Securing central lines in rambunctious toddlers.

Central line dislodgment in toddlers continues to be a problem. The deployment of a spandex/nylon bodysuit has resulted in eliminating this problem in two overactive toddlers. We highly recommend using this type of garment in appropriate clinical situations.

Serum gastrin levels in infants and children.

Fasting serum gastrin concentrations were determined by radioimmunoassay for 124 infants and children free of gastrointestinal disease. Values for the entire group ranged from 1.1 to 167.9 pg/ml (mean, 32.3 pg/ml). Mean serum gastrin levels for children who fasted eight or more hours were 22.5+/-23.9 pg/ml while the mean serum gastrin levels for children who fasted four to eight hours ranged from 42.4+/-33.9 pg/ml to 59.2+/-49.6 pg/ml. The mean serum gastrin levels varied inversely with body surface area among children who fasted the same length of time.

Balloon embolization of a bleeding gastroduodenal artery in a 1-year-old child.

Severe stress can produce ulceration and uncontrollable hemorrhage in the pediatric age group. Modern angiographic techniques, using embolization of a Silastic balloon to occlude a visualized bleeding vessel, can successfully control hemorrhage and avoid surgical intervention and its resultant disordered gastric physiology. Recently this technique was used to control hemorrhage from the gastroduodenal artery in a 1-year-old child with severe respiratory sepsis. This is the youngest reported child in whom the technique has been used to control bleeding from this vessel.

Thoracoscopic evaluation of intrathoracic lesions in children.

In the last 3 years, we have used transthorascopic biopsy for the diagnosis of intrathoracic pulmonary lesions in 17 children ranging in age from 5 months to 17 years. The procedure is performed under a variety of anesthetic conditions ranging from local infiltrative to general endotracheal anesthesia. A fiberoptic rod lens system with cautery is utilized for direct observation and biopsy of intrathoracic pulmonary lesions. Biopsy specimens have been adequate for diagnosis in each child. Death and morbidity have not occurred. This technique is a safe, direct means under minimal anesthesia for the diagnosis of diffuse or localized intrathoracic disease in children.

Wide gap esophageal atresia with inaccessible upper pouch.

Circular myotomy of the proximal esophageal pouch has allowed end-to-end esophagoesophagostomy in infants with wide gap esophageal atresia. Occasionally, the proximal pouch ends so high in the thorax that the circular myotomy is technically impossible under conventional means. Exteriorization, mobilization, and myotomy of the proximal esophageal pouch via a separate cervical incision has allowed us to overcome this limitation of an inaccessible upper pouch and has permitted esophagoesophagostomy. This technique has been performed successfully in two infants with good results and no morbidity over a follow-up period of 1 1/2 to 3 1/2 years.

Congenital funnel-shaped tracheal stenosis: an asymptomatic lethal anomaly of early infancy.

Two infants with an unusual variant of congenital tracheal stenosis (funnel-shaped distal trachea) are described. Six other reports have appeared in the literature. This anomaly is asymptomatic from 1 to 3 months after birth, despite nearly complete tracheal obstruction. Staged surgical repair and/or definitive correction have been hampered by the size of the tracheal lumen, length of the deformity, and nondistensibility of the complete cartilaginous rings in the distal trachea.

Pediatric appendicitis. A 20-year study of 1,640 children at Cook County (Illinois) Hospital.

Of 1,640 children with acute appendicitis treated at Cook County (Illinois) Hospital between Jan 1, 1957, and Dec 31, 1976, 35% had appendiceal perforation. Overall morbidity was 12.8% and mortality was 0.24%. Antibiotics, transperitoneal drainage, and delayed wound closure were used routinely in children with appendiceal perforation. Antibiotics and transperitoneal drains did not appreciably alter the incidence of intraabdominal abscess formation. Delayed wound closure in patients with appendiceal perforation reduced the incidence of wound infection by 75%.

Prevention of postoperative peritoneal adhesions: efficacy of povidone.

The appearance and severity of peritoneal adhesions after simple laparotomy and after adhesiolysis were studied in a rabbit model. Adhesions were induced by direct abrasion with latex glove and dry gauze; control rabbits had abrasion only. Study groups had abrasion and treatment with 10% or 25% povidone. Results showed a significant reduction in the number of adhesions and in the severity of adhesions after treatment with povidone. This study supports the further investigation of the efficacy of povidone in preventing postoperative peritoneal adhesions.

Nonischemic intussusception.

Nonischemic intussusception is defined as a variant of acute intussusception exhibiting less acute symptoms of abdominal pain, vomiting, and diarrhea in the older child, longer duration of symptoms (usually 4-14 days), signs of imcomplete bowel obstruction, and absence of intestinal ischemia. Over a 10 yr period (1964-1973) 20 children with this disease were treated without mortality or recurrence at three children's hospitals in Chicago, Illinois. The higher incidence of diarrhea, the lower incidence of a palpable abdominal mass, and the lower incidence of blood per rectum in nonischemic intussusception predispose to diagnostic errors and delays in treatment. Despite the longer duration of symptoms, this variant of intussusception can be treated initially with a careful attempt at barium hydrostatic reduction. If this fails, easy operative manual reduction is the rule.

