Experience with endoscopy and endoscopy-assisted management of pediatric surgical problems: results and lessons.

Minimally invasive surgical techniques are becoming increasingly popular within the pediatric population. Flexible endoscopy may enhance or replace existing techniques in the future. Many of the reported benefits of laparoscopy and thoracoscopy may apply to endoscopy and endoscopy-assisted procedures; however, no reports exist as to the application, results, and outcomes for these procedures in children. It was hypothesized that endoscopy is a useful and safe adjunct for pediatric surgical patients. Retrospective review of medical records for patients who underwent endoscopy or endoscopy-assisted operations at two children's hospitals over 3 years (August 31, 2007-August 31, 2010) was completed. During this time period, 30 procedures were performed on 28 patients. Indications for procedure, age, operative technique, operative times, surgical outcomes, complications, and length of stay for each patient were reviewed. Patient age ranged from 3 days to 20 years. Indications for operation included esophageal pathology (13), gastroduodenal pathology (14), pancreatic pseudocyst (2), and displaced sigmoid Chait® (Cook, Inc., Bloomington, IN, USA) tube. Although endoscopy was intended only as an adjunct in all cases, the planned procedure was satisfactorily completed with a purely endoscopic approach in six cases. There were no intraoperative complications, and minor postoperative complications including one stricture requiring dilation, postoperative stridor, and esophageal leak, were each successfully managed conservatively. Endoscopy offers a promising adjunct to more traditional minimally invasive techniques in children. In some cases, endoscopy may offer an alternative to more invasive procedures or eliminate the need for tube thoracostomy or post-procedural contrast studies in some esophageal cases.

Laparoscopic Nissen fundoplication.

UNLABELLED: This article will focus on a review of the history and current status of laparoscopic Nissen fundoplication for gastroesophageal reflux disease in infants and children. METHODS: Review of the available current literature concerning laparoscopic Nissen fundoplication in infants and children. Information regarding the current approach for gastroesophageal reflux disease (GERD) in children will be reviewed in addition to the indications for surgical antireflux operation; application and safety of laparoscopy; and the outcomes of laparoscopic Nissen fundoplication in both normal and neurologically impaired children. Finally, the reported data regarding the learning curve in performing the procedure and short-term and long-term complications of laparoscopic Nissen procedure will be discussed. Compared to open antireflux operations, the laparoscopic Nissen approach in infants and children is safe; durable; provides better cosmetic results; and allows for earlier institution of feedings. The established ''learning curve'' for safe and competent performance of laparoscopic Nissen fundoplication is from 25-50 cases. Neurologically impaired patients may indeed benefit from a minimally invasive approach to GERD and enteral access related to improvement of quality of life. Better nutrition and decreased complications related to malnutrition and a decreased incidence of aspiration pneumonia may be realized for these patients. The laparoscopic Nissen approach to GERD is well accepted and widely utilized in infants and children. Prospective randomized multi-institutional studies will be necessary to accurately determine whether this therapeutic approach to GERD in both neurologically impaired and neurologically normal children is the superior option compared to continued medical therapy or gastrojejunal feeding tube approaches to GERD.

Pediatric burn patients with respiratory failure: predictors of outcome with the use of extracorporeal life support.

Extracorporeal life support (ECLS) for pediatric burn patients is a viable option for respiratory failure that is unresponsive to maximal conventional therapy. No criteria have been identified that are predictive of the success of the use of ECLS for these patients. This article presents a retrospective review of the pediatric burn patients placed on ECLS at a single pediatric medical center. It was found that 12 patients (mean age, 30.3 months; range 6 to 69 months) were placed on ECLS because of profound pulmonary failure that was unresponsive to aggressive ventilatory support. The mean size of the burns of these patients was 50.2% of the total body surface area (average size of full-thickness burns, 41.8% total body surface area), with 6 patients having scald burns and 6 having flame burns. The overall survival was 67% (8 of 12). Nonsurvivors had greater positive end-expiratory pressure, mean airway pressure, peak inspiratory pressure, and oxygenation index before ECLS. It is felt that ECLS is a life-saving therapy for pediatric patients with thermal injury. Greater ventilator requirements before ECLS are associated with nonsurvival. Early institution of ECLS in pediatric burn patients with severe respiratory failure may prevent excessive barotrauma and thus discourage the onset of irreversible lung injury.

