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Peritoneal cultures and antibiotic therapy in pediatric perforated appendicitis
INTERNATIONAL
ABSTRACTS
1507
for gastrointestinal diseases. Major and minor complications and the efficacy of the PEGS with respect to nutritional support were tabulated. There were 13 major complications (19%) including two gastrocolic fistulas, one episode of necrotizing fascitis, three episodes of gastroesophageal reflux-associated aspiration pneumonia. and two cases in which the worsened, necessitating a Nissen fundoplication. These were 16 minor complications (22%) including three stoma1 leakages, three superficial wound infections, two tube dislodgemrnts, and two tube migrations. Most of the major complications (64%) occurred in the children with multisystem organ failure. Overall. 70% of the patients derived nutritional benefit from placement of the PEG. Those with cystic fibrosis and congenital heart disease benefited most, whereas those with multisystem organ failure and gastrointestinal disease benefited least. The authors conclude that PEG is safe and effective for providing enteral feeding to children but point out that patients with multisystern organ failure have the highest rate of major complications and derive the least nutritional benefit from the procedure. Therefore, alternative methods of nutritional support should be explored in this population.-Richard R. Ricketts Meconium lleus Equivalent in Children and Adults. K Khoshoo and J.N. Udull. Jr. Am J Gastroenterol 89:153-157. (February), 1994. Meconium ileus equivalent (MIE) occurs in 2.1% to 41.3% of patients with cystic fibrosis. It is 2.5 times more common in males than in females. It is uncommon in children under 5 years of age, and the prevalence seems to increase after age 5. The peak prevalence is in patients older than 20 or 30 years. Dehydration, prolonged fasting, dietary indiscretion, and reduction of pancreatic enzyme supplement may be potential precipitating factors. There has been no consistent correlation of MIE with pulmonary function, disease severity, previous abdominal surgery, or occurrence of meconium ileus in the neonatal period. The classical diagnostic triad of this condition consists of abdominal pain, a right lower quadrant mass, and feces in the right colon (noted on abdominal radiographs). The acute phase of treatment involves correction of fluid and electrolyte imbalances and treatment of associated problems, such as infection. Enemas and laxatives are used to help eliminate the inspissated plug. Oral Mucomyst (10% to 20%) and/or a Mucomyst enema (5% to 10%) also can be effective. Similarly, oral Gastrografin or a Gastrografin enema may be used. Recently, successful treatment of MIE with a balanced electrolyte intestinal lavage solution (Golytely) was reported. After resolution of the acute symptomatology of MIE, the target is to prevent recurrence. This may consist of the regular administration of a laxative or stool softener or use of the newer prokinetic agent cisapride.-Richard R. Ricketts Successful Intestinal Transplantation for Microvillus sion Disease. M.M. Olilla* J.A. Perman, J.M. Saavedra, Gastroenterology 106:771-774, (.March), 1994.
Incluet al.
Microvillus inclusion disease (MID) is an autosomal-recessive disorder characterized by cytoplasmic inclusions of microvillus membrane in the enterocytes. It presents with refractory, watery diarrhea in the early newborn period, which leads to severe electrolyte imbalance and an inability to absorb even simple nutrients. As a result. patients eventually depend on parenteral nutrition for survival. All therapeutic attempts to control the diarrhea and allow tolerance to enteral feeding have failed. Of more than 30 patients reported on in the literature, the vast majority have died by 18 months of age. This report presents the first child with MID in whom small bowel transplantation was successful, allowing for the administration of total caloric requirements enterally. The patient
was 2% years old at the time of transplantation. Her bowel from the third portion of the duodenum to the sigmoid colon was removed and replaced with a graft from an ABO-compatible, cytomegalovirus-negative pediatric donor. She received FK-506 for immunosuppression and is currently on a dose of 0.7 mgikgid. Now, more than 2 years after transplantation. she continues to receive jejunal feeding, administered continuously for I6 hours each day. Her oral intake is minimal.-Richard R. Ricketts Motility of the Transplanted Small Bowel: A Manometric Study in the Piglet. C; Leuurd, Y Revillon. P. Arhan, et al. Eur J Pediatr Surg 4:98-102, (April). 1994. Complete transection of sympathetic and parasympathetic nerves is an inevitable consequence of intestinal transplantation. The aim of this study was to evaluate whether extrinsic denervation alters the motor function of the graft. Ten large, white piglets were used. In group 1 (control, n = 5). a segment of distal ileum was isolated on its intact neurovascular pedicle. In group 2 (study, n = 5). the distal ileum was transplanted as a free autograft. The motility of the intestinal loops was studied by intraluminal pressure recordings on the 8th and 15th postoperative days in conscious animals fasted for 24 hours. The motor function of the loops was studied after intraluminal perfusion of a cholinergic compound (carbachol). The results indicate that extrinsic denervation does not modify the interdigestive cyclic motor activity nor the response to cholinergic stimulation of the autotransplanted ileum in piglets.