age-matched controls with no evidence of gastrointestinal disease. Standard radioimmunoassay techniques were used to detect circulating levels of the hormones. A two-tailed t-test was used for statistical analysis. The levels of the two hormones (mean +/- SEM) revealed that there was no evidence of hypergastrinaemia in IHPS compared with controls (75.6 +/- 16.1 and 68.1 +/- 7.8 ng l(-1), respectively), but that the level of somatostatin was significantly elevated (38.9 +/- 6.4 and 30.5 +/- 5.8 ng l(-1), p = 0.016). An inverse trend in the gastrin/somatostatin levels could not be identified in IHPS. CONCLUSION: Somatostatin but not gastrin is raised in IHPS. Somatostatin is known to inhibit the actions of inhibitory neurotransmitters in the pylorus and may explain the development of pylorospasm, which is believed to be important in the development of pyloric tumours. These results do not agree with a previous long-term follow-up study, but reflect the hormonal imbalance at the time of pyloric hypertrophy.

Laparoscopic fundoplication in children--an audit of fifty cases.

UNLABELLED: Critical evaluation of new laparoscopic procedures in childhood are essential. The aim of this study was to audit fifty laparoscopic fundoplications in children. METHOD: Evaluation of the financial implications, hospital stay, analgesia requirements, operative morbidity and symptom control was undertaken. RESULTS: 50 laparoscopic fundoplications were performed on children (6 months to 13 years) with a median follow-up period of 31.8 months. The conversion rate to an open procedure was 8%. The median length of opiate requirement for opiate analgesia was 1 day (range 1-5), post-operative stay 2 days (range 2-15). The operative morbidity was 8% (respiratory infection, pneumothorax, two patients, oesophageal perforation one patient). The recurrences rate was 6%. Whilst a prospective randomised trial is essential to satisfy the requirements of evidence-based medicine, the results of our review of laparoscopic fundoplication are encouraging.

A comparative study of the analgesia requirements following laparoscopic and open fundoplication in children.

To introduce a new procedure, careful evaluation of its effects must be undertaken to assess its impact. Laparoscopic procedures in children are a relatively new phenomenon. A reduction in analgesia is a frequently quoted benefit of a laparoscopic procedure. The introduction of laparoscopic fundoplication into our surgical armoury lead us to evaluate the analgesia requirements of a laparoscopic procedure compared to conventional surgery. Comparative analysis of the analgesia requirements of 40 fundoplication procedures (20 laparoscopic, 20 open) was undertaken. All the pain-relief data was prospectively documented by a pain team as part of an ongoing hospital audit. This pain team was unaware of the comparative study, but were assessing the quality of analgesia within the hospital trust. The total amount of morphine analgesia required was similar for both laparoscopic and open surgery (0.432+/-0.28, 0.427+/-0.28 mg/kg). The period for which analgesia was required was significantly less in the laparoscopic group (1.2+/-0.46, 2.7+/-0.67 days; p = 0.03), yet the requirement for morphine during the first 24 hours was greater in the laparoscopic group (0.399+/-0.19, 0.22+0.11 mg/kg, p = 0.02) despite similar NSAID requirements (18+/-17.28, 18+/-20.16 mg/kg, respectively). The benefit of a laparoscopic over an open fundoplication would appear to be in the decreased duration of pain, as indicated by the decreased duration of analgesia following surgery.

Pyloric stenosis: is over-reliance on ultrasound scans leading to negative explorations?

AIM: To see whether increasing use of ultrasound scans in pyloric stenosis is leading to false-positive diagnoses, and even negative laparotomies. METHODS: Over a 2-year period, 76 neonates underwent laparotomy with a preoperative diagnosis of pyloric stenosis (PS). There were 57 males and 19 females, age ranged from 10 days to 7 weeks. RESULTS: Six patients proceeded straight to surgery after undergoing a test feed. The remaining 70 patients had one or more imaging investigations. Of these; 56 patients had an ultrasound only, 5 had a barium meal only while 9 patients had both investigations. Ultrasound showed evolving lesions in 2 patients. It was equivocal or falsely negative in 8 - all were diagnosed correctly after undergoing barium meals. Fifty-two patients were diagnosed correctly on ultrasound. There were, however, 3 false-positive ultrasonic diagnosis--i.e., at laparotomy the pylorus was found to be normal. One of these patients even had a "diagnostic" barium meal. The factors leading to these negative explorations are discussed. CONCLUSION: Pyloric "tumours" can be difficult to palpate early in the evolution of the disease. Reliance upon the ultrasound appearance of the pylorus without taking into account other important diagnostic evidence will increase the risk of false-positive diagnoses and unnecessary laparotomy. The importance of clinical examination and test feed is emphasised.