The detection of microbial DNA in the blood: a sensitive method for diagnosing bacteremia and/or bacterial translocation in surgical patients.

OBJECTIVE: The purpose was to determine the sensitivity of detecting microbial DNA in the blood of surgical patients as a measure for diagnosing systemic infection and/or translocation from the gut. SUMMARY BACKGROUND DATA: Microbial infections and translocation of intestinal bacteria are thought to contribute to multiple system organ failure, but bacterial cultures are often negative in patients with this complication. METHODS: DNA was extracted from the blood of 40 surgical patients and 20 healthy controls. Polymerase chain reaction (PCR) techniques were used to amplify genes from Escherichia coli, Bacteroides fragilis, and a region of 16S ribosomal RNA found in many gram-positive and -negative bacteria. RESULTS: Bacterial DNA genes were not detected in healthy volunteers but were found in all patients with positive blood cultures. All eight transplant patients receiving OKT3 therapy had microbial DNA in their blood, possibly indicating translocation from the gut. Sixty-four percent of critically ill patients had microbial DNA detected in their blood, but only 3 (14%) had positive blood cultures. CONCLUSIONS: The PCR method is more sensitive than blood cultures for detecting bacterial components in the blood of critically ill surgical patients and may detect microbial translocation from the intestine.

Alveolar capillary dysplasia with misalignment of the pulmonary veins: a rare but fatal cause of neonatal respiratory failure.

Respiratory failure in the neonate that is refractory to maximal medical management is a frequent indication for extracorporeal life support (ECLS). Alveolar capillary dysplasia with misalignment of the pulmonary veins is an irreversible cause of respiratory failure that cannot be diagnosed on clinical grounds alone and would not be expected to respond to ECLS therapy. A recent experience with a patient prompted us to review the literature regarding this condition for the purpose of identifying factors suggestive of this diagnosis. This condition should be considered in neonates with presumed pulmonary hypertension who cannot be weaned from ECLS. If the diagnosis is made by antemortem open-lung biopsy, a costly, protracted, and unnecessary continued course of ECLS may be avoided.

Bacterial translocation in organ donors: clinical observations and potential risk factors.

Thirty-nine solid-organ donors were evaluated to determine the incidence of bacterial translocation to mesenteric lymph nodes. In addition, clinical variables from 59 local recipients of renal allografts from these donors were examined to assess whether translocation in donors was associated with increased morbidity in the recipients of organs from node-positive donors. Ileocecal lymph node cultures were positive in 18 of 39 donors (46%). Sixteen donors (41%) were hypotensive [systolic blood pressure (SBP) < 90 mmHg] and 27 (69%) received blood product transfusions before organ donation. The presence of hypotension and blood product transfusion were associated with positive and negative cultures, respectively. In 24 (41%) of 59 organs transplanted from donors with periods of hypotension, significantly more (16 of 24, 67%) were associated with positive lymph node cultures than with negative cultures (8 of 24, 33%; p = 0.029). In recipients of organs from node-positive versus node-negative donors there was a trend toward higher incidence of infection (32% vs. 25%), need for hemodialysis post-transplant (29% vs. 23%), graft loss within 1 yr (24% vs. 19%), and lack of blood transfusion prior to organ procurement (43% vs. 23%), although these variables were not significantly different between the groups. Hypotension or inadequate resuscitation may contribute to increased bacterial translocation to mesenteric lymph nodes. The overall impact upon the recipients of organs from donors with demonstrable translocation to lymph nodes remains undefined.

Early versus late tracheostomy in the trauma patient.

The use of early tracheostomy in the multiply injured trauma patient has many advantages both in terms of patient management and reduction of morbidity associated with prolonged translaryngeal intubation. Tracheostomy (percutaneous or open technique) has been associated with very low risk of mortality and comparable morbidity to prolonged endotracheal intubation. There exist improved clinical criteria for predicting which patients will require prolonged mechanical ventilation in the trauma and critical care setting. A delay in converting translaryngeal intubation to tracheostomy had been associated with longer ICU stays; conversely, early tracheostomy has been associated with a reduction in ICU stays, incidence of hospital-acquired pneumonias, mechanically ventilated days, and length of hospital stay. Thus, the benefits of early tracheostomy are improved care for patients in the trauma or critical care setting and reduced hospital and patient costs.

