Experience with gastrojejunal feeding tubes in children

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induced diaphragmatic hernia at 90 days’ gestation, followed by delivery near term. These lambs were randomized to one of two groups. All animals underwent reduction of the diaphragmatic hernia at about 15 minutes of age and were gas-ventilated to 30 minutes. In one group, gas ventilation alone was continued; in the second group, PFC was instilled. Mechanical ventilation was continued for up to 3.5 hours. Gas exchange, pulmonary mechanics, and histology were analyzed at the end of the experiment. A morphometric analysis was performed, reporting proportions of parenchyma, bronchi, perivascular emphysema, etc. Pulmonary trauma was described using the perivascular compression index. In normal lungs, adequate gas exchange was achieved in all groups. No statistically significant differences were found with regard to the degree of lung trauma between the groups. In the hypoplastic lungs of the lambs with diaphragmatic hernias, gas ventilation with instillation of PFC improved survival, gas exchange, and pulmonary mechanics, compared with animals that had only gas ventilation. However, no difference was found in pulmonary trauma between the two groups. The authors conclude that partial liquid ventilation may be an alternative therapeutic method for severe congenital diaphragmatic hernia--P. Puvi Congenital Adenomatoid Disease of the Lung: nosis and Perinatal Management. E. Supin, Barget, et al. Pediatr Sing Int 12:126-129, (February),

Prenatal DiagK Lejeune, %I? 1997.

The aim of this study was to analyze the significance of ultrasonographic findings of congenital adenomatoid malformation (CAM) with respect to prognosis and to delineate a suggested plan for perinatal management. Eighteen patients diagnosed in the 17th to 36th gestational week were evaluated. Thirteen lesions were left-sided, four were right-sided, and one was bilateral. Using the Stocker classification, 12 patients had type I lesions (macrocystic lesions), 4 had type II (polymicrocystic lesion), and 2 type III lesions (homogenous solid lesions). The prenatal course was monitored in 13 cases. In eight babies the size of the lesion was stable; in 5 cases it decreased. Abortion was performed in one case. Six neonates needed surgery in the newborn period because of respiratory symptoms. Nine babies underwent delayed surgery. In two babies, there was spontaneous regression of the lesion. Of the surgical patients, eight underwent lobectomy; segmentectomy was sufficient in six cases. Twelve patients had uncomplicated postoperative courses. At follow-up, 15 patients were well. The authors conclude that one should not overestimate a poor prognosis in cases of prenatally detected CAM.-T. Wester

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had medical therapy, two of whom later underwent thymectomy because of failed medical therapy. Overall, two patients died and one was lost to follow-up. Among the surgical cases there was no operative mortality or morbidity. In 10 cases, thymic hyperplasia was found; in two cases the thymus was normal. At follow-up (1 to 10 years after surgery), 50% of the patients were in remission and 33% were much improved. One patient remained unchanged, and one patient deteriorated and died. All patients in remission underwent surgery before 6 years of age and had thymic hyperplasia. The authors conclude that thymectomy may provide a better chance of remission than medical therapy, particularly when it is performed in young children who have a hyperplastic thymus-R Puri

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Gastric Transposition for Esophageal Replacement dren-An Indian Experience. D.K. Gupta, R. K&aria, Bajpai. Em-J Pediatr Surg 7:143-146, (June), 1997.

in Chiland M.

Most pediatric surgeons are wary of gastric transposition as a means of esophageal replacement in children, especially during infancy. The authors present their initial experience with this technique in five children with follow-up averaging 1.7 years postoperatively. Four were infants (5 to 10 months) with long gap esophageal atresia; one was operated on for an extended corrosive esophageal stricture at 4 years. The stomach was placed tmnshiatally in three patients and retrostemally in two. A gastric outlet drainage procedure was performed in all cases. Three of the four infants required postoperative ventilation (mean, 40 hours), their average hospital stay was 24 days. The first transposition resulted in death (20%), owing to ventilation problems. Other complications included anastomotic leakage and subsequent stricture, adhesive obstruction, transient Homer’s syndrome, recurrent laryngeal nerve palsy, and poor weight gain. No duodenogasuic reflux was observed. The authors recommend their method as a safe, relatively simple, and physiological procedure for esopageal replacement.--Thomas A. Angerpointner The Incidence of Adenocarcinoma in Barrett’s Esophagus: A Prospective Study of 170 Patients Followed 4.8 Years. D.J. Drewitz, R.E. Samplinel; and H.S. Garewal. Am J Gastroenterol92:212215 (February), 1997.