Endoscopic treatment of vesico-ureteric reflux in neurogenic bladder--8 years' experience.

During an 8-year period, 51 children with neurogenic bladder had endoscopic injection of Teflon (STING) for the management of 69 refluxing ureters. There were 21 boys and 30 girls (age range, 10 month to 16 years). Vesico-ureteral reflux (VUR) had been present for a mean of 4.1 years, and severity distribution was as follows: grade I, 1 ureter; grade II, 5 ureters, grade III, 9 ureters; grade IV, 39 ureters; and grade V, 15 ureters. The follow-up period ranged from 3 months to 8 years (mean, 4 years). Reflux ceased in 57 ureters (82%); in four ureters the VUR recurred (9 months to 6 years later). Bilateral vesico-ureteric junction (VUJ) obstruction occurred in one patient, which required surgical correction 3 years after STING. These data suggest that for difficult cases of VUR in neurogenic bladders, STING is a safe and effective option and should be the initial treatment of choice. However, because of the possibility of late recurrence of VUR or obstruction at the VUJ, long-term follow-up is required.

Effect of general anaesthesia on prolonged intraoesophageal pH monitoring.

Investigation of gastro-oesophageal reflux often includes endoscopy, usually under general anaesthesia, and pH monitoring. In most cases, the pH probe is passed when the child is awake and is poorly tolerated. The effect of general anaesthesia on pH monitoring is unknown. The aim of the study was to determine if placing the probe in the anaesthetised child gives a representative pH study. Twenty children aged 4 months to 13 years underwent oesophago-gastroduodenoscopy under general anaesthesia. A pH electrode was placed under direct vision in the distal oesophagus. pH monitoring was begun after completion of anaesthesia and continued for 18-24 hours. The study was repeated within 14 days without anaesthetic. The reproducibility of values of percent pH < 4, number of reflux episodes/hour, reflux episodes lasting > 5 min, and longest reflux episode was 85%, 90%, 75%, and 75% respectively. These results are comparable with those in adults and children in whom pH studies were performed on consecutive days (without anaesthetic) keeping all variables constant. Therefore pH data collected in a child within 24 hours of endoscopy under general anaesthesia are representative.

Age dependent hypergastrinaemia in children with Helicobacter pylori gastritis--evidence of early acquisition of infection.

Acute Helicobacter pylori associated gastritis causes achlorhydria, a powerful stimulus to gastrin secretion. If H pylori infection is acquired primarily in early childhood, then the degree of hypergastrinaemia in seropositive children should be age dependent. Anti-Helicobacter antibodies and fasting gastrin concentrations were measured in 439 children aged 4 to 13 years attending hospital for routine day case surgery not connected with any gastrointestinal disorder. Thirty per cent were seropositive for H pylori. There was an inverse relationship between the fasting gastrin concentration and age; the mean fasting gastrin in children aged 4-5 years, 155 ng/l, was significantly higher than that seen in children aged 12-13 years, 90 ng/l. The more noticeable hypergastrinaemia seen in young children with H pylori associated gastritis may reflect achlorhydria associated with acute H pylori infection and suggests that this is primarily acquired in early childhood.

Helicobacter pylori, hypergastrinaemia, and recurrent abdominal pain in children.

The association between Helicobacter pylori and recurrent abdominal pain (RAP) is controversial. In this cross-sectional study, the authors aim to determine whether hypergastrinaemia causes RAP in children with H pylori gastritis. In 439 children age 4 to 13 years (mean 7.3 years) attending for nongastrointestinal day-case surgery, anti-Helicobacter immunoglobulin G (IgG) was identified in serum by an enzyme-linked immunosorbent assay (ELISA) method validated in children and fasting plasma gastrin was measured. A history of RAP was sought. One hundred twenty-seven children (29%) tested seropositive for H pylori. Fifty-one seronegative children (16.3%) and 22 seropositive children (17.3%) gave a history of RAP. The mean fasting gastrin in seronegative children was 52 ng/L compared with 117 ng/L in seropositive children (P < .001). The mean fasting gastrin in seropositive children with RAP (124 ng/L) was not significantly different from that of seropositive children without RAP (115 ng/L). The high prevalence of H pylori seropositivity in this study is at variance with other reported paediatric data from the developed world. No association between childhood H pylori gastritis, hypergastrinaemia, and RAP was found. In children with H pylori gastritis, the increase in circulating gastrin (mean 140% increase) is greater than that seen in adults (50% increase).

Transperitoneal closure of the internal ring in incarcerated infantile inguinal hernias.

Over a 6-year period, 14 infants with a total of 16 inguinal hernias (IH) underwent transperitoneal closure of the internal ring (TPIR). This was performed through a minilaparotomy, using a purse-string suture placed around the internal ring from within. A difficult inguinal dissection of an edematous and friable spermatic cord was avoided. TPIR was performed for incarceration in 13 of the infants and for recurrence of the hernia within 24 hours of herniotomy in one. There were no intraoperative problems, and during follow-up there was no evidence of testicular atrophy or recurrence of the hernia. This suggests that TPIR is a reliable and safe operation in babies for whom the alternative inguinal approach would be difficult. These situations include hernias that are irreducible and early recurrence in which dissection of the cord would risk damage to the vas deferens or testicular vessels.

Inguinal herniotomy in young infants, with emphasis on premature neonates.

Over a period of 6 years, 251 infants under 6 months of age underwent repair of inguinal hernias (IH; n = 311). There were 241 males and 10 females. Incarceration occurred in 59 infants (24%), one of whom had bilateral incarceration. As a result of the authors' policy to operate on infantile IH within 7 days of diagnosis, only 6% of the incarcerations occurred in already diagnosed cases. Sedation and taxis did not reduce the hernia in 22 cases (38%); transperitoneal closure of the internal ring was performed in 14 of these. Eighty-nine infants (36%) were born premature; thirty-nine (41%) of these had been ventilated before, a possible cause of the hernia. Bilateral presentation was more common in the premature infants (35% v 17%); surprisingly, incarceration was less common (13% v 24%). Hence, the policy of delaying herniotomy until discharge from the neonatal unit was justified. During follow-up, six recurrences were noted and two cases of testicular atrophy.

Acute appendicitis in young children in the Belfast urban area: 1985-1992.

Eighty-one cases of acute appendicitis in children aged less than six years were identified in the Belfast urban area between 1985 and 1992. Appendiceal perforation, found in 43%, was related to symptom duration but not to age at presentation. Prolongation of symptoms was related to parental delay in seeking medical advice (52% > 36 hours), delayed or inappropriate general practitioner referral to hospital (19%) and diagnostic delay following surgical consultation (12% > 12 hours). Diagnostic delay in hospital was usually the result of nonspecificity of symptoms and signs and was therefore largely unavoidable. Delayed referral from general practice did not contribute unnecessarily to appendiceal perforation, and given that an individual general practitioner will see a case of preschool appendicitis once in 30 years, diagnostic accuracy was remarkably high.

Chronic organoaxial malrotation of the stomach in childhood.

During a six-month period five patients presented to The Royal Belfast Hospital for Sick Children between the ages of three weeks and three years with recurrent vomiting and failure to thrive. All were diagnosed as having organoaxial malrotation of the stomach by barium meal examination. Symptoms were refractory to conservative management but combined gastropexy and fundoplication was successful in all cases.

Henoch-Schönlein purpura: problems in surgical diagnosis and management.

The clinico-pathological features of 133 consecutive cases of Henoch-Schönlein purpura are presented, with emphasis on the gastrointestinal manifestations. The potential pitfalls of contrast radiography are underlined with respect to management of intussusception and a plea is made to re-establish clinical assessment of the abdomen as the prime indicator in deciding to undertake laparotomy.

Neonatal duodenal obstruction with emphasis on cases with Down's syndrome.

In the past 31 years, 47 cases of duodenal obstruction were admitted to the Royal Belfast Hospital for Sick Children. Thirty-six per cent of these had Down's syndrome. The crude mortality was 48% but this figure was reduced to 33% in the last five years of the study. The combination of duodenal obstruction, Down's syndrome and any other abnormality carried an 89% risk of mortality.

Pancreoblastoma in a neonate associated with Beckwith-Wiedemann syndrome.

A cystic abdominal mass was removed from a male child born at 32 weeks gestation. Histological examination showed this to be a pancreoblastoma. Both clinical and histological features of Beckwith-Wiedemann syndrome developed within the first 12 weeks of life. The child remains well and thriving with no tumour recurrence at 10 months of age.

Extra-lobar pulmonary sequestration. A report of three cases and a review of the literature with special reference to the embryogenesis.

Three cases of extra-lobar pulmonary sequestration are reported, and the literature reviewed. Phylogenetically several mechanisms are possible. A local problem with separation of part of the developing lung, is thought to be more likely than a widespread teratogenic insult.