Neonatal gastric perforation

INTERNATIONAL

ABSTRACTS OF PEDIATRIC SURGERY

627

swallowed a penny. The penny was found to be in the esophagus. Without anesthesia, the child

This technic offers a simple life-saving procedure restricted to the abdomen. Later reconstruction of

had a #16 Foley catheter passed through the nostril into the esophagus past the level of the coin. The Foley balloon was then gently inilated with 8 cc. of air and the catheter was withdrawn pulling the coin with it. When the coin reached the pharynx the child spit it out--E. J. Berman.

the esophagus is done through virgin tissue and is accordingly easier.-D. T. Cloud.

DEMONSTRATION OF THE DISTAL ESOPHAGEAL POUCH IN ESOPHAGEAL ATRESU WITHOUT FISTULA. Leonard E. Swischuck. Amer. J. Roentgen. 103:277-280 (June) 1968. Four cases are presented proach to the management without fistuln.

demonstrating of esophageal

an apatresia

A primary consideration is the length of the distal pouch. This can be evaluated after routine gastrostomy by refluxing contrast into the distal pouch. All four cases presented similarly with regurgitation and unsuccessful attempts by the examiner to pass a nasogastric tube. X-ray revealed a gasfilled proximal pouch and a gasless abdomen. After gastrostomy the distal pouch was evaluated successfully. Two patients were operated for primary repair. One did well but the anastamosis in the second broke down. This patient was rescheduled for future bowel interposition. The other two cases could not be operated upon and both expired (gastric perforation and gastro-enteritis with septicemia).-W. L. S&y. GASTRIC DIVISION IN THE CRITICALLY ILL INFANT WITH ESOPHAGEALATRESIA AND TRACHEOESOPHAGEAL FIST~JLA. I. G. Randolph, W. I’. Tune& and .I. R. I.illy. Surgery 63:49&502 (March) 1968. In esophageal atresia with tracheoesophageal fistula, primary closure of the trachea with esophageal anastomosis is desirable. However, in small infants and those with associated congenital anomolies or pulmonary disease a staged procedure is desirable. The technic of gastric division as employed in this circumstance is described. The stomach is divided transversly in its upper portion through an abdominal incision, and the gastrostomy tube placed in each pouch. This defunctionalizes the tracