Air encircling the intussusceptum on air enema for intussusception reduction: an indication for surgery?

OBJECTIVES: The prompt identification of children in whom enema reduction of intussusception might fail and surgery is necessary is crucial in order to avoid futile repeat attempts and untoward complications. The purpose of this retrospective review was to determine whether air encircling the intussusceptum in the small bowel during air enema for intussusception reduction could serve as an indication for operation rather than repeat attempts at radiological reduction. METHODS: Imaging studies of 83 children aged 4 to 40 months with idiopathic intussusception who had air enema for intussusception reduction were reviewed for the presence of air encircling the intussusceptum in the distal small bowel. Findings were correlated with clinical course and surgical findings. RESULTS: In 12 of 83 patients, air was seen encircling the intussusceptum in the small bowel, and in 11 of these (88%) air enema failed to reduce the intussusception. In 8 of the 11, delayed repeated attempts using air enema failed to reduce intussusception. Clinical signs and their duration did not differ between those children without and those with air encircling the intussusceptum. CONCLUSION: In the presence of air encircling the intussusceptum in the distal small bowel on air enema, delayed repeated attempts for intussusception reduction are unlikely to succeed, and surgery is indicated.

Ectopic liver tissue within the umbilical cord.

A solid mass in the umbilical cord is a very rare finding. A neonate with isolated ectopic liver tissue found in the umbilical cord is reported. This is the first known such reported case.

Liquid enteral diets induce bacterial translocation by increasing cecal flora without changing intestinal motility.

The aim of this study was to determine the contribution of intestinal motility and cecal bacterial overgrowth to liquid diet-induced bacterial translocation (BT). Three different commercially available liquid diets were offered to mice for 1 week. BT to the mesenteric lymph nodes (MLN), spleen, and liver were examined as well as cecal bacterial counts and populations, small bowel length and weight, and histopathologic changes in the ileal and jejunal mucosa. In addition, the effect of the various diets on intestinal motility was measured by the transit index of a charcoal mixture introduced into the stomach. The incidence of BT to the mesenteric lymph nodes was significantly and similarly increased (p < .05) in mice fed Vivonex (30%), Ensure (30%), and Osmolite (33%) compared with chow-fed controls (0%). Compared with chow-fed controls, all three liquid diets were associated with the development of cecal bacterial overgrowth (p < .01). There were no significant changes in the transit index for the three liquid diet groups compared with the chow-fed controls. BT to the MLN was induced by all three liquid diets tested, casting some doubts as to their role in preventing BT in clinical use. BT was associated with a statistically significant increase in cecal bacterial count but was not associated with gut motility changes in this model. In fact, no significant changes in intestinal motility were noted in all groups tested.

The alpha-defensins stimulate proteoglycan-dependent catabolism of low-density lipoprotein by vascular cells: a new class of inflammatory apolipoprotein and a possible contributor to atherogenesis.

Inflammation may contribute to the pathogenesis of atherosclerosis. On the basis of previous reports that human atherosclerotic lesions contain alpha-defensins, a class of cationic proteins released by activated neutrophils, the study was designed to ask whether defensins modulate the binding and catabolism of low-density lipoprotein (LDL) by human vascular cells. The results of the study demonstrated that defensin stimulated the binding of (125)I-LDL to cultured human umbilical vein endothelial cells, smooth muscle cells, and fibroblasts approximately 5-fold in a dose-dependent and saturable manner. Defensin and LDL formed stable complexes in solution and on cell surfaces. Stimulation of LDL binding by defensin was not inhibited by antibodies against the LDL-receptor (LDL-R), or by recombinant receptor-associated protein, which blocks binding of ligands to the alpha(2)-macroglobulin receptor/LDL-R-related protein and other LDL-R family members. Furthermore, defensin stimulated the binding, endocytosis, and degradation of LDL by fibroblasts lacking LDL-R. Stimulation of LDL degradation by defensin was inhibited approximately 75% by low concentrations of heparin (0.2 units/mL) and was similarly reduced in CHO cells lacking heparan-sulfate-containing proteoglycans. The effect of defensin was substantially increased in cells overexpressing the core protein of the syndecan-1 heparan sulfate proteoglycan. The alpha-defensins released from activated neutrophils may provide a link between inflammation and atherosclerosis by changing the pattern of LDL catabolism from LDL-R to the less efficient LDL-R-independent, proteoglycan-dependent pathway. (Blood. 2000;96:1393-1398)

Pulmonary fibrosarcoma in childhood: fiber-optic bronchoscopic diagnosis and review of the literature.

