Evaluation of perioperative cholangiography in one thousand laparoscopic cholecystectomies.

We analyzed a teaching institution's experience with intra-operative cholangiography (IOCG) and endoscopic retrograde cholangiopancreatography (ERCP) and established an algorithm for their timing and use. The records of all patients undergoing LC during a five year period were reviewed. Patients with a history of jaundice or pancreatitis, abnormal bilirubin, alkaline phosphatase, serum glutamic-oxaloacetic transaminase, or radiographic evidence suggestive of choledocholithiasis were considered "at risk" for common bile duct stones (CBDS). The remaining patients were considered to be at low "risk." LC was attempted on 1002 patients during the study period and successfully completed on 941 (94% of the time). The major complication rate was 3.1% and the common bile duct injury rate 0.1%. Eighty eight (9.5%) patients underwent ERCP, 67 in the preoperative period and 19 in the postoperative period. IOCG was attempted in 272 (24%) patients and completed in 234 for a success rate of 86%. Intraoperative cholangiography (IOCG) and preoperative endoscopic retrograde cholangiopancreatography (ERCP) were equivalent in the detection of CBDSs Twelve of the 21 patients (57%) with IOCG positive for stones underwent successful laparoscopic clearance of the common duct, and did not require postop. ERCP. No patients were converted to an open procedure for common bile duct exploration. Because postoperative ERCP was 100% successful in clearing the common duct, reoperation for retained common bile duct stones was not necessary. IOCG is an alternative procedure to ERCP for patients at risk with biochemical, radiological, or clinical evidence of choledocholithiasis. The incidence of CBDS in low-risk patients is 1.7%, a risk that does not warrant routine cholangiography. Preoperative ERCP is recommended in cases of cholangitis unresponsive to antibiotics, suspicion of carcinoma, and biliary pancreatitis unresponsive to supportive care. Although IOCG leads to a similar percentage of nontherapeutic studies as preoperative ERCP, it often allows for one procedure therapy.

Effects of interleukin-11 and epidermal growth factor on residual small intestine after experimental massive small bowel resection.

Interleukin 11 (IL-11) is a multifunctional cytokine derived from bone marrow, which has a trophic effect on small bowel epithelium. This study compares the effects of IL-11 with epidermal growth factor (EGF), a growth factor known to enhance small bowel adaptation. Forty Sprague-Dawley rats (90-100g) underwent an 85% mid-small bowel resection with primary anastomosis on day 0. Rats were divided into four treatment groups: controls (group I) received bovine serum albumin (BSA), group II received IL-11, 125 microg/kg subcutaneously (SC) twice daily, group III received EGF, 0,10 microg/g SC bid, and group IV received EGF and IL-11 in the above doses. Half of the animals (five per group) were killed on day 4 of therapy, and the rest on day 8. Animals were evaluated for weight, mucosal length, and bowel wall muscle thickness on days 4 and 8, and expression of proliferating cell nuclear antigen (PCNA) in intestinal crypt and smooth muscle cells on day 8. Body weight was similar at day 4 and 8. Mucosal thickness in groups 11 (IL-11) and IV (IL-11 and EGF) was significantly increased at day 4 and 8 compared with controls (group I) and EGF (group III, P<.001). Muscle thickness was significantly increased in the EGF and combined group IV compared with the BSA controls and IL-11 groups (P < .001). Thirty-two percent of the mucosal crypt cells in group I stained positive for PCNA, whereas 51%, 53%, and 60% stained positive in groups II (IL-11), III (EGF), and IV (IL-11 and EGF), respectively. In groups I and II, 2% and 1.7% of the myocytes stained positive for PCNA, whereas 11.2% and 5.2% in group III and IV. These data suggest that IL-11 has a trophic effect on small intestinal enterocytes, causing cell proliferation and increased mucosal thickness. EGF has a more generalized effect causing proliferation of both enterocytes and myocytes. IL-11, with or without EGF may be a useful adjunct in treatment of short bowel syndrome.

Results of treatment of malignant germ cell tumors in 93 children: a report from the Childrens Cancer Study Group.

