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Abnormality of lower oesophagus associated with congenital diaphragmatic hernia
1206
INTERNATIONAL
Conservative Management of Children With Spinal Dysraphism ................................ .................. 1212 Treatment of Spinal Deformity in Myelomeningocele ....... ................................................ .......... 1212 Neoplasms
Surgical Complications After Nephrectomy for Wilms’ Tumor ......_........-.... _...... ............. .......... 1212 Treatment of Pulmonary Metastases of Initial Stage I Hepatoblastoma in Childhood ,............ 1213 Pulmonary Hamartoma ............................ ............ 1213 Multicentric Infantile Myofibromatosis With Spontaneous Regression ................................ ... 1213 Malignant Melanoma in a 3-Year-Old Child....... 1213 Lipid-Secreting Breast Carcinoma in Childhood. 1213 GENERAL CONSIDERATIONS Pediatric Trauma Score: Is It Reliable in Predicting Mortality? E. Balik, &ok G, Ulman I, et al. Pediatr Surg Int 8:54-55, (Janu-
ary), 1993. The Pediatric Trauma Score (PTS) is used for triage and to predict the severity of injury in childhood trauma. The scoring system incorporates different parameters, such as the weight of the patient, airway, systolic blood pressure, central nervous system assessment, open wounds, and skeletal injuries. The authors in this study assessed the predictability of PTS in childhood trauma. They managed 533 patients. Mean PTS was 8.9 2 2.2. There were 24 deaths (14.7%) in 163 patients with PTS < 8. Mortality was 0.8% in 370 patients with PTS > 8. The authors did not find the size of the patients an important predictors of the severity of pediatric trauma. Mortality was 7.7% in children weighing less than 10 kg with PTS 6.4 ? 2.1 as compared with the overall mortality rate of 14.7% in all patients with PTS 18. The authors point out that intraabdominal hemorrhage from internal visceral injury is also important in predicting morbidity and mortality associated with pediatric trauma. It is noted that 49 of 71 patients (69%) undergoing emergency laparotomy for visceral injuries had PTS scores > 8, and that 50 of the 71 patients (70%) needed 20 mL/kg or more blood transfusions.-Prem Pun’ Plasma Thromboxane and Pulmonary Artery Pressure in Neonates Treated With Extracorporeal Membrane Oxygenation. K.C. Bui, G. Martin, LA. Kammerman, et al. J Thordc Cardiovasc
Surg 104:124-129, (July), 1992. The authors performed serial measurements of plasma thromboxane Br and pulmonary artery pressure before, during, and after extracorporeal membrane oxygenation (ECMO). These studies were undertaken to examine whether neonates with persistent pulmonary hypertension are subject to thromboxane-mediated elevation of pulmonary hypertension during ECMO. Elevated pulmonary artery pressures before ECMO were found to decrease after 48 hours of ECMO treatment. Mean pulmonary artery pressure decreased by 50% and mean plasma thromboxane Br levels by 70%. Serial plasma tbromboxane & levels correlated significantly with pulmonary artery pressures in individual infants with a primary diagnosis of meconium aspiration. The authors speculate that thromboxane Bz may play a role in regulating pulmonary artery pressure in infants with meconium aspiration. Decreasing levels of
ABSTRACTS
this mediator of pulmonary vasoconstriction correlates with resolution of acute lung injury-Thomas F. Tracy, Jr Continuous Atteriovenous Hemofiltration (CAVH) in a Premature Newborn as Treatment of Overhydration and Hyperkalemia Due to Sepsis. C.H. Schrijder, R.S. KM Severijnen, and C.M.J. Potting. Eur J Pediatr Surg 2:368-369, (December), 1992.
If renal replacement therapy is required in the neonatal period, peritoneal dialysis is generally applied. In some cases, for example after extensive abdominal surgery, peritoneal dialysis is not possible. Continuous arteriovenous hemofiltration may then be an attractive alternative. The article describes the positive results in a 1265-g premature baby.-Thomas A. Angerpointner HEAD AND NECK Incomplete Bilateral Transverse Facial Cleft-A Previously Unreported Associated Defect of the Kallmann’s Syndrome. J.F. H&zig. Eur J Pediatr Surg 2:357-360, (December), 1992.