Primary pulmonary fibrosarcoma is a rare malignant tumor in childhood. In the absence of metastases, complete resection is curative. An 8-year-old boy suffered from unresolving pneumonia due to an obstructing lesion in the left main bronchus. Cytology of the bronchoalveolar lavage fluid and histology of bronchial biopsy revealed the diagnosis of pulmonary fibrosarcoma. The tumor did not respond to chemotherapy, and a total lobectomy with sleeve resection was performed with complete removal of the neoplasm. Two years after the operation the child has no evidence of disease.

Thoracoscopic surgery in a general surgical service.

Following the great success and wide acceptance of laparoscopic surgery, the mini-invasive approach has been adopted for use in thoracic surgery. Thoracoscopic surgery is gaining acceptability as the procedure of choice for the treatment of recurrent pneumothorax and bullous lung disease, peripheral benign and malignant lesions, diffuse pulmonary infiltrates, mediastinal and pleural lesions, esophageal surgery, and major pulmonary resections for primary lung tumors. We present the 4-year experience of a general surgery service that extended the use of its advanced laparoscopic skills to the performance of thoracoscopic surgery in 80 patients. Using thoracoscopy, we performed biopsy or excision of pulmonary lesions (23 patients), spontaneous pneumothorax (14 patients), thoracic sympathectomy (41 patients), and Heller's esophagomyotomy and pericardiotomy (1 patient each). The results are excellent, and we believe the procedures presented in this series, and similar ones, can be accomplished safely and successfully by well-trained laparoscopic surgeons.

Nitroxide radical attenuates ischaemia/reperfusion injury to the rat small intestine.

BACKGROUND: Free radicals are associated with post-ischaemic intestinal injury and contribute to major clinical problems primarily in premature infants. Various antioxidative means and modes of intervention, previously tested, have demonstrated only limited efficacy. AIMS: To study the protective activity of the stable nitroxide radical 4-OH, 2,2,6,6-tetramethylpiperidine-1-oxyl (TPL) and its respective hydroxylamine (TPL-H) against ischaemia/reperfusion (I/R) injury. METHODS: An isolated loop of ileum was created in laboratory male Sabra rats and constantly perfused with warmed normal saline. Intestinal injury was elicited through clamping of the superior mesenteric rat artery followed by reperfusion. Either TPL or TPL-H was given intravenously immediately before ischaemia or reperfusion and continuously afterwards. The rate of mucosal to lumen clearance of para-aminohippurate (PAH) was used to evaluate intestinal mucosal injury. Serum and perfusate levels of both TPL and TPL-H were measured using electron paramagnetic resonance spectrometry. RESULTS: The increase in intestinal permeability induced by I/R was significantly inhibited by both TPL and TPL-H. The nitroxide was effective also when given immediately before reperfusion. CONCLUSIONS: Through a continuous exchange, TPL and TPL-H act as self-replenishing antioxidants and thus protect from intestinal injury. This demonstrates the potential of the family of nitroxide antioxidants against oxidative stress in general and I/R injury in particular.

Plasma-to-lumen clearance of para-aminohippurate can replace 51Cr EDTA clearance in the evaluation of intestinal mucosal injury.

