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Congenital diaphragmatic hernia in older children
INTERNATIONAL ABSTRACTS Congenital Diaphragmatic Hernia: A 20 Year Experience. J.N.L.
Simpson and H.B. Eckstein. Br J Surg 72:733-736, (September), 1985.
Two hundred fifty-three children who presented during the four 5-year periods between 1961 and 1980 are reviewed and compared to assess any changes in patient population and mortality. Twenty patients required a patch repair. Tolazoline was used in nine children. The sicker patients were usually operated on sooner. The overall mortality was 37% and remained constant. The proportion of children undergoing surgery within six hours of birth increased from 13% in 1961 to 1965 to 39% in 1976 to 1980, with no difference in the mortality rates (65%). This is due to speedier transfer rather than more severely affected children being treated, because parameters, such as birth weight, time of onset of signs, and lung weight were unchanged. In those children that died within 48 hours of surgery there was a significant correlation between lung weight relative to body weight and length of postoperative survival with a critical lung weight of 20 g. Twenty-five percent of those that died had a lung weight greater than 60% of that expected for their body weight. It is these babies that might benefit from pharmacological manipulation of their pulmonary vasculature or ECMO.--N.P. Madden
Congenital Diaphragmatic Hernia in Older Children. J. McCue, .4. Ball, R.J. Brereton, et al. J R Coil Surg (Ed) 30:305-310, (October), 1985.
Late presentation of diaphragmatic hernia is uncommon but not rare. This is the conclusion of the authors who report their experience in six cases of posterolateral diaphragmatic hernia in older children. All presented as emergencies, four with gastrointestial and two with respiratory symptoms. Interpretation of abdominal and chest x-rays was often difficult, leading to misdiagnosis. The defect in the diaphragm was small with most commonly large bowel herniation and ischemia. Barium enema is recommended as the initial investigation with barium meal and follow-through in nonurgent cases to rule out malrotation. An abdominal approach is advised. The results of surgical treatment are excellent provided there is no delay in diangosis.--W.G. Scobie
ALIMENTARY TRACT The Exploding Bottle Top and Oropharyngeal Injuries. M . P . Vallis
289
geal layering was seen at a variable distance from the tracheobronchial end of the fistula. Tracheobronchial elements, including cartilage, were also seen in two other surgical specimens, which suggests that tracheobronchial elements may be very common in tracheoesophageal fistula and, in some cases, may lead to stenosis or abnormal motility following otherwise successful anastomosis.-Prem Puri Gastroesophageal Reflux: pH Probe-Directed Therapy. M.L. Ramenofsky, R.W. Powell, and P.W. Curreri. Ann Surg 203:531536, (May), 1986.
The accuracy of extended intraesophageal pH monitoring in predicting the necessity for surgical intervention of gastroesophageal reflux (GER) is retrospectively evaluated. Fifty patients (aged 1 week to 6 months, mean 3.4 months) seen over a 4-year period for a symptomatic GER were divided into two groups. Group 1 (28 patients) suffered recurrent pneumonia. Group 2 (22 patients) suffered apneic spells requiring cardiopulmonary resuscitation. Barium esophagram and 24-hour esophageal pH monitoring were accomplished in all patients. Barium esophagram was accurate in diagnosis in 23 patients (46%), whereas, accurate diagnosis was made in 100% of patients using the pH probe. All patients were initially treated nonsurgically with frequent low volume feedings, thickening of feedings, best therapeutic positioning (identified by pH probe), metoclopramide, and continuous apnea monitoring for those patients suffering apneic episodes. Patients failing medical treatment were surgically treated with "floppy" Nissen fundoplication. Fourteen of 28 patients in group 1 required surgical intervention. Thirteen have had no recurrent symptomatology (follow-up 6 months to 4 years). The patient failing surgical therapy has been shown to be immunologicaUy compromised. Thirteen of 22 patients in group 2 required surgical intervention. All patients have done well. Review of pH probe data shows a significant difference in the frequency of GER over 24 hours between the medically treated groups (group 1, 24 episodes; group 2, 26 episodes) and those requiring surgical intervention (group 1, 63 episodes; group 2, 67 episodes). There was no overlap between the two groups. Although the number of patients in this study is not large, the authors suggest that the accuracy of intraesophageal pH monitoring and the short evaluation time required (24 hours) make this a promising modality in accurately identifying the appropriate mode of therapy. In this series no patients would have been treated inappropriately.Edward G. Ford
and K.P. Gibbin. Br J Surg 73:221, (March), 1986.