We report treatment results in 93 children entered on study from 1978 to 1984 with malignant germ cell tumors (MGCTs), excluding dysgerminoma and tumors of the testis or brain. The estimated 4-year survival and event-free survival (EFS) for all 93 patients were 54% and 49%, respectively. For 30 children with ovarian tumors, the estimated 4-year survival was 67% and EFS was 63%. For 63 children with nongonadal tumors, survival and EFS were 48% and 42%, respectively. The comparison of EFS between ovarian and nongonadal tumors was significant at P = .03. The treatment plan included a second-look surgical procedure after 18 weeks of chemotherapy. Over half of 36 patients evaluated as having a residual mass present immediately before second-look surgery had no malignant tumor after review of surgical specimens. Age greater than 11 years at diagnosis, incomplete removal of tumor at first surgery, and more than one structure or organ involved at diagnosis increased the risk for adverse event. The histologic subtype of the primary tumor was not related to outcome. Diagnosis was verified by independent pathologic review, and treatment was uniform. Seventeen percent of all registered patients (21 of 127) were excluded because of ineligible pathologic diagnoses; sixty percent (13 of 21) were immature teratomas.

Effectiveness of enteral and parenteral nutrition in the nutritional management of children with Wilms' tumors.

The effectiveness of enteral and parenteral feeding in supporting a satisfactory nutrition status and/or reversing protein-energy malnutrition was evaluated in nine children, ages 1 to 7 years (eight female), with Wilms' tumors. At the onset of treatment, eight patients received comprehensive enteral nutrition (CEN) which included intense nutritional counseling and oral supplements while one received total parenteral nutrition (TPN). Despite CEN, the initial, intense treatment period was associated with a decreased energy intake (64 +/- 27% Recommended Dietary Allowances), dramatic weight loss (22 +/- 7% by 26 +/- 17 days from the beginning of treatment), decreased skinfold thickness (< 10th percentile), and decreased albumin concentrations (< 3.2 g/dl). Four of those who initially received CEN subsequently required TPN. A total of five patients received TPN for a mean of 31 days (range 11 to 60); kcal averaged 105 +/- 9% Recommended Dietary Allowances during weight gain. At onset of TPN, the mean albumin, transferrin, total lymphocyte count were 3.02 +/- 0.45 g/dl, 155 +/- 40 mg/dl, and, 655 +/- 437/mm3, respectively; all children had abnormal anthropometric measurements and anergy to recall skin test antigens. TPN for 28 or more days supported weight gain (+ 2.44 kg), increased serum albumin (+ 0.58 +/- 0.47 g/dl) and transferrin (+ 76 +/- 34 mg/dl), and reversed anergy despite low total lymphocyte counts. During maintenance treatment, nutritional status was maintained or restored with CEN in the group who responded. These preliminary data document the severity of protein-energy malnutrition which accompanies initial, intense treatment of children with Wilms' tumors, the nutritional and immunological benefits of TPN during continuing intense treatment and the effectiveness of CEN in maintaining a satisfactory nutritional status during maintenance treatment.

Effectiveness of central parenteral nutrition versus peripheral parenteral nutrition plus enteral nutrition in reversing protein-energy malnutrition in children with advanced neuroblastoma and Wilms' tumor: a prospective randomized study.

The effectiveness of central parenteral nutrition (CPN) versus peripheral parenteral nutrition (PPN) plus enteral nutrition in reversing protein-energy malnutrition was evaluated in 19 children (nine CPN, 10 PPN) with advanced neuroblastoma or Wilms' tumor. Weekly dietary, anthropometric, and biochemical measurements were compared for 15 patients (eight CPN, seven PPN) who completed more than 25 days of nutrition support. The groups had similar mean energy and protein intakes (CPN: 95 +/- 5% of healthy children, 2.5 +/- 0.3 g/kg; PPN: 102 +/- 5% of healthy children, 2.9 +/- 0.3 g/kg). Increases in weight (p less than 0.001), subscapular skinfold thickness (p less than 0.001), albumin (p less than 0.05), and transferrin (p less than 0.05) for the first 28 days were significant and did not differ between groups. Fever, sepsis, elevated SGOT, and severe anemia occurred with both CPN and PPN. PPN resulted in subcutaneous infiltrations and more psychological trauma. PPN with enteral nutrition seems most appropriate for short term intravenous nutrition support or as a temporary substitute for CPN; CPN is preferred for long-term support.