Intestinal mucosal injury of various degrees occurs in many clinical situations and is initially evidenced by altered mucosal permeability. The latter may be assessed in animal models by determination of plasma-to-intestinal lumen clearance of specific molecules, usually chromated 51Cr EDTA. The purpose of this study was to evaluate the usage of para-aminohippurate (PHA) as a substitute for the commonly used radioactive material, i.e., 51Cr-EDTA, in the evaluation of intestinal mucosal injury. An isolated loop of ileum was created in rats and constantly perfused with warmed normal saline. Both renal pedicles were ligated. Either 51Cr-EDTA (18.5 Bq/kg) or PAH (58 mg/kg) was injected i.v. Fifteen-minute intestinal ischemia was produced by clamping the superior mesenteric artery immediately after the end of an equilibration period. The perfusate was collected for 10 min prior to the initiation of intestinal ischemia, during the last 10 min of ischemia, and during the following three 10-min periods of reperfusion. Blood samples were collected at the end of each collection period for the determination of either PAH or 51Cr-EDTA concentrations and the calculation of either PHA or 51Cr-EDTA plasma-to-lumen clearances. PAH and 51Cr-EDTA plasma-to-lumen clearances followed the same pattern in all five assessed periods with no statistical difference between the two. PAH plasma-to-lumen clearance is a feasible, reliable, and inexpensive method for the evaluation of ischemia/reperfusion injury to the intestinal mucosa. It can safely replace the commonly used method in animal models that utilizes radioactive materials such as 51Cr-EDTA.

Laparoscopic Nissen fundoplication in children under 2 years of age.

BACKGROUND: Antireflux operations have been recommended for infants and children suffering from complications related to gastroesophageal reflux (GER). In recent years, the laparoscopic approach has been used increasingly for antireflux surgery in adult patients. This is our initial experience with Nissen fundoplication in infants and children under 2 years of age. PATIENTS: We operated on 11 patients weighing between 3.0 and 10.0 kg. The main indications for surgery were GER-induced aspiration pneumonia and failure to thrive, in spite of intensive conservative treatment. All patients except one had an associated neurological abnormality, including six patients with familial dysautonomia. RESULTS: All attempted operations were completed successfully laparoscopically, with only a few postoperative complications and acceptable short-term results. The clinical considerations and technical aspects unique to this specific group of patients are discussed. CONCLUSION: Laparoscopic Nissen fundoplication is feasible, safe, and effective, even in very small babies.

Infantile hemangioendothelioma of the ovary: a monodermal teratoma or a neoplasm of ovarian somatic cells?

Vascular tumors of the female genital tract are uncommon, and only a few cases have been reported in the ovary. We describe herein, an unusual tumor of the ovary: infantile hemangioendothelioma (cellular hemangioma of infancy) in a newborn. The tumor consisted of well-formed blood vessels and proliferating endothelial cells that were arranged in solid cordlike structures. The tumor permeated the ovarian stroma and entrapped normal ovarian follicles. By immunohistochemistry the neoplastic cells expressed factor VIII, CD34, and alpha smooth-muscle actin, and ultrastructurally they had the features of endothelial cells that were focally associated with pericytes. We examined simple sequence repeat (SSR) polymorphic markers in the tumor tissue, as well as in the patient's and parents' blood. The informative SSR markers were found to be identical in the tumor and in the patient's somatic cells. We suggest that the tumor described herein is a congenital infantile hemangioendothelioma arising from ovarian parenchymal cells rather than a teratoma originating from germ cells. A similar morphologic lesion has been described recently in the ovary and interpreted as monodermal teratoma composed of vascular tissue.

Late-appearing diaphragmatic hernia following resolution of right pleural effusion.

A case of late-appearing congenital diaphragmatic hernia in a premature infant with previously normal chest X-ray is reported. Pleural effusion accumulation and resolution preceded herniation of the liver to the right hemithorax and development of respiratory symptoms. Chest X-ray, ultrasound and computed tomography of the chest were useful in establishing the correct diagnosis. Pleural effusion without obvious cause should alert the paediatrician to the possibility of this rare condition.

Cooling strangulated intestine before and following release of an obstruction protects from ischemia/reperfusion injury.