In 1944 Kallmann et al described sex-linked inheritance of hypogonadotropic hypogonadism with anosmia and noted the cooccurrence of cleft lip, cleft palate, and craniofacial asymmetry. Since then, other clinical cases associated with various skeletal, opthalmic, urogenital, cardiovascular, and central nervous system disorders have been reported. This article presents the case of a 17-year-old girl with a bilateral incomplete facial cleft in association with Kallmann’s syndrome, a previously unreported connection. The plastic surgical reconstruction of the cleft is described. It is suggested that the pathoembryologic association is due to a developmental disturbance in the region of the median forebrain organizer and associated structures, possibly in connection with a pleiotropic genetic mechanism.-Thomas A. Angepointner Teratoma in a Thyroglossal Duct Cyst: A Rare Occurrence. GE. Besner, J.E. Fisher, F.C. Mauadri, ef al. Pediatr Surg Int
8:66-70, (January), 1993. A case of teratoma in a thyroglossal duct cyst is reported. The authors point out the rarity of this condition, there being only three previously reported cases. Cervical teratomas, as such, form only a small proportion of teratomas encountered in paediatric practice. This lesion was resected using the Sistrunk technique.-R.H. Surana Pharyngostoma: Case Report and Review of the Literature. C. Benlloch, A. Marco, A. Cariete, et al. Pediatr Surg Int 856-57,
(January), 1993. The authors present a unique case of a complete pharyngocutaneous fistula located in the midline of the neck at the hyoid-bone associated with hypoplastic jaw and low set ears. This was surgically repaired by enlarging its margins and suturing the base of epiglottis to the prelaryngeal space. The hypothesis of error during the last period of formation and fusion of 3rd arch has been suggested.Prem Puri
ALIMENTARY
TRACT
Abnormality of Lower Oesophagus Associated With Congenital Diaphragmatic Hernia. K. Sue, T. Yamada, Y Hirayama, et al.
Pediatr Surg Int 8:14-16, (January), 1993. The authors present two cases of lower esophageal anomalies associated with congenital diaphragmatic hernia (CDH). One patient had esophageal ectasia with gastroesophageal reflux, while another patient had esophageal atresia. They support the theory of
INTERNATIONAL
1207
ABSTRACTS
kinking of the esophagocardiac junction as the etiopathogenesis, and that atresia represents the extreme outcome. They also point out that further studies of the pathogenesis are required-Prem
ever, as they point out, further investigations are required to evaluate the efficacy of high dose dexamethasone in the presence of more serious initial lesions.-RH. Surana
PWi Membranous Atresia of the Lower Oesophagus. SC. Gopal, A.N. Gangopadhyay, SK. Pandit, et al. Pediatr Surg Int 8:140-141,
(February), 1993. A rare case of membranous esophageal atresia in the lower esophagus is described. This was managed by an abdominal approach. The lower esophagus was mobilized as usual. A gastrotomy was performed and the membrane excised after it was pushed down by a transoral gum elastic bougie. The esophageal muscular wall was continuous. A Thal procedure was performed to prevent reflux.-P. Pun’ Conservative Treatment of Corrosive Esophageal Strictures: A Comparative Study of Endoscopic Dilatations and Esophageal Stenting. F. De Peppo, M. Rivosecchi, G. Federici, et al.
Pediatr Surg Int 8:2-7, (January), 1993. The authors present their experience with corrosive esophageal injuries over a 9-year period. Of 222 patients, 126 patients were noted to have esophageal injuries on endoscopy. Eighteen children proceeded to develop esophageal strictures. Four were treated surgically. Of the remaining 14, seven patients before 1987 were treated with periodic esophageal dilatations, and seven since 1988 were treated with esophageal stents. The latter patients also received steroids, antibiotics, and Hz-blockers. Although this is not a prospective randomized controlled study, the authors showed that esophageal stents reduced the number of dilatations required as well as duration of treatment. They also emphasize the importance of treating gastroesophageal reflux (GER) in these patients surgically to achieve faster healing. It is suggested that these patients are more prone to GER because of stricture, scarring, and narrowing of esophagus.-Prem Puri Treatment of Esophageal Caustic Injuries: Experience With High-Dose Dexamethasone. S. Cadranel, M. Scaillon, P. Goyens. et al. Pediatr Surg Int 8:97-102, (February), 1993.