The authors report on 32 cases of early decortication for postpneumanic empyema. Twenty were male and 12 were female. Decortication was reserved for patients in whom antibiotic therapy and closed-tube drainage had failed, and was performed on the 10 to 15 days after diagnosis had been established. Indications for decortication were persistent fever (9), pulmonary air leakage (7), localized effusion (7), persistent respiratory distress (5), and pleural thickening without resolution (28). Decortication was achieved via standard posterolateral thoracotomy. The patients were discharged on the 8th postoperative day, and morbidity was minimal. There were no deaths. Low morbidity, short hospitalization period, quick improvement of respiratory function, and return to a normal and healthy life in a short time are the most important advantages of this technique.--Thornus A. Angevpointner

Although the patients in this study are adults and the study was conducted in a VA hospital, the results are at such variance with other studies that the reviewer felt it was appropriate to include them here. The significance of Barrett’s esophagus lies in its potential to develop adenocarcinoma. Virtually all cases of adenocarcinoma of the esophagus occur in the background of Barrett’s esophagus. Adenocarcinoma of the esophagus and of the esophagogastric junction had had the most rapidly increasing incidence of all tumors in the United States over the past two decades. The aim of this study was to prospectively determine the incidence of adenocarcinoma in patients with Barrett’s esophagus. One hundred seventy-four males and three females with a mean age at diagnosis of 62 years (range, 30 to 85 years), had follow-up for a mean of 4.8 years (range, 6 to 156 months) for a total of 834 patient-years. The prevalence of adenocarcinoma in this patient population was 4%. Adenocarcinoma developed in an additional four patients, for an incidence of 1 per 208 patient-years of follow-up. Therefore, the study demonstrates a lower incidence of adenocarcinoma associated with Barrett’s esophagus than had been reported previously, and it supports surveillance of patients with Barrett’s esophagus as an appropriate clinical practice.-Richard R. Rickeffs

Thymectomy in Black Children Gravis. K. Lakhoo, J. De Fonseca, 12:113-115, (February), 1997.

Experience With Gastrojejunal Feeding Tubes in Children. J.M. Peters, f! Simpsott, and R Tolia. Am J Gastroenterol 92:476-480 (March), 1997.

Postpneumonic Empyema in Children Treated by Early Decortication. R. Rizalal; S. Somuncu, R Bemay, et al. Eur J Pediatr Surg 7:135-137, (June), 1997.

With Juvenile Myasthenia J. Rodda, et al. Pediatr Surg Int

The authors report on 15 black children gravis, 12 of whom underwent thymectomy.

with juvenile myasthenia Five of the fifteen initially

The main indications for use of a jejunal feeding tube include aspiration, reflux esophagitis, or gastroparesis. Use of jejunal

tracheal feeding

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tubes also has been suggested as an alternative to the performance of a Nissen fundoplication with G-tube placement. A chart review of 28 patients with percutaneously placed gastrojejunal tubes (GJT) was performed. At the time of tube insertion, the mean age was 47.2 months and the mean weight was 11.7 kg (range, 2.28 to 42.7 kg). The mean duration of follow-up was 17.3 months. The patients were evaluated for the persistence or new development of vomiting, hematemesis, abdominal pain, constipation, diarrhea, pain at the site of G-tube insertion, stridor during feeding, and dumping. One or more of these symptoms were present or developed de novo in 20 children (71.4%), with vomiting being the most common. Major complications occurred in 11 patients, with fundoplication being required in seven patients. Children without complications were significantly older and heavier at the time of GJT placement than the children who had major complications. The authors conclude that ongoing or new gastrointestinal symptoms and minor complications are common in children with GJT, and that several problems in maintaining the GJT in a functional state compromised its utility.-Richard R. Ricketts Laparotomy or Drain for Perforated Necrotizing Enterocolitis: Who Gets What and Why? KS. Azarov, S.H. Ein, B. Shandling, et al. Pediatr Surg Int 12:137-139, (February), 1997. The authors compare 86 neonates with perforated necrotizing enterocolitis treated with laparotomy versus peritoneal drain inserted under local anesthesia. Treatment was decided according to the surgeon’s preference. Forty-two patients underwent laparotomy, and44 had drainage. The average weight was 1,700 g for the laparotomy group and 1,100 g for the drainage-only group. Of the babies who weighed less than 1,000 g, 22% survived laparotomy and 69% survived drainage. Of those between 1,000 and 1,500 g, 60% survived laparotomy and 33% survived drainage. Of those heavier than 1,500 g, 72% survived laparotomy and 50% survived drainage. The overall survival rates were 57% with laparotomy and 59% with peritoneal drainage. It is concluded that treatment of perforated necrotizing enterocolitis with peritoneal drainage in neonates who weigh less than 1,000 g may result in improved survival rates-l? Wester Crohn’s Disease: Influence of Age at Diagnosis on Site and Clinical Type of Disease. J.M. Polito II, B. Childs, E.D. Mellits, et al. Gastroenterology 111580-586 (September), 1996. The aim of this study was to examine the influence of age at the time of diagnosis of Crohn’s disease on disease, type, and clinical course. Patients younger than 20 years at the time of onset were compared with those older than 40 years at onset. The younger patients had a greater prevalence of family history of Crohn’s disease (29.9% v 13.6%), greater likelihood of small bowel involvement (88.7% v 57.5%), more stricturing-type disease (45.8% v 28.8%), and a higher frequency of surgery (70.6% v 55.3%). Older age at diagnosis was associated with a greater prevalence of colonic disease (84.8% v 71.2%), and of the inflammatory type of Crohn’s disease (54.5% v 34.4%). In summary, Crohn’s disease occurring at an early age is associated with more complicated disease and a greater likelihood of having affected relatives.-Richard R. Ricketts Surgical Therapy for Crohn’s Disease of the Colon and Rectum. VU! Fazio and J.S. Wu. Surg Clin North Am 77:197-210 (February), 1997. When Crohn’s disease is confined to the colon at initial presentation, both the recurrence rate and the site of recurrence after surgery are influenced by the type of procedure performed. The authors discuss the common operations performed for Crohn’s disease of the colon and rectum, including (1) subtotal colectomy and ileostomy, (2) ileostomy, (3) total proctocolectomy and ileostomy, (4) abdominal colectomy and