The vulnerability of the vas deferens.

Transection of the vas deferens is considered a disaster, but other manipulations may have unpredictable and hitherto undocumented effects. In order to delineate the structural changes in the vas deferens after operative manipulation, 40 Wistar rats (300-500 g) were divided into four groups and subjected to four different operative manipulations (grasping with fingers, nontoothed Adson forceps, bulldog vascular clamp, clamping with "mosquito" hemostat). Histologic studies performed at 6 wk postmanipulation demonstrated a variable intra- and transmural inflammatory reaction in all groups. Thirty percent of the specimens grasped by the forceps showed disruption of the muscle wall. One-hundred percent of the specimens clamped by the hemostat showed mural disruption and marked inflammatory reaction; in addition 30% had an associated abscess. Therefore all manipulation of the vas deferens should be minimized to avoid triggering inflammation and secondary obstruction. Grasping with a nontoothed forceps results in appreciable damage. Clamping with a hemostat is as serious as complete transection.

The vulnerability of the vas deferens (II): the case against routine bilateral inguinal exploration.

The results of operative manipulation of the vas deferens have unknown results. In order to document early and late structural changes in the vas after simple operative manipulations, the vasa deferentia of 120 Wistar rats were subjected to 4 different manipulations. Subsequently, they were removed at intervals (up to 6 mo) and examined after appropriate staining. Finger or vascular clamp grasping resulted in mild inflammation at 6 wk, which resolved thereafter. Forceps grasping disrupted the muscle layers in 30%-40% of the vasa. Hemostat clamping damaged muscle layers in 100% of the vasa and resulted in abscess formation in 30%. Healing in forceps grasped and hemostat clamped specimens was negligible and haphazard with minimal evidence of normal collagen or elastin at 6 mo. All differences were significant (p less than 0.05). These results suggest that operative manipulations of the vas should be minimized and limited to digital maneuvers. Damage from other manipulations is appreciable, long-term, and only minimally repaired at 6 mo.

Normal intestinal rotation with non-fixation: a cause of chronic abdominal pain.

The majority of clinically significant gastrointestinal rotational anomalies involve:(1) an arrest of rotation about the superior mesenteric vessels, (2) abnormal peritoneal bands, and (3) obstruction with or without volvulus. Between 1973 and 1978, six children had chronic intermittent volvulus secondary to a nonfixed but normally-rotated intestine; this is 10% of all infants and children treated for malrotation in our hospital during the same period. Barium studies showed normal duodenojejunal configuration and a colon that was normally situated on at least one study. All were labeled as functional complainers by their pediatricians. One died of a volvulus because her complaints were appreciated too late. At laparotomy, evidence of chronic intermittent volulus secondary to nonfixation from the ligament of Treitz to the transverse colon was found in all patients. A Ladd procedure with appendectomy was performed and immediate resolution of symptoms was noted in each surviving child. Children with a story of chronic abdominal pain deserve a carefully interpreted history and radiographic examination before being labeled as chronic complainers.

Peritoneal drainage under local anesthesia for necrotizing enterocolitis (NEC) perforation: a second look.

Between 1974 and 1979, 15 extremely ill neonates with necrotizing enterocolitis (NEC) were initially treated with peritoneal drainage under local anesthesia for intestinal perforation. They weighed 600 to 3040 g with half less than 1000 g. Most had other serious illnesses (RDS, PDA, jaundice, CNS abnormalities). There were no immediate complications such as hemorrhage or bowel evisceration from the local drainage procedures. Seven of the 15 (46%) survived. Three (20%) died because of unrelated problems (CNS, liver failure) with an intact gastrointestinal tract, while another 8 (34%) died from intestinal sepsis. Seven (87%) of the neonates weighing less than 1000 g had an adequately functioning GI tract after this drainage procedure. Half of the neonates requiring additional surgery within 24 hr of initial peritoneal drainage survived and half of the neonates requiring subsequent surgery survived. Five of 15 infants developed strictures one died before excision. This technique is contrary to standard practice and was employed in less than 10% of the neonates with NEC treated at our institution. These results indicate that this method is effective in possibly temporizing the very ill neonate with NEC. An added bonus, however, is that 40% of the neonates treated in this fashion had complete resolution of their disease without residual scarring of the gastrointestinal tract requiring further surgery. It is our continued conclusion that this form of peritoneal drainage under local anesthesia is warranted in certain carefully selected instances.

Intestinal stricture after necrotizing enterocolitis.