Two case reports of children receiving severe injuries to the mouth and pharynx while removing the top from home made beer and wine bottles with their teeth are reported. The explosive release of the metal tops into the mouth represents a close range explosion with the damage being caused by the sudden distension of the pharynx with gases rather than by the bottle top itself. All such patients need to be admitted for observation. Endoscopy should be performed at an early opportunity if there is any doubt about the extent of injury. Prophylactic antibiotics should be given and oral intake stopped.Tony Sparnon
Esophageal Atresia With Tracheo-esophageal Fistula. A. Hokama,
N.A. Myers, M. Kent, et al. Pediatr Surg lnt 1:117-121, (June), 1986.
A histologic study was conducted on unoperated specimens from six infants with esophageal atresia and tracheo-esophageal fistula. Subserial sections of the distal segment showed tracheobronchial elements in five cases, including cartilage in three. Normal esopha-
Oesophageal Peristalsis and Acid Clearance. A Method for Its Study. J. Arana, J.A. Tovar, and J. Garay. Chir P6diatr 26:88-91,
(March), 1985. The aim of this preliminary study was to consider peristaltic esophageal waves as a second antireflux barrier. The authors developed a procedure combining oesophageal motility and pH studies. They used a three-lumen plastic catheter (diameter 38 mm) constantly perfused (0.8 mL/min) and a pH microelectrode. The two catheters are fixed 1 cm above the oesophageal sphincter. Three recordings are made: in basal condition, after injection of saline serum (3 mL), and HCI 0.1 N (5 mL). Primary and secondary esophageal waves are able to clear injected acid, while nonpropulsive tertiary waves do not raise the pH back to normal level. Three situations are identified: (1) good clearance after serum and acid; (2) good after serum and poor with acid; and (3) poor in all situations. Children with severe gastroesophageal reflux resulted in a high proportion of tertiary waves. Indication for surgical treatment can be proposed sooner in these cases than in children with good clearance.--J.M. Guys
Simpson and H.B. Eckstein. Br J Surg 72:733-736, (September), 1985.
Two hundred fifty-three children who presented during the four 5-year periods between 1961 and 1980 are reviewed and compared to assess any changes in patient population and mortality. Twenty patients required a patch repair. Tolazoline was used in nine children. The sicker patients were usually operated on sooner. The overall mortality was 37% and remained constant. The proportion of children undergoing surgery within six hours of birth increased from 13% in 1961 to 1965 to 39% in 1976 to 1980, with no difference in the mortality rates (65%). This is due to speedier transfer rather than more severely affected children being treated, because parameters, such as birth weight, time of onset of signs, and lung weight were unchanged. In those children that died within 48 hours of surgery there was a significant correlation between lung weight relative to body weight and length of postoperative survival with a critical lung weight of 20 g. Twenty-five percent of those that died had a lung weight greater than 60% of that expected for their body weight. It is these babies that might benefit from pharmacological manipulation of their pulmonary vasculature or ECMO.--N.P. Madden
Congenital Diaphragmatic Hernia in Older Children. J. McCue, .4. Ball, R.J. Brereton, et al. J R Coil Surg (Ed) 30:305-310, (October), 1985.
Late presentation of diaphragmatic hernia is uncommon but not rare. This is the conclusion of the authors who report their experience in six cases of posterolateral diaphragmatic hernia in older children. All presented as emergencies, four with gastrointestial and two with respiratory symptoms. Interpretation of abdominal and chest x-rays was often difficult, leading to misdiagnosis. The defect in the diaphragm was small with most commonly large bowel herniation and ischemia. Barium enema is recommended as the initial investigation with barium meal and follow-through in nonurgent cases to rule out malrotation. An abdominal approach is advised. The results of surgical treatment are excellent provided there is no delay in diangosis.--W.G. Scobie
ALIMENTARY TRACT The Exploding Bottle Top and Oropharyngeal Injuries. M . P . Vallis
289
geal layering was seen at a variable distance from the tracheobronchial end of the fistula. Tracheobronchial elements, including cartilage, were also seen in two other surgical specimens, which suggests that tracheobronchial elements may be very common in tracheoesophageal fistula and, in some cases, may lead to stenosis or abnormal motility following otherwise successful anastomosis.-Prem Puri Gastroesophageal Reflux: pH Probe-Directed Therapy. M.L. Ramenofsky, R.W. Powell, and P.W. Curreri. Ann Surg 203:531536, (May), 1986.