The authors compare the results of high-dose dexamethasone (1 mg/kg daily for 4 to 6 weeks) and fine silicone nasogastric tubes (6F to 8F) (protocol C) with previously used protocols using prednisolone (2 mg/kg daily) with fine silicone nasogastric tube (protocol A) and prednisolone with a wide silicone stent (12F to 18F) (protocol B). Group C consisted of heterogenous group of 9 patients, including 4 children who were initially treated according to scheme A or B but had unsatisfactory results. All patients in group A had III+ lesions (extended mucosal ulcerations, white plaques, and sloughing of the mucosa in a circumferential pattern) and required multiple dilatations (13-33). Group B included 7 patients: 1 with II+, 5 with III, and 1 with III+ lesions. Group C included 9 patients: 5 with II+ lesions have no strictures while of 4 patients with III+ lesions, one was operated elsewhere, one patient has a stricture. and one patient is still active. Data are not provided with regard to what percentage of patients from each category proceeded to develop strictures. The authors state that there was a dramatic reduction in the number of dilatations in some children from group B with introduction of high-dose dexamethasone. Five of the 9 patients in group C developed dexamethasone associated complications: infection (3). prepyloric ulceration (l), and osteoporosis (1). The authors believe that patients with a history of caustic ingestion should receive dexamethasone. How-
Esophagocoloplasty for Caustic Stricture of the Esophagus: Changing Concepts. A.F. Bahnassy and I.E. Bass&my. Pediatr
Surg Int 8:103-108, (February), 1993. The authors present their experience of esophagocoloplasty in 520 patients over 15 years. The indications for this procedure in patients with caustic strictures included undilatable stricture (287). multiple strictures (115), frequent occlusions of the stricture with solid food (38), failure of repeated dilatations to achieve a normal growth rate (75), and esophageal perforation (5). Temporary tube gastrostomy was performed prior to reconstruction in the majority of the patients to correct any nutritional deficit. The operation was done by two teams. The preferred colonic transplant was the transverse colon and proximal part of descending colon based upon the left colic vessels. In 455 patients simple bypass of the strictured esophagus through a retrostemal tunnel, and in 65 patients simultaneous transhiatal esophagectomy was performed. End-to-end anastomosis of esophagus and colon was changed to end-to-side anastomosis, which the authors believe has resulted in decreased (3.19% from 9.14%) anastomotic leaks. The mortality was 4.42% and due mainly to pneumonia. Early preoperative complications included anastomotic leaks (S.OZ%), small bowel obstruction (3.27%), pneumothorax (12.41%), and infection (5.76%). Twenty one (4.2%) patients developed late complications: stenosis at cervical anastomosis (ll), redundant colonic segment (9) and gastrocolic reflux with peptic ulcer (1). Two hundred ninety-six patients were available for long-term follow-up (1 to 5 years). Most of the patients were able to swallow and eat a normal diet without limitation, had gained weight, and had a normal life pattern. The authors believe that redundancy of the colon is an avoidable complication and that the lower incidence of peptic ulceration or gastrocolic reflux may be due to routine pyloromyotomy or pyloroplasty.-R. H. Surana Corrosive Strictures of the Desophagus in Children. S. Cywes, A.J.W. Millar, H. Rode, et al. Pediatr Surg Int 8:8-13, (January).
1993. Of 55 children with corrosive strictures of the esophagus, 22 responded to esophageal dilatations while 33 underwent a bypass procedure. A description of the authors’ operative technique for esophageal bypass procedure with isoperistaltic left colonic retrosternal interposition is presented. The mortality in these patients was 15% (5/33). Complications included anastomotic leaks, strictures, and reflux in majority of patients. Suggestions to prevent anastomotic leaks and strictures include preservation of the vascular pedicle, avoidance of torsion and redundancy, meticulous anastomosis, pyloroplasty to avoid gastric stasis, and decompression of the conduit.--Prem Pun‘ Caustic Ingestion in Childhood: Current Treatment Possibilities and Their Complications. C. Pin&r, C. Manzoni, S. Nappo. et al. Pediatr Surg Int 8:109-112, (February), 1993.