Between 1974 and 1979 inclusive, 20 of 175 neonates with previous necrotizing enterocolitis (NEC) developed obstruction from intestinal stricture 1-20 mo after the diagnosis of NEC. Seven were found in the small bowel, 19 in the colon. Treatment included proximal decompressive enterostomy with subsequent resection in 6 and primary resection in 11. Two died during attempts to restore GI continuity and one died from cardiac disease before any GI surgery. Morbidity occurred in six. Various stages of wound healing from acute inflammation to dense fibrosis were found in pathologic specimens. Fibrosis was most marked in the submucosa and most consistently found in specimens resected 3 mo after the acute episode of NEC. Intestinal stricture develops in 6%-33% of the infants with previous NEC. Eighty percent of these strictures are colonic, 30% are left sided, and 15% are multiple. Multiple lesions are exclusively colonic. Histology varies with age of lesion. The predominant feature of stricture is submucosal fibrosis. Strictures less than 3 mo old still have acute inflammatory disease, older strictures are mature and fibrotic. The best diagnostic tools are a high index of suspicion and a barium enema. An intestinal stricture should be suspected in any infant with a past history of NEC and: (1) symptoms of obstruction or failure to thrive; (2) previous exteriorization or proximal diversion of acute or chronic NEC lesions; or (3) peritoneal drainage under local anesthesia for NEC perforation. Treatment should be tailored to the infant's condition and the time elapsed since the acute NEC episode. Resection of the stricture must be complete otherwise recurrence or leak is unlikely. Intestinal diversion with a 3-6-mo delay before reconstruction appears safer in the child with little margin for error. Earlier restoration of blood flow and cessation of intestinal function during the acute episode of NEC might reduce the incidence of stricture.

Intrathyroid parathyroid gland and neonatal primary hyperparathyroidism.

Neonatal hyperparathyroidism (NPHP) is exceedingly rare and often fatal. A neonate is presented with a serum calcium concentration of 33 mg/dL, an intrathyroid parathyroid gland, and a family history of hypocalciuric hypercalcemia (FHH). She underwent successful total parathyroidectomy. Six years later, the child is normocalcemic and developmentally normal, requiring calcium and calcitrol replacement. The results of this case support the concept that NPHP is associated with parathyroid hyperplasia and is part of a continuum that includes FHH.

Colon esophagoplasty in the orthotopic position.

Three cases of long-gap esophageal atresia were repaired using a technique that included a right extrapleural thoracotomy, preservation of the entire esophagus available, both anastomoses in the mediastinum, use of a short segment of colon, and preservation of the ileocecal valve. This approach, not previously described, combines multiple features aimed at decreasing complications related to traditional techniques. Successful early results are promising.

The role of gastrin in congenital hypertrophic pyloric stenosis.

A study was designed and carried out to determine if the canine model of hypertrophic pyloric stenosis is applicable to other species and to demonstrate the transplacental passage of gastrin. Results of the study show that (1) pentagastrin does not induce hypertrophic pyloric stenosis in the rabbit; (2) human gastrin does not cross the canine placenta, and (3) gastrin has no documented and little inferred role in the etiology of CHPS.

Bronchoscopy in childhood.

One hundred and seventeen patients underwent 183 bronchoscopies with no fatalities. Thirteen patients had complications related to their bronchoscopy and not the underlying disease state. Only the 33 patients with a diagnosis of foreign body aspiration had a high (88%) correlation of the preoperative diagnosis or condition and the postoperative findings. Fifty-one of the 117 patients had normal bronchoscopies and the number of normal bronchoscopies in patients who had wheezing, croup, hoarseness, stridor, and chronic cough was high. Assessing justification for bronchoscopies despite the negative correlation of pre- and postoperative diagnosis is difficult due to many factors, including pediatrician and parental anxiety, and the recognized consequences of missing a foreign body or other lesion in the airway of a child. Using liberal criteria for justification. fewer than 10% of the patients in this series had an unwarranted bronchoscopy, and the safety of the procedure would indicate that bronchoscopy in a pediatric medical center should be performed with minimal clinical justification.

Occult coin perforation of the esophagus.

Only a small number of ingested foreign bodies perforate the esophagus and even a smaller fraction migrate extraluminally with no symptoms. Both of these events are even rarer after coin ingestion. Between 1972 and 1984, three children (16 months to 5 years), who had unabating upper respiratory symptoms, were found to have ingested coins. In only one child could the time interval between ingestion and appearance of symptoms (3 years) be established, and in this child the diagnosis was delayed because of failure to x-ray the chest after an ingestion episode. Surgical evaluation included chest/neck films: tracheal and esophageal shadows were separated by the object and a soft tissue mass; esphagogram: deviation of the esophagus, irregularity of the lumen, and no leak or tracheoesophageal fistula (TEF) and esophagoscopy: mucosa was intact with no direct visualization of the coin. Treatment consisted of exploration: cervical, one; thoracic, two; localization: coin in extraluminal granulomatous soft tissue; removal: without resection of the soft tissue mass or esophagus, and drainage: penrose, one; chest tube, two. There was no morbidity or mortality from 1 to 13 years later. Though generally harmless, ingested coins are capable of penetrating the esophagus. Sporadic literature reports confirm that the clinical findings and operative results are typical of this seemingly intermediate stage between perforation with mediastinitis and perforation with TEF.

Ileal atresia with total colonic aganglionosis.

This is the 17th report of the case of an infant who had ileal atresia associated with Hirschsprung's disease, and the second with ganglion cells distal to the atresia. Experience suggests that Hirschsprung's disease should be suspected in all forms of bowel atresia.