Perinatal management of ventral wall defects.

Reported is the analysis of morbidity, mortality, and mode of delivery in 38 cases of ventral wall defects identified from among 128,500 consecutive live births in Maine (January 1975 to December 1982). Thirteen of the ventral wall defects were classified as gastroschisis, and only one had an additional defect not directly attributable to the ventral wall defect itself. By contrast, 16 of the 25 omphalocele cases had additional defects, including eight congenital heart lesions, four genitourinary malformations, two neural tube defects, and three trisomies. Ten cases of omphalocele and one of gastroschisis died, all as a result of independent defects or involvement of adjacent structures. Intrauterine growth retardation was prominently associated with gastroschisis. Vaginal delivery occurred in three of the six ventral wall defects diagnosed antenatally and in 28 of the 32 ventral wall defects not diagnosed until delivery. The only episode of birth trauma to ventral wall defect sac or abdominal viscera occurred during cesarean section in an undiagnosed case. The present data provide a basis for prognosis and management of antenatally diagnosed ventral wall defects and suggest that these defects are not, a priori, an indication for abdominal delivery.

Problems associated with a Nissen fundoplication following tracheoesophageal fistula and esophageal atresia repair.

Gastroesophageal reflux is frequently associated with esophageal atresia and tracheoesophageal fistula repair. Following unsuccessful medical treatment, 14 (45%) of 31 patients underwent a Nissen fundoplication. Five of these 14 patients had prolonged dysphagia requiring supplemental gastrostomy feeding. Four of these five patients underwent postoperative manometry and extended pH monitoring, which revealed a normal lower-esophageal sphincter pressure (greater than 15 mm Hg), normal pH results, and marked esophageal dysmotility. The fundoplication creates a mechanical obstruction for those patients with a dyskinetic esophagus who cannot generate the pressure to open the "new sphincter". To avoid this complication, antireflux surgery should be deferred, if possible, in those patients with severe gastroesophageal reflux and marked esophageal motility abnormalities.

The treatment of complicated appendicitis in children. What is the gold standard?

From 1976 to 1985, 233 consecutive children were treated for appendicitis by a standardized protocol. Forty-nine percent of these cases were complicated: 11% by gangrene, 33% by perforation, and 4% by perforations with well-developed abscesses. Treatment of gangrenous and perforated appendicitis consisted of administration of ampicillin sodium, gentamicin sulfate, and clindamycin phosphate; appendectomy; and saline peritoneal irrigation. Transperitoneal drainage was not used. Skin and subcutaneous tissues were left open for delayed primary wound closure. Perforations with well-developed abscesses were treated with triple antibiotic therapy and interval appendectomy. The only infectious complication was one intra-abdominal abscess. There were no wound infections or deaths. The rate of infectious complications was 0.9%, and the overall morbidity was 4.4%. This standardized treatment of complicated appendicitis in children prevents wound infection and significantly decreases the incidence of intra-abdominal abscess formation and mortality.

Intra-abdominal abscess after laparoscopic appendectomy for perforated appendicitis.

HYPOTHESIS: The incidence of postoperative intra-abdominal abscess is higher after laparoscopic compared with open appendectomy for perforated appendicitis. METHODS: A historical cohort study of pediatric patients operated on for suspected appendicitis by open appendectomy or laparoscopic appendectomy compares the incidence of postoperative intra-abdominal abscess for each procedure. SETTING: A tertiary care center. PATIENTS: Five hundred thirty-eight pediatric patients were operated on for suspected appendicitis at our institution between 1974 and 1999. Of these, 453 were included in the study. Of the excluded patients, 9 had incomplete medical records, 69 had normal or interval appendectomies, and 7 had appendixes removed by methods other than laparoscopy or right lower quadrant incision. INTERVENTIONS: Open appendectomy performed through a right lower quadrant incision or laparoscopic appendectomy performed through a 3-trocar approach by 1 of 3 pediatric surgeons at our institution. MAIN OUTCOME MEASURE: The incidence of postoperative intra-abdominal abscess after laparoscopic vs open appendectomy. RESULTS: In perforated appendicitis (170 patients), the incidence of postoperative abscess after laparoscopic appendectomy was 24% vs 4.2% after open appendectomy. The relative risk ratio of developing a postoperative abscess after perforated appendicitis was 5.6 (confidence interval, 2.1-16.0) after laparoscopic vs open appendectomy. The results remained significant when controlled for age, sex, intraoperative irrigation, and preoperative antibiotics. Postoperative abscess in all acute, gangrenous, and perforated appendicitis after laparoscopic appendectomy was 6.4% vs 3.0% after open appendectomy. This was not statistically significant. CONCLUSION: There is a significant increase in the incidence of postoperative intra-abdominal abscess with perforated appendicitis after laparoscopic compared with open appendectomy in pediatric patients.