The authors describe their experience of managing 15 children with a history of ingestion of caustic substances over a 5-year period. All patients had esophagogastroduodenoscopy within 12 to 24 hours. Ten patients had esophagitis: 3 grade I, 2 grade II, 5 grade III. Grade II and III patients were treated with broadspectrum antibiotics, high-potency corticosteroids, and Hz antagonists. Nasogastric tube was placed for more severe lesions. All five
INTERNATIONAL
Conservative Management of Children With Spinal Dysraphism ................................ .................. 1212 Treatment of Spinal Deformity in Myelomeningocele ....... ................................................ .......... 1212 Neoplasms
Surgical Complications After Nephrectomy for Wilms’ Tumor ......_........-.... _...... ............. .......... 1212 Treatment of Pulmonary Metastases of Initial Stage I Hepatoblastoma in Childhood ,............ 1213 Pulmonary Hamartoma ............................ ............ 1213 Multicentric Infantile Myofibromatosis With Spontaneous Regression ................................ ... 1213 Malignant Melanoma in a 3-Year-Old Child....... 1213 Lipid-Secreting Breast Carcinoma in Childhood. 1213 GENERAL CONSIDERATIONS Pediatric Trauma Score: Is It Reliable in Predicting Mortality? E. Balik, &ok G, Ulman I, et al. Pediatr Surg Int 8:54-55, (Janu-
ary), 1993. The Pediatric Trauma Score (PTS) is used for triage and to predict the severity of injury in childhood trauma. The scoring system incorporates different parameters, such as the weight of the patient, airway, systolic blood pressure, central nervous system assessment, open wounds, and skeletal injuries. The authors in this study assessed the predictability of PTS in childhood trauma. They managed 533 patients. Mean PTS was 8.9 2 2.2. There were 24 deaths (14.7%) in 163 patients with PTS < 8. Mortality was 0.8% in 370 patients with PTS > 8. The authors did not find the size of the patients an important predictors of the severity of pediatric trauma. Mortality was 7.7% in children weighing less than 10 kg with PTS 6.4 ? 2.1 as compared with the overall mortality rate of 14.7% in all patients with PTS 18. The authors point out that intraabdominal hemorrhage from internal visceral injury is also important in predicting morbidity and mortality associated with pediatric trauma. It is noted that 49 of 71 patients (69%) undergoing emergency laparotomy for visceral injuries had PTS scores > 8, and that 50 of the 71 patients (70%) needed 20 mL/kg or more blood transfusions.-Prem Pun’ Plasma Thromboxane and Pulmonary Artery Pressure in Neonates Treated With Extracorporeal Membrane Oxygenation. K.C. Bui, G. Martin, LA. Kammerman, et al. J Thordc Cardiovasc
Surg 104:124-129, (July), 1992. The authors performed serial measurements of plasma thromboxane Br and pulmonary artery pressure before, during, and after extracorporeal membrane oxygenation (ECMO). These studies were undertaken to examine whether neonates with persistent pulmonary hypertension are subject to thromboxane-mediated elevation of pulmonary hypertension during ECMO. Elevated pulmonary artery pressures before ECMO were found to decrease after 48 hours of ECMO treatment. Mean pulmonary artery pressure decreased by 50% and mean plasma thromboxane Br levels by 70%. Serial plasma tbromboxane & levels correlated significantly with pulmonary artery pressures in individual infants with a primary diagnosis of meconium aspiration. The authors speculate that thromboxane Bz may play a role in regulating pulmonary artery pressure in infants with meconium aspiration. Decreasing levels of
ABSTRACTS
this mediator of pulmonary vasoconstriction correlates with resolution of acute lung injury-Thomas F. Tracy, Jr Continuous Atteriovenous Hemofiltration (CAVH) in a Premature Newborn as Treatment of Overhydration and Hyperkalemia Due to Sepsis. C.H. Schrijder, R.S. KM Severijnen, and C.M.J. Potting. Eur J Pediatr Surg 2:368-369, (December), 1992.
If renal replacement therapy is required in the neonatal period, peritoneal dialysis is generally applied. In some cases, for example after extensive abdominal surgery, peritoneal dialysis is not possible. Continuous arteriovenous hemofiltration may then be an attractive alternative. The article describes the positive results in a 1265-g premature baby.-Thomas A. Angerpointner HEAD AND NECK Incomplete Bilateral Transverse Facial Cleft-A Previously Unreported Associated Defect of the Kallmann’s Syndrome. J.F. H&zig. Eur J Pediatr Surg 2:357-360, (December), 1992.