--Thomas.4. Angerpointner Peritoneal Cultures and Antibiotic Therapy in Pediatric Perforated Appendicitis. D.M. Mosdell, D.M. Morris. and D. E. Fy Am J Surg 167:313-316. (March), 1994. This is a retrospective review of 70 children with appendicitis who presented over a 3-year period. Fifty-eight of the patients had cultures performed, and the majority had one or more clinical isolates. The specific bacterial species were most commonly Escherichiu coli and Bacteriaties. Seventy-seven percent of patients received ampicillin, gentamicin, and clindamycin. Fourteen percent received cefoxitin. The remainder received only gentamicin and clindamycin. Ten percent of patients had a change in antibiotics during their treatment course, without culture data available. Three percent had changes when cultures were available. the changes being based on the isolates and sensitivities. The authors suggest that these data indicate that surgeons select antibiotic therapy for children with perforated appendicitis based on assumptions regarding which organisms should be present and not on the culture data. There appears to be no clinical usefulness for performing routine cultures of the peritoneal cavity in children with perforated appendicitis. In addition, the authors emphasize the cost savings in using a single antibiotic. Again, single-agent antibiotic therapy is directed at E co/i and B fragilis. It is somewhat surprising that there were no patients whose culture was positive for pseudomonas, which would be an important isolate for which an antibiotic change could be critical.--Thomas F Trq,. Jr Exclusion of APC and MCC as the Gene Defect in One Family With Familial Juvenile Polyposis. B.A. Leggett, L.R. Thomas. N. Knight, etal. Gastroenterology 105:1313-1316, (November), 1993. Familial juvenile polyposis is an autosomal-dominant syndrome associated with a predisposition to gastrointestinal malignancy. Whereas juvenile polyps commonly occur as single lesions in the colons of children without a positive family history, in cases of familial juvenile polyposis. there are hundreds of polyps throughout the colon. Although the polyps are generally hamartomas, adenomatous epithelium is sometimes present. The risk of colon
ABSTRACTS
1507
for gastrointestinal diseases. Major and minor complications and the efficacy of the PEGS with respect to nutritional support were tabulated. There were 13 major complications (19%) including two gastrocolic fistulas, one episode of necrotizing fascitis, three episodes of gastroesophageal reflux-associated aspiration pneumonia. and two cases in which the worsened, necessitating a Nissen fundoplication. These were 16 minor complications (22%) including three stoma1 leakages, three superficial wound infections, two tube dislodgemrnts, and two tube migrations. Most of the major complications (64%) occurred in the children with multisystem organ failure. Overall. 70% of the patients derived nutritional benefit from placement of the PEG. Those with cystic fibrosis and congenital heart disease benefited most, whereas those with multisystem organ failure and gastrointestinal disease benefited least. The authors conclude that PEG is safe and effective for providing enteral feeding to children but point out that patients with multisystern organ failure have the highest rate of major complications and derive the least nutritional benefit from the procedure. Therefore, alternative methods of nutritional support should be explored in this population.-Richard R. Ricketts Meconium lleus Equivalent in Children and Adults. K Khoshoo and J.N. Udull. Jr. Am J Gastroenterol 89:153-157. (February), 1994. Meconium ileus equivalent (MIE) occurs in 2.1% to 41.3% of patients with cystic fibrosis. It is 2.5 times more common in males than in females. It is uncommon in children under 5 years of age, and the prevalence seems to increase after age 5. The peak prevalence is in patients older than 20 or 30 years. Dehydration, prolonged fasting, dietary indiscretion, and reduction of pancreatic enzyme supplement may be potential precipitating factors. There has been no consistent correlation of MIE with pulmonary function, disease severity, previous abdominal surgery, or occurrence of meconium ileus in the neonatal period. The classical diagnostic triad of this condition consists of abdominal pain, a right lower quadrant mass, and feces in the right colon (noted on abdominal radiographs). The acute phase of treatment involves correction of fluid and electrolyte imbalances and treatment of associated problems, such as infection. Enemas and laxatives are used to help eliminate the inspissated plug. Oral Mucomyst (10% to 20%) and/or a Mucomyst enema (5% to 10%) also can be effective. Similarly, oral Gastrografin or a Gastrografin enema may be used. Recently, successful treatment of MIE with a balanced electrolyte intestinal lavage solution (Golytely) was reported. After resolution of the acute symptomatology of MIE, the target is to prevent recurrence. This may consist of the regular administration of a laxative or stool softener or use of the newer prokinetic agent cisapride.-Richard R. Ricketts Successful Intestinal Transplantation for Microvillus sion Disease. M.M. Olilla* J.A. Perman, J.M. Saavedra, Gastroenterology 106:771-774, (.March), 1994.