Gastroesophageal reflux in children: an underrated disease.

Gastroesophageal reflux in infants and children is a complex disease. The diagnosis in 14 operative patients was made utilizing a careful history, barium swallow, technetium radionuclide milk scan, and endoscopy with esophageal biopsy. Symptoms were intractable vomiting, failure to thrive, recurrent pneumonia, apnea, asthma and bronchitis, esophagitis, and esophageal stricture. The pernicious aspects of this disease include a potentially significant mortality in children with severe apnea episodes, increased morbidity with esophagitis, and psychosocial disruption for those children that progress to the teenage years with recurrent vomiting, rumination, heartburn and stricture formation. A high incidence of gastroesophageal reflux unresponsive to medical management was noted with esophageal atresia and neurologic disease. The Nissen fundoplication was used in all patients and proved an effective procedure with a low morbidity and recurrence rate.

Prenatal diagnosis of congenital anomalies requiring surgical correction. Implications for the future.

With the use of maternal ultrasonography, 22 infants had an anomaly identified before delivery. Nine had gastrochisis. In all, ultrasonography was performed because of an elevated maternal serum alpha 1 fetoprotein level. Ultrasonography for other indications identified three infants with omphaloceles, three with cystic adenomatoid malformation of the lung, two with duodenal atresia, two with posterior urethral valves, and one each with obstruction of the ureteropelvic junction, a retroperitoneal teratoma, and an ovarian cyst. Infants were delivered in a neonatal center able to provide total care from the time of birth, thus the risks of transport over long distances were avoided. One of the infants with cystic adenomatoid malformation was incorrectly diagnosed as having a congenital diaphragmatic hernia, and the complete posterior urethral valve bilateral hydronephrosis complex was not identified in this infant until after delivery. The ability to diagnose complex anomalies correctly places new responsibilities on the surgeon who must counsel the parents on his ability to successfully treat the identified anomaly. Improved diagnostic accuracy, increased case findings, careful counselling, and delivery of high-risk infants in regional centers must be major priorities to improve neonatal surgical care in the next decade.

Rectal suction biopsy in the diagnosis of Hirschsprung disease in infants.

Our experience with 47 rectal suction biopsies performed in infants up to six months of age indicates that this is a simple and effective method for the exclusion of Hirschsprung disease. It requires the recognition of immature ganglion cells in neural units as equivalent to mature ganglion cells. Absence of these immature neural units in an adequate sample is highly suggestive of Hirschsprung disease.

Congenital diaphragmatic hernia: hypoplastic lung and pulmonary vasoconstriction.

The abnormal pulmonary vasculature of the infant with congenital diaphragmatic hernia combined with a single expanded lung creates persistent pulmonary hypertension. Survival depends on the ability of the myocardium to withstand this increased work load until the second lung expands and pulmonary hypertension ceases.

Bilateral chylothorax in a newborn.

Bilateral chylothorax as a result of superior vena cava (SVC) thrombosis is reported. A 1.6-kg infant drained an average of 240 ml per day from an indwelling chest tube during a 3-wk period after thrombosis of the SVC secondary to an indwelling silastic catheter. This daily fluid loss was 1.7 times the patient's blood volume and was replaced ml for ml with fresh frozen plasma. This extraordinary volume continued despite the patient being NPO and receiving peripheral intravenous nutrition. Since no improvement occurred after a 3-wk period, a thoracotomy was performed. A parietal pleurectomy was performed since on specific site for a chyle leak was identified. The chylothorax cleared immediately following the operation. This patient is unique in both the total volume of chylous drainage obtained (5000 ml) and the surgical technique employed to correct this problem.

Compressed air injury to the esophagus: case report.

Compressed air injuries to the esophagus are uncommon. They characteristically present with respiratory distress, subcutaneous and mediastinal emphysema, and may have a pneumothorax. The distal esophagus is always the site of rupture and requires prompt surgical repair to avoid serious morbidity and potential lethal complications.

CT of an actively-hemorrhaging liver laceration in a 9-year-old child.

A 9-year-old female with blunt abdominal trauma following a motor vehicle accident was referred from the Emergency Room for abdominal CT imaging. CT demonstrated the unusual and heretofore unreported finding of an actively hemorrhaging liver laceration.