Suppurative thrombophlebitis in childhood.

Thrombophlebitis in children is almost always related to intravenous therapy. In most cases the inflammatory reaction is self-limited and resolves when the intravenous catheter or needle is removed. In some cases contamination may result in suppurative thrombophlebitis, a potentially life-threatening complication of intravenous therapy. This report describes two-6-year-old children with suppurative thrombophlebitis that was successfully treated by drainage of periphlebitic abscess and excision of the infected vein. Early recognition and prompt surgical management should reduce morbidity and prevent mortality in these cases.

Congenital rectal stenosis: a sign of a presacral pathologic condition.

Congenital rectal stenosis may be detected in the newborn during the initial physical examination. Failure of conservative therapy (dilatation) should alert the physician to the presence of an associated pathologic condition in the presacral space. Presacral teratoma, anterior sacral meningocele, or bony anomalies may be the underlying extrinsic causes of congenital rectal stenosis. Prompt recognition and appropriate operative management directed at the presacral lesion will relieve obstructive symptoms and minimize morbidity.

Gastric teratoma: unusual cause for bleeding of the upper gastrointestinal tract in the newborn.

Bleeding of the upper gastrointestinal tract in the full-term newborn is a relatively benign and rare occurrence. This report describes a female infant with a gastric teratoma who experienced recurrent bleeding of the upper gastrointestinal tract as a neonate and infant secondary to gastric outlet obstruction. Anteroposterior and lateral abdominal radiographs revealed a large calcified abdominal mass with the pathognomonic features of a teratoma with a mandible and teeth. Gastric teratomas have not been previously reported as an etiologic or predisposing condition of gastrointestinal hemorrhage in two large reviews concerning this topic in the newborn and infant. This patient represents the 51st case and only the second female described in the literature. The frequency and unusual features of this treatable lesion, as well as the diagnostic approach to bleeding of the upper gastrointestinal tract in the newborn, are reviewed.

The causes of interstitial pneumonitis in immunocompromised children: an aggressive systematic approach to diagnosis.

A systematic, aggressive approach to the immunocompromised child with interstitial pneumonitis has been used in 24 consecutive patients. Parent and physician awareness of early symptoms and signs had been emphasized. When laboratory data confirmed clinical suspicion, open lung biopsy was done and lung tissue was studied by impression smears, sections, and culture techniques. The etiologic agent was established by stained impression smears within three hours of receipt of tissue in 21 of 24 patients. Eighteen of 24 patients survived. Patients had a poor prognosis if they required ventilatory assistance (five of seven died) or had respiratory symptoms for three days or more prior to biopsy (four of 13 died). Children with solid tumors who had absolute lymphocyte counts less than 500/cu mm, had received chemotherapy and radiotherapy to the chest, and had developed Pneumocystis carinii pneumonitis had a poor outcome (all three died).

Unusual manifestations of histoplasmosis in childhood.

Nine previously healthy children were seen with unique, and in several instances, unreported manifestations of acute histoplasmosis. Presenting manifestations included: obstructive airway disease; subacute parotitis; unilateral cervical lymphadenopathy; anterior mediastinal mass-simulating neoplasm; immune hemolytic anemia; a cutaneous lesion with regional lymphadenopathy; mediastinal mass and pericardial effusion; pulmonary infarction; and a symptom complex of cervical lymphadenopathy, CSF pleocytosis, arthritis, and interstitial nephritis. In eight children histoplasmosis was not initially considered, and the correct diagnosis was made only after complex, and sometimes invasive, diagnostic evaluation and considerable delay. All patients recovered fully without antifungal therapy. Reports of uncontrolled trials of new antifungal agents for treatment of histoplasmosis in immunocompetent hosts should be cautiously evaluated.

Surgical treatment of gastroesophageal reflux in children: a combined hospital study of 7467 patients.