In 1944 Kallmann et al described sex-linked inheritance of hypogonadotropic hypogonadism with anosmia and noted the cooccurrence of cleft lip, cleft palate, and craniofacial asymmetry. Since then, other clinical cases associated with various skeletal, opthalmic, urogenital, cardiovascular, and central nervous system disorders have been reported. This article presents the case of a 17-year-old girl with a bilateral incomplete facial cleft in association with Kallmann’s syndrome, a previously unreported connection. The plastic surgical reconstruction of the cleft is described. It is suggested that the pathoembryologic association is due to a developmental disturbance in the region of the median forebrain organizer and associated structures, possibly in connection with a pleiotropic genetic mechanism.-Thomas A. Angepointner Teratoma in a Thyroglossal Duct Cyst: A Rare Occurrence. GE. Besner, J.E. Fisher, F.C. Mauadri, ef al. Pediatr Surg Int
8:66-70, (January), 1993. A case of teratoma in a thyroglossal duct cyst is reported. The authors point out the rarity of this condition, there being only three previously reported cases. Cervical teratomas, as such, form only a small proportion of teratomas encountered in paediatric practice. This lesion was resected using the Sistrunk technique.-R.H. Surana Pharyngostoma: Case Report and Review of the Literature. C. Benlloch, A. Marco, A. Cariete, et al. Pediatr Surg Int 856-57,
(January), 1993. The authors present a unique case of a complete pharyngocutaneous fistula located in the midline of the neck at the hyoid-bone associated with hypoplastic jaw and low set ears. This was surgically repaired by enlarging its margins and suturing the base of epiglottis to the prelaryngeal space. The hypothesis of error during the last period of formation and fusion of 3rd arch has been suggested.Prem Puri
ALIMENTARY
TRACT
Abnormality of Lower Oesophagus Associated With Congenital Diaphragmatic Hernia. K. Sue, T. Yamada, Y Hirayama, et al.
Pediatr Surg Int 8:14-16, (January), 1993. The authors present two cases of lower esophageal anomalies associated with congenital diaphragmatic hernia (CDH). One patient had esophageal ectasia with gastroesophageal reflux, while another patient had esophageal atresia. They support the theory of
INTERNATIONAL
1207
ABSTRACTS
kinking of the esophagocardiac junction as the etiopathogenesis, and that atresia represents the extreme outcome. They also point out that further studies of the pathogenesis are required-Prem
ever, as they point out, further investigations are required to evaluate the efficacy of high dose dexamethasone in the presence of more serious initial lesions.-RH. Surana
PWi Membranous Atresia of the Lower Oesophagus. SC. Gopal, A.N. Gangopadhyay, SK. Pandit, et al. Pediatr Surg Int 8:140-141,
(February), 1993. A rare case of membranous esophageal atresia in the lower esophagus is described. This was managed by an abdominal approach. The lower esophagus was mobilized as usual. A gastrotomy was performed and the membrane excised after it was pushed down by a transoral gum elastic bougie. The esophageal muscular wall was continuous. A Thal procedure was performed to prevent reflux.-P. Pun’ Conservative Treatment of Corrosive Esophageal Strictures: A Comparative Study of Endoscopic Dilatations and Esophageal Stenting. F. De Peppo, M. Rivosecchi, G. Federici, et al.
Pediatr Surg Int 8:2-7, (January), 1993. The authors present their experience with corrosive esophageal injuries over a 9-year period. Of 222 patients, 126 patients were noted to have esophageal injuries on endoscopy. Eighteen children proceeded to develop esophageal strictures. Four were treated surgically. Of the remaining 14, seven patients before 1987 were treated with periodic esophageal dilatations, and seven since 1988 were treated with esophageal stents. The latter patients also received steroids, antibiotics, and Hz-blockers. Although this is not a prospective randomized controlled study, the authors showed that esophageal stents reduced the number of dilatations required as well as duration of treatment. They also emphasize the importance of treating gastroesophageal reflux (GER) in these patients surgically to achieve faster healing. It is suggested that these patients are more prone to GER because of stricture, scarring, and narrowing of esophagus.-Prem Puri Treatment of Esophageal Caustic Injuries: Experience With High-Dose Dexamethasone. S. Cadranel, M. Scaillon, P. Goyens. et al. Pediatr Surg Int 8:97-102, (February), 1993.