OBJECTIVE: To evaluate whether cooling of ischemic intestine before and immediately after the release of the obstruction is more advantageous than is warming in an isolated ileal loop rat model. DESIGN: Prospective randomized experimental trials. SETTING: Laboratory. MATERIALS: Male Sabra rats. INTERVENTIONS: An isolated loop of ileum was created in rats and constantly perfused with warmed normal saline (37 degrees C). Intestinal ischemia was caused by clamping of the superior mesenteric artery for 15 minutes. Cooling of the isolated ileal loop to 32 degrees C by the application of cold saline was done for the last half of the ischemic period and continued during the first 10 minutes of reperfusion. The intestine was warmed to 37 degrees C for the next 20 minutes of reperfusion. MAIN OUTCOME MEASURES: The chromium 51-labeled ethylenediaminetetraacetic acid (51Cr-EDTA) plasma-to-lumen clearance rate was used for the evaluation of intestinal mucosal injury. Multiple intestinal samples were harvested at the end of the reperfusion period, and the histological features were evaluated. RESULTS: The 51Cr-EDTA plasma-to-lumen clearance rates were significantly lower (P < .001) in the rats in which cooling of the ischemic intestine was performed in comparison with the control group, indicating reduced intestinal mucosal injury in all three 10-minute reperfusion periods. Cooling also significantly changed the resultant histological damage to the intestinal mucosa exerted by ischemia (P < .001). CONCLUSION: Cooling of the ischemic intestine before the release of the obstruction and for a short period during reperfusion provides significant protection from ischemia/ reperfusion injury compared with the traditional method of warming the ischemic intestine.

Gastric outlet obstruction caused by prepyloric mucosal diaphragm mimicking duodenal ulcer: a case report.

An 11-year-old child was evaluated for chronic gastric obstruction with intermittent symptoms from the age of 11 months. An upper gastrointestinal series performed at the age of 11 months was interpreted as compatible with severe pyloric stenosis due to a duodenal ulcer, but no surgery was recommended. Several other UGIT series, and at least four endoscopies performed during the following years by experienced gastroenterologists in Israel and in the United States, failed to reveal the true nature of the gastric outlet obstruction. The patient was operated upon shortly after referral to our institute. Upon celiotomy, a congenital antral web was found, the excision of which resulted in long-term relief of all symptoms. The differential diagnoses of childhood gastric outlet obstruction and the possible pitfalls in the diagnostic workup are discussed.

[Nissen fundoplication by laparoscopy].

Short term results following laparoscopic Nissen fundoplication were evaluated in 31 patients with symptomatic gastroesophageal reflux. 6 were females and 26 males, and they ranged in age from 5 months to 64 years (mean: 4.9 years in 19 younger than 18 years, and 39.3 years in 12 adults). Most of the adults who complained of pain and heartburn underwent pH monitoring, endoscopy, and manometry as needed. Milk scan was the most useful diagnostic tool for the evaluation of the children, who suffered mainly from gastroesophageal-related pulmonary disease. Indications for laparoscopic operation were identical with those for conventional open Nissen fundoplication. 1 case of dysautonomia died postoperatively; the rate of complications, mostly minor, was 22.5%. 3 patients required conversion to open Nissen fundoplication due to cardiorespiratory instability secondary to pneumothorax in 2, and to esophageal perforation in the third. 5 adults developed temporary dysphagia. 3 children had only partial improvement in their pulmonary disease following the operation, while the other 15 had complete relief. The total time for the laparoscopic operation averaged 245 minutes in adults, and 228 in children. Discharge was usually on the fourth postoperative day in adults (mean: 6.0 days). Regurgitation and heartburn were cured in 10 out of 11 adults (91%). All parents of children were satisfied. Symptomatic outcomes following laparoscopic Nissen fundoplication compare favorably with those of open surgery with respect to mortality, complications, and outcome.

Laparoscopic-modified Nissen fundoplication in children with familial dysautonomia.