OBJECTIVE: To review retrospectively the combined clinical experience with the surgical treatment of persistently symptomatic gastroesophageal reflux (SGER) in childhood from seven large children's surgery centers in the United States. DESIGN: During the past 20 years, 7467 children <18 years of age underwent antireflux operations for SGER at the seven participating hospitals. Fifty-six percent were neurologically normal (NN) and 44% were neurologically impaired (NI). The most frequent diagnostic studies were upper gastrointestinal series (68%), esophageal pH monitoring (54%), gastric emptying study (32%), and esophagoscopy (25%). The age at operation was under 12 months in 40% and 1 to 10 years in 48%. The type of fundoplication was Nissen (64%), Thal (34%), and Toupet (1.5%). A gastric emptying procedure was performed on 11.5% of NN patients and 40% of NI patients. Laparoscopic fundoplication was performed on 2.6% of patients. RESULTS: Good to excellent results were achieved in 95% of NN and 84.6% of NI patients. Major complications occurred in 4.2% of NN and 12.8% of NI patients. The most frequent complications were recurrent reflux attributable to wrap disruption (7.1%), respiratory (4.4%), gas bloat (3.6%), and intestinal obstruction (2.6%). Postoperative death occurred in 0.07% of NN and 0.8% of NI patients. Reoperation was performed in 3.6% of NN and 11.8% of NI patients. The results and complications were similar among the participating hospitals and did not seem related to the type of fundoplication used. CONCLUSION: The excellent results (94% cure) and low morbidity with gastroesophageal fundoplication with or without a gastric emptying procedure from a large combined hospital study indicate that operation should be used early for SGER in NN children and to facilitate enteral feedings and care in NI children.

Multiple esophageal duplication cysts.

During thoracic exploration for resection of an esophageal duplication cyst, a second such cyst was encountered and removed. Although the association of esophageal duplication cysts with other intestinal duplications has been described, to our knowledge this is the first reported case of multiple esophageal duplication cysts.

Changes of hepatoma echo patterns with tumor growth. A study of the microanatomic basis in a rat model.

OBJECTIVES: The echo patterns of human hepatoma vary considerably as the tumors grow. This sonographic study investigates the microanatomic basis of the echo-pattern changes in an animal model. METHODS: ACI rats (n = 35) with intrahepatically implanted Morris hepatoma 3924A were imaged with 10-MHz ultrasound from days 7 to 28 after tumor implantation. The sonograms were precisely correlated with the histologic sections and microangiograms obtained from the same section plane. RESULTS: Small hepatomas (size = 6.6 +/- 1.6 mm) without necrosis demonstrated a low-echo pattern. Medium-sized tumors (size = 11.7 +/- 3.3 mm) had a low-echo periphery and a high-echo center. The low-echo periphery corresponded to viable tumor and the high-echo core corresponded to central coagulation necrosis. Large tumors (size = 20.9 +/- 7.5 mm) with extensive necrosis revealed an irregular mixed-echo pattern. CONCLUSIONS: The trend of increasing echogenicity of the hepatomas with tumor growth is due to the progression of coagulation necrosis.

Sonographic and computed tomography characteristics of liver ablation lesions induced by high-intensity focussed ultrasound.

RATIONALE AND OBJECTIVES: The authors have previously demonstrated the ability of high-intensity focused ultrasound (HIFU) to extracorporeally induce selective tissue destruction in the liver without causing damage to the intervening abdominal wall. The potential usefulness of HIFU as a noninvasive therapy for liver cancer has been suggested. This study observes sonographic and computed tomography (CT) characteristics of HIFU-ablated liver tissue in an attempt to assess the possibility of using these imaging methods to monitor the therapeutic results. METHODS: A sonoablated lesion was induced in the liver in each of 20 rabbits with a HIFU therapeutic system. Sequential imaging of the hepatic sonolesions with sonography and CT was performed up to 8 days after treatment, and the imaging patterns were correlated with the histopathology. RESULTS: Hepatic sonoablated tissue could be clearly visualized by sonography as a hypoechoic lesion. On contrast-enhanced CT, the sonolesions were depicted as nonenhanced low-density regions. There was good correlation among the sizes of sonography- and CT-depicted lesions and pathologic specimens. CONCLUSION: In this model, sonography and contrast-enhanced CT were useful imaging modalities for monitoring sonolesion evolution after HIFU treatment.

Extracorporeal liver ablation using sonography-guided high-intensity focused ultrasound.