The accuracy of extended intraesophageal pH monitoring in predicting the necessity for surgical intervention of gastroesophageal reflux (GER) is retrospectively evaluated. Fifty patients (aged 1 week to 6 months, mean 3.4 months) seen over a 4-year period for a symptomatic GER were divided into two groups. Group 1 (28 patients) suffered recurrent pneumonia. Group 2 (22 patients) suffered apneic spells requiring cardiopulmonary resuscitation. Barium esophagram and 24-hour esophageal pH monitoring were accomplished in all patients. Barium esophagram was accurate in diagnosis in 23 patients (46%), whereas, accurate diagnosis was made in 100% of patients using the pH probe. All patients were initially treated nonsurgically with frequent low volume feedings, thickening of feedings, best therapeutic positioning (identified by pH probe), metoclopramide, and continuous apnea monitoring for those patients suffering apneic episodes. Patients failing medical treatment were surgically treated with "floppy" Nissen fundoplication. Fourteen of 28 patients in group 1 required surgical intervention. Thirteen have had no recurrent symptomatology (follow-up 6 months to 4 years). The patient failing surgical therapy has been shown to be immunologicaUy compromised. Thirteen of 22 patients in group 2 required surgical intervention. All patients have done well. Review of pH probe data shows a significant difference in the frequency of GER over 24 hours between the medically treated groups (group 1, 24 episodes; group 2, 26 episodes) and those requiring surgical intervention (group 1, 63 episodes; group 2, 67 episodes). There was no overlap between the two groups. Although the number of patients in this study is not large, the authors suggest that the accuracy of intraesophageal pH monitoring and the short evaluation time required (24 hours) make this a promising modality in accurately identifying the appropriate mode of therapy. In this series no patients would have been treated inappropriately.Edward G. Ford
and K.P. Gibbin. Br J Surg 73:221, (March), 1986.
Two case reports of children receiving severe injuries to the mouth and pharynx while removing the top from home made beer and wine bottles with their teeth are reported. The explosive release of the metal tops into the mouth represents a close range explosion with the damage being caused by the sudden distension of the pharynx with gases rather than by the bottle top itself. All such patients need to be admitted for observation. Endoscopy should be performed at an early opportunity if there is any doubt about the extent of injury. Prophylactic antibiotics should be given and oral intake stopped.Tony Sparnon
Esophageal Atresia With Tracheo-esophageal Fistula. A. Hokama,
N.A. Myers, M. Kent, et al. Pediatr Surg lnt 1:117-121, (June), 1986.
A histologic study was conducted on unoperated specimens from six infants with esophageal atresia and tracheo-esophageal fistula. Subserial sections of the distal segment showed tracheobronchial elements in five cases, including cartilage in three. Normal esopha-
Oesophageal Peristalsis and Acid Clearance. A Method for Its Study. J. Arana, J.A. Tovar, and J. Garay. Chir P6diatr 26:88-91,
(March), 1985. The aim of this preliminary study was to consider peristaltic esophageal waves as a second antireflux barrier. The authors developed a procedure combining oesophageal motility and pH studies. They used a three-lumen plastic catheter (diameter 38 mm) constantly perfused (0.8 mL/min) and a pH microelectrode. The two catheters are fixed 1 cm above the oesophageal sphincter. Three recordings are made: in basal condition, after injection of saline serum (3 mL), and HCI 0.1 N (5 mL). Primary and secondary esophageal waves are able to clear injected acid, while nonpropulsive tertiary waves do not raise the pH back to normal level. Three situations are identified: (1) good clearance after serum and acid; (2) good after serum and poor with acid; and (3) poor in all situations. Children with severe gastroesophageal reflux resulted in a high proportion of tertiary waves. Indication for surgical treatment can be proposed sooner in these cases than in children with good clearance.--J.M. Guys