Children with familial dysautonomia (FD) often require an antireflux operation and gastrostomy to prevent the detrimental effects of aspirated gastric juice on the lungs and to facilitate liquid feeding. The aim of this study was to examine whether a laparoscopic procedure in such patients is as safe and effective as the traditional open technique. The data for all pediatric patients who underwent a laparoscopic antireflux procedure for familial dysautonomia were reviewed and compared with those the last pediatric patients with FD who were operated upon using the open technique, before the introduction of the laparoscopic procedure. Of the 61 children who underwent an antireflux procedure for FD (1978-1996), 13 were operated on laparoscopically. The authors found that the postoperative course of these patients was less complicated than that of patients who had the traditional laparotomy procedure. There was no need for mechanical ventilation during the postoperative course, and there were no respiratory complications. The mean hospitalization period was significantly shorter (7.9 days v 13.2 days). There were no complications attributable to laparoscopy, and the antireflux procedure has been effective in all patients (short-term follow-up). The authors conclude that laparoscopic procedures that include a modified Nissen fundoplication, gastrostomy, and appendectomy are feasible and as safe as conventional surgery for the treatment of FD in children. It appears that this approach has fewer complications than laparotomy, might reduce the need for postoperative mechanical ventilation, and is associated with a shorter postoperative stay.

Pentoxifylline attenuates ischemia/reperfusion injury to the small intestine in the rat.

There is a large body of evidence that neutrophils may play an important role in the mucosal injury that follows ischemia of the intestine. Pentoxifylline (PTF), a methylxanthine derivative, prevents leukocyte adherence to vascular endothelium and restores intestinal blood flow following hemorrhagic shock and sepsis. The purpose of this study was to evaluate the protective properties of PTF in an ischemia-reperfusion model of the intestine and whether its action is mediated through tissue neutrophils as assessed by myeloperoxidase (MPO) determination. Intestinal ischemia of either 1 or 2 h was induced in rats by clamping the superior mesenteric artery, followed by a 17-min reperfusion period. PTF (25 mg/kg) or saline solution was injected IP 10 min prior to ischemia. Multiple bowel samples were harvested at the end of the reperfusion period and evaluated for histology and tissue MPO. PTF significantly changed the resultant histologic damage to the intestinal mucosa exerted by prolonged ischemia of 1 and 2 h duration, although the beneficial effect of PTF in this animal model was independent of the number of tissue neutrophils as assessed by tissue MPO levels. Pretreatment with PTF can thus reduce the histologic damage caused by prolonged ischemia to the intestine.

[Laparoscopic surgery in children and adolescents].

Laparoscopic surgery is a rapidly developing field in general surgery. The advantages of laparoscopic procedures are short postoperative courses, fewer wound-related complications, possible reduction in rate of late postoperative adhesions and better cosmetic results. Laparoscopic procedures are indicated in well-defined clinical settings, after enough experience has been acquired and technical problems solved. Children and adolescents may also benefit from laparoscopic procedures. The technique is suitable for cholecystectomies, appendectomies in selected cases, splenectomies, anti-reflux procedures, bowel resections, and diagnostic procedures, among others. In the past 3 years we have performed 65 laparoscopic procedures in patients younger than 17 years, including 10 cholecystectomies, 31 appendectomies and 7 Nissen fundoplications.

Nitric oxide-containing nerves in bowel segments of patients with Hirschsprung's disease.

To assess the role of nerves that synthesize nitric oxide (NO) in Hirschsprung's Disease (HD), the authors studied the distribution of the enzyme NADPH diaphorase (NADPHd) in normal and diseased bowel segments. In the proximal (ganglionic) segment of the colon, NADPHd-positive neurons were present in both myenteric and submucosal plexuses. In the distal involved colonic segments from HD patients, the typical pattern of the neuronal network was completely missing in the regions of the two plexuses; instead, only disorganized NADPHd-positive nerve fibers were present and NADPHd-reactive neurons were absent. Mucosal NO synthase activity was 2.76 +/- 0.38 nmol/g/min in the proximal segment and only 0.83 +/- 0.49 nmol/g/min in the distal segment (P < .05, N = 3).