Incluet al.
Microvillus inclusion disease (MID) is an autosomal-recessive disorder characterized by cytoplasmic inclusions of microvillus membrane in the enterocytes. It presents with refractory, watery diarrhea in the early newborn period, which leads to severe electrolyte imbalance and an inability to absorb even simple nutrients. As a result. patients eventually depend on parenteral nutrition for survival. All therapeutic attempts to control the diarrhea and allow tolerance to enteral feeding have failed. Of more than 30 patients reported on in the literature, the vast majority have died by 18 months of age. This report presents the first child with MID in whom small bowel transplantation was successful, allowing for the administration of total caloric requirements enterally. The patient
was 2% years old at the time of transplantation. Her bowel from the third portion of the duodenum to the sigmoid colon was removed and replaced with a graft from an ABO-compatible, cytomegalovirus-negative pediatric donor. She received FK-506 for immunosuppression and is currently on a dose of 0.7 mgikgid. Now, more than 2 years after transplantation. she continues to receive jejunal feeding, administered continuously for I6 hours each day. Her oral intake is minimal.-Richard R. Ricketts Motility of the Transplanted Small Bowel: A Manometric Study in the Piglet. C; Leuurd, Y Revillon. P. Arhan, et al. Eur J Pediatr Surg 4:98-102, (April). 1994. Complete transection of sympathetic and parasympathetic nerves is an inevitable consequence of intestinal transplantation. The aim of this study was to evaluate whether extrinsic denervation alters the motor function of the graft. Ten large, white piglets were used. In group 1 (control, n = 5). a segment of distal ileum was isolated on its intact neurovascular pedicle. In group 2 (study, n = 5). the distal ileum was transplanted as a free autograft. The motility of the intestinal loops was studied by intraluminal pressure recordings on the 8th and 15th postoperative days in conscious animals fasted for 24 hours. The motor function of the loops was studied after intraluminal perfusion of a cholinergic compound (carbachol). The results indicate that extrinsic denervation does not modify the interdigestive cyclic motor activity nor the response to cholinergic stimulation of the autotransplanted ileum in piglets.--Thomas.4. Angerpointner Peritoneal Cultures and Antibiotic Therapy in Pediatric Perforated Appendicitis. D.M. Mosdell, D.M. Morris. and D. E. Fy Am J Surg 167:313-316. (March), 1994. This is a retrospective review of 70 children with appendicitis who presented over a 3-year period. Fifty-eight of the patients had cultures performed, and the majority had one or more clinical isolates. The specific bacterial species were most commonly Escherichiu coli and Bacteriaties. Seventy-seven percent of patients received ampicillin, gentamicin, and clindamycin. Fourteen percent received cefoxitin. The remainder received only gentamicin and clindamycin. Ten percent of patients had a change in antibiotics during their treatment course, without culture data available. Three percent had changes when cultures were available. the changes being based on the isolates and sensitivities. The authors suggest that these data indicate that surgeons select antibiotic therapy for children with perforated appendicitis based on assumptions regarding which organisms should be present and not on the culture data. There appears to be no clinical usefulness for performing routine cultures of the peritoneal cavity in children with perforated appendicitis. In addition, the authors emphasize the cost savings in using a single antibiotic. Again, single-agent antibiotic therapy is directed at E co/i and B fragilis. It is somewhat surprising that there were no patients whose culture was positive for pseudomonas, which would be an important isolate for which an antibiotic change could be critical.--Thomas F Trq,. Jr Exclusion of APC and MCC as the Gene Defect in One Family With Familial Juvenile Polyposis. B.A. Leggett, L.R. Thomas. N. Knight, etal. Gastroenterology 105:1313-1316, (November), 1993. Familial juvenile polyposis is an autosomal-dominant syndrome associated with a predisposition to gastrointestinal malignancy. Whereas juvenile polyps commonly occur as single lesions in the colons of children without a positive family history, in cases of familial juvenile polyposis. there are hundreds of polyps throughout the colon. Although the polyps are generally hamartomas, adenomatous epithelium is sometimes present. The risk of colon