RATIONALE AND OBJECTIVES: High-intensity focused ultrasound (HIFU) is the only radiation beam that can remotely destroy deep-seated tissue targets without causing damage to the intervening tissues. This study evaluates the ability of sonography-guided HIFU to extracorporeally induce liver ablation in a rabbit model. METHODS: Under sonographic guidance, the HIFU beam was transcutaneously focused at the target tissue in the liver through a subcostal approach. A computer controlled the HIFU exposure and transducer movement to destroy a preselected tissue volume. Simultaneous sonography monitored the tissue response. Ten insonated rabbits were killed from days 0 to 10, and the liver and intervening tissues were examined histologically. RESULTS: A sharply demarcated sonolesion of coagulation necrosis was produced in the liver in 9 of 10 animals. No damage was found in the intervening tissues (n = 6) when adequate acoustic coupling and proper beam path was applied. CONCLUSION: Sonography-guided HIFU might be a potential new modality for extracorporeal inducement of liver cancer ablation without resorting to laparatomy.

Intestinal atresia and stenosis: analysis of survival in 120 cases.

This report reviews the clinical presentation, operative management, and survival in 120 infants with intestinal atresia and stenosis treated from 1972 to 1984. Duodenal atresia occurred in 39 neonates and duodenal stenosis in 19. Thirty-two infants had severe associated anomalies. Operative management included duodenoduodenostomy in 47 infants, duodenotomy and web excision in four, and duodenojejunostomy in seven. Jejunoileal atresia occurred in 49 infants and stenosis in three. Six infants had cystic fibrosis and nine had gastroschisis. Operative therapy included wide proximal resection and end-to-end anastomosis in 18 infants, minimal resection with antimesenteric tapering enteroplasty and anastomosis in 14 neonates, and resection with temporary enterostomies in 20 infants. Twenty-nine infants (56%) required total parenteral nutrition. Colon atresia occurred in 11 infants and stenosis in one. Initial end-colostomy with subsequent resection and anastomosis was performed in 11 infants while one underwent a primary resection. The survival rate was 91% for duodenal defects, 87% for jejunoileal cases, and 100% for colonic anomalies. Death is currently caused by severe associated anomalies in infants with duodenal atresia and sepsis and total parenteral nutrition-related cholestasis with progressive liver failure in instances of jejunoileal atresia.

Esophageal atresia and tracheoesophageal fistula: Effect of delayed thoracotomy on survival.

Eighty-four infants with esophageal atresia and/or tracheosophageal (TE) fistula were treated from 1972 to 1977. Twenty-eight percent were premature and 24% weighed less than 2.0 kg. Major symptoms included excess salivation (56 patients), respiratory distress (28 patients), cyanosis (26 patients), and choking (nine patients). Pneumonia and or atelectasis occurred in 58% and associated anomalies in 68%. Seventy-three of 84 patients (87%) had proximal esophageal atresia and distal TE fistula (type C defect). Operation was carried out in 79 patients. Gastrostomy was performed in 75 patients, often under local anesthesia with subsequent delayed extrapleural thoractomy (mean, 3.9 days), when the infant's pulmonary condition was improved. Primary anastomosis was performed in 55 patients, division TE fistula and esophagostomy in ten, staged anastomosis in seven, cervical esophagostomy alone in three, division H fistual in two, ligation TE fistula alone in one, and gastrostomy alone in one. Complications were frequent, including need for ventilator support in 28 patients, atelectasis in 28, pneumonia in 18, jaundice in 13, heart failure in 11, anastomotic leak in 10, and stricture in four. Operative mortality was 5% (four of 79). Two deaths followed immediate thoracotomy and two were premature with anomalies. There were eight late deaths 4 to 39 months after operation. Seven had multiple anomalies. The overall mortality was 15%. Management of high-risk cases by preliminary gastrostomy and delayed extrapleural thoracotomy is associated with improved survival (67 to 79) (85%). Neonatal intensive care, detection of associated anomalies, and long-term follow-up are essential factors in reducing mortality.

Intussusception: current management in infants and children.

Intussusception remains a leading cause of bowel obstruction in early infancy and childhood. From 1970 to 1985, 83 patients with intussusception were treated. There were 51 boys and 32 girls ranging in age from 2 months to 22 years. Ten patients had a total of 14 separate recurrences; nine occurred during the initial hospitalization. Symptoms on presentation included abdominal pain (80%), palpable mass (60%), rectal bleeding (53%), and lethargy or sepsis (45%). Fifteen children underwent exploration without contrast studies based on duration of symptoms (greater than 5 days) and evidence of severe obstruction on plain abdominal x-ray films. In the remaining children, diagnosis was confirmed by barium enema and hydrostatic reduction was achieved in only 34 patients (42% success rate). Symptoms were present more than 48 hours in 55% of the reduction failures. At operation, five children had spontaneously reduced and an appendectomy was performed. Manual reduction was possible in 32 patients. The intussusception was irreducible in 26 patients, and 18 required temporary stomas. Pathologic lead points were found in 11 patients. Average length of hospitalization was 1.5 days after barium enema reduction, 9.6 days after manual reduction, and 13.8 days after bowel resection. There were no recurrences of intussusception after surgical reduction. A significant morbidity rate was observed with a delay in diagnosis. Adequate preoperative preparation and prompt surgical intervention are associated with 100% survival.

Esophageal replacement in children: experience with thirty-one cases.

Esophageal replacement procedures in adults are often performed for malignancy and are associated with significant morbidity and death. This article describes 31 children who underwent esophageal replacement procedures between 1970 and 1985. Diagnosis in the 18 boys and 13 girls included esophageal atresia in 23, caustic ingestion in six, and distal esophageal stricture caused by reflux in two. Replacement procedures performed included right colon isoperistaltic segments in 23 children, left colon antiperistaltic interposition in two, and gastric tube in four. Immediate complications included atelectasis (20), pneumothorax (four), and ventilator support greater than 2 days (eight). Ten patients developed leaks at the cervical anastomosis and required subsequent dilation. Seven patients had pulmonary restrictive disease caused by recurrent aspiration despite compliance with anti reflux measures. Four of these same children developed peptic ulceration before pyloroplasty. No patient who had a gastric drainage procedure as part of the initial operation has developed ulcer disease or aspiration pneumonitis. These data suggest that esophageal replacement procedures are relatively well tolerated in children with no deaths observed in this series. A gastric drainage procedure is an important adjunct in minimizing long-term morbidity. Since reflux, peptic ulceration, and pulmonary complications may occur, long-term follow-up essential.

Experimental liver cancer: improved response after hepatic artery ligation and infusion of tumor necrosis factor-alpha and interferon-gamma.

BACKGROUND: The aim of this study is to investigate whether regional infusion of tumor necrosis factor-alpha (TNF-alpha) and interferon-gamma (IFN-gamma) could improve the therapeutic results of hepatic artery ligation (HAL) on liver cancer in a rat model. METHODS: Morris hepatoma 3924A was implanted intrahepatically in 50 ACI rats. Two weeks after tumor implantation, 40 rats underwent hepatic artery cannulation and ligation. The cannula was connected to an infusion port implanted subcutaneously. Animals were then divided into four groups of 10 each to receive seven daily intraarterial injections of IFN-gamma 100,000 IU/rat/day (HAL + IFN group), TNF-alpha 30 micrograms/rat/day (HAL + TNF group), IFN + TFN (HAL + IFN + TNF group), or normal saline solution (HAL group). The remaining 10 rats received a laparotomy only and served as untreated controls. Tumor volume, viable tumor area, and histopathology were assessed after 3 weeks. RESULTS: The tumor growth was significantly retarded in the HAL group compared with the controls (tumor volume 683 +/- 245 mm3 vs 2424 +/- 596 mm3, p < 0.05 ANOVA). HAL + TNF (221 +/- 93 mm3) and HAL + IFN + TNF groups (74 +/- 31 mm3), but not the HAL + IFN group (493 +/- 164 mm3), were much more effective than the HAL group in controlling tumor growth (p < 0.05). HAL + IFN + TNF achieved the best tumor control resulting in a 60% tumor-free rate (p < 0.05 vs all other groups). CONCLUSIONS: These data suggest that HAL combined with regional infusion of TNF-alpha and IFN-gamma significantly reduces tumor growth in a rat liver model. This attractive concept of combined modality therapy may have utility in the clinical setting in instances of unresectable liver cancer.