ileorectal anastomosis, (5) segmental colectomy. and (6) surgery for internal fistulas. Recurrence rates are lowest after total proctocolectomy and end ileostomy and are highest after segmental colonic resection. Total proctocolectomy is the most appropriate operation for treatment of Crohn’s colitis, especially if there is significant anorectal disease. The two most common complications after this procedure are proximal small bowel recurrence and nonhealing of the perineal wound. Reports of small bowel recurrence after total proctocolectomy vary from 3% to 46%. Abdominal colectomy and ileorectal anastomosis in patients with Crohn’s disease is appropriate if the rectum is spared of the disease and anal sphincter function is normal. Contraindications to ileorectal anastomosis include the presence of active perineal disease, rectal cancer or dysplasia, and a poorly distensible rectum. Both the surgeon and the patient should realize that there is distinct likelihood of further surgery, directed toward the rectum, in patients who have ileorectal anastomosis. Approximately 23% of patients will require a later proctectomy, and 13% may require proximal diversion. Segmental colectomy in patients with Crohn’s disease has a limited role. It is appropriate when only short segments of colon or rectum are involved and the rest of the colon is absolutely normal. Attempts at saving the rectum when obvious disease is present by using a Hartman procedure or a mucous fistula are not likely to be successful.-Richard R. Ricketts The Long-Term Outcome of Ulcerative Colitis Treated With 6-Mercaptopurine. .I. George, D.H. Present, R. Pou, et al. Am J Gastroenterol91:1711-1714 (September), 1996. Chronic refractory cases of ulcerative colitis can achieve 40% complete response rate and 30% partial response rate when treated with 6-MP. However, the duration for which 6-MP must be maintained once remission has been achieved is not clear. Long-term follow-up data on 10.5 patients with ulcerative colitis were reviewed. The initial dose of 6-MP was 50 mg/d, with gradual increases depending on the clinical response. Complete clinical remission was defined as the ability to discontinue oral steroids, and partial remission was defined as a 50% reduction in the steroid dose. The average age of onset of ulcerative colitis in these patients was 30.8 years (range, 11 to 68 years), and the average age at 6-MP initiation was 38.6 years (range, 13 to 76 years). Sixty-five percent of the patients achieved complete clinical remission, and 24% achieved partial remission. Of those who achieved complete clinical remission, 35% had a breakthrough while still on 6-MP. Eighty-seven percent of patients who electively discontinued 6-MP at various intervals after achieving complete clinical remission had a relapse. The estimated mean time until relapse was 14 months. Therefore, 6-MP is effective in the treatment of refractory ulcerative colitis. Patients who discontinue 6-MP after successful treatment have a high relapse rate, and therefore 6-MP must be maintained long-term to sustain remission.-Richard R. Ricketts Surgical Options in Ulcerative ton. Surg Clin North Am 77:85-94

Colitis. R. Faroukand (February), 1977.

J.H. Pember-

The following surgical questions in the management of ulcerative colitis are discussed, using experience from the Mayo Clinic as a basis for the discussion: (1) Which pouch design is best? (2) Is there a role for defunctioning ileostomy? (3) When should the anal transition zone be excised? (4) When should a stapled anastomosis be avoided? (5) How does the finding of cancer of the colon influence the decision to create a pouch? The authors believe that there is little difference in functional outcome between the S, W, J, K, and H reservoirs if approximately 30 to 40 cm of ileum are used for reservoir construction. Because of the relative ease in constructing the J pouch, this is the option preferred by the authors. Use of a loop ileostomy does not appear to fully protect the patient from pelvic sepsis, but it is much easier to manage a patient with sepsis if an ileostomy is in place. Because of this, the authors recom-