The authors compare the results of high-dose dexamethasone (1 mg/kg daily for 4 to 6 weeks) and fine silicone nasogastric tubes (6F to 8F) (protocol C) with previously used protocols using prednisolone (2 mg/kg daily) with fine silicone nasogastric tube (protocol A) and prednisolone with a wide silicone stent (12F to 18F) (protocol B). Group C consisted of heterogenous group of 9 patients, including 4 children who were initially treated according to scheme A or B but had unsatisfactory results. All patients in group A had III+ lesions (extended mucosal ulcerations, white plaques, and sloughing of the mucosa in a circumferential pattern) and required multiple dilatations (13-33). Group B included 7 patients: 1 with II+, 5 with III, and 1 with III+ lesions. Group C included 9 patients: 5 with II+ lesions have no strictures while of 4 patients with III+ lesions, one was operated elsewhere, one patient has a stricture. and one patient is still active. Data are not provided with regard to what percentage of patients from each category proceeded to develop strictures. The authors state that there was a dramatic reduction in the number of dilatations in some children from group B with introduction of high-dose dexamethasone. Five of the 9 patients in group C developed dexamethasone associated complications: infection (3). prepyloric ulceration (l), and osteoporosis (1). The authors believe that patients with a history of caustic ingestion should receive dexamethasone. How-
Esophagocoloplasty for Caustic Stricture of the Esophagus: Changing Concepts. A.F. Bahnassy and I.E. Bass&my. Pediatr
Surg Int 8:103-108, (February), 1993. The authors present their experience of esophagocoloplasty in 520 patients over 15 years. The indications for this procedure in patients with caustic strictures included undilatable stricture (287). multiple strictures (115), frequent occlusions of the stricture with solid food (38), failure of repeated dilatations to achieve a normal growth rate (75), and esophageal perforation (5). Temporary tube gastrostomy was performed prior to reconstruction in the majority of the patients to correct any nutritional deficit. The operation was done by two teams. The preferred colonic transplant was the transverse colon and proximal part of descending colon based upon the left colic vessels. In 455 patients simple bypass of the strictured esophagus through a retrostemal tunnel, and in 65 patients simultaneous transhiatal esophagectomy was performed. End-to-end anastomosis of esophagus and colon was changed to end-to-side anastomosis, which the authors believe has resulted in decreased (3.19% from 9.14%) anastomotic leaks. The mortality was 4.42% and due mainly to pneumonia. Early preoperative complications included anastomotic leaks (S.OZ%), small bowel obstruction (3.27%), pneumothorax (12.41%), and infection (5.76%). Twenty one (4.2%) patients developed late complications: stenosis at cervical anastomosis (ll), redundant colonic segment (9) and gastrocolic reflux with peptic ulcer (1). Two hundred ninety-six patients were available for long-term follow-up (1 to 5 years). Most of the patients were able to swallow and eat a normal diet without limitation, had gained weight, and had a normal life pattern. The authors believe that redundancy of the colon is an avoidable complication and that the lower incidence of peptic ulceration or gastrocolic reflux may be due to routine pyloromyotomy or pyloroplasty.-R. H. Surana Corrosive Strictures of the Desophagus in Children. S. Cywes, A.J.W. Millar, H. Rode, et al. Pediatr Surg Int 8:8-13, (January).
1993. Of 55 children with corrosive strictures of the esophagus, 22 responded to esophageal dilatations while 33 underwent a bypass procedure. A description of the authors’ operative technique for esophageal bypass procedure with isoperistaltic left colonic retrosternal interposition is presented. The mortality in these patients was 15% (5/33). Complications included anastomotic leaks, strictures, and reflux in majority of patients. Suggestions to prevent anastomotic leaks and strictures include preservation of the vascular pedicle, avoidance of torsion and redundancy, meticulous anastomosis, pyloroplasty to avoid gastric stasis, and decompression of the conduit.--Prem Pun‘ Caustic Ingestion in Childhood: Current Treatment Possibilities and Their Complications. C. Pin&r, C. Manzoni, S. Nappo. et al. Pediatr Surg Int 8:109-112, (February), 1993.
The authors describe their experience of managing 15 children with a history of ingestion of caustic substances over a 5-year period. All patients had esophagogastroduodenoscopy within 12 to 24 hours. Ten patients had esophagitis: 3 grade I, 2 grade II, 5 grade III. Grade II and III patients were treated with broadspectrum antibiotics, high-potency corticosteroids, and Hz antagonists. Nasogastric tube was placed for more severe lesions. All five