Detection of intestinal bacterial translocation using PCR.

Microbial translocation has been suspected to be a major contributing factor in the development of sepsis of unknown origin and multiple organ failure syndrome, but there are currently no tests capable of detecting and quantitating translocation sequentially in humans. The purpose of this study was to develop a sensitive polymerase chain reaction (PCR) test to detect Escherichia coli (E. coli) DNA in the blood of animals after inducing bacterial translocation from the gut. DNA was extracted from blood and primers were used to amplify an 800-bp gene fragment of E. coli by 30-cycle PCR. Detection by southern blotting achieved a sensitivity of 10-100 organisms per 0.3 cc blood. Experimental groups included mice gavaged with 10(10) E. coli followed by 20% body surface area thermal injury, or no injury. Controls included burn only and no treatment groups. Blood was obtained by cardiac puncture 1 hr after burn. Cultures were done on blood samples from all groups. More animals in the burn/gavage group had positive bacterial cultures. All controls were culture negative. E. coli detection by PCR was 100% sensitive in culture positive animals with detection in the gavage/burn group higher than that in all other groups. PCR was negative for all mice without treatment. Several culture negative animals had detectable bacterial DNA by PCR. This highly sensitive and specific method can be used repeatedly to test the blood of patients for the presence of microbial DNA, which could be originating from the gut.

Sequence analysis of an immunogenic and neutralizing domain of the human T-cell lymphoma/leukemia virus type I gp46 surface membrane protein among various primate T-cell lymphoma/leukemia virus isolates including those from a patient with both HTLV-I-associated myelopathy and adult T-cell leukemia.

Human T-cell lymphoma/leukemia virus type I (HTLV-I) causes adult T-cell leukemia/lymphoma and HTLV-I-associated myelopathy. Specific regions within the outer envelope proteins of other retroviruses, e.g., human immunodeficiency virus type 1, are highly immunogenic and, because of the selective pressure of the host immune system, quite variable. Mutations in the external envelope protein gene of murine retroviruses and human immunodeficiency virus type 1 influence cellular tropism and disease pathogenesis. By contrast, no disease-specific viral mutations have been identified in HTLV-I-infected patients. However, all isolates studied thus far have originated from leukemic cell lines, peripheral blood mononuclear cells, or cerebrospinal fluid lymphocytes from patients with HTLV-I-associated myelopathy and adult T-cell leukemia/lymphoma and, therefore, may not truly reflect tissue-associated variation. The midregion of the HTLV-I gp46 external envelope glycoprotein (amino acids 190-209) induces an antibody response in 90% of infected individuals, and a hexapeptide in this region (amino acids 191-196) elicits antibodies in rabbits which inhibit syncytia formation and infection of target lymphocytes. Because of the above, we expected the neutralizing domain of the gp46 env gene of HTLV-I to possess disease or organ-associated mutations selected by the infected host's immune system. Hence, we amplified, cloned, and sequenced HTLV-I DNA directly from in vivo central nervous system, spleen, and kidney specimens, and a leukemic cell line from a patient (M. J.) with both HTLV-I-associated myelopathy and adult T-cell leukemia/lymphoma to discern the possibility of tissue- and/or disease-specific variants. In addition, we sequenced several HTLV-I isolates from different regions of the world, including Papua New Guinea, Bellona, and Liberia, and compared them to other previously published HTLV-I and related retroviral sequences. The 239-base pair sequence corresponding to amino acids 178 to 256 in gp46 displayed minor tissue-specific variation in clones derived from central nervous system tissues from patient M. J., but overall was highly conserved at both the DNA and amino acid levels. Variation was observed in this region among the other HTLV-I, simian T-cell lymphoma virus type I, and HTLV-II isolates in a pattern that was consistent with their known phylogenetic relationship. No consistent disease-related changes were observed.(ABSTRACT TRUNCATED AT 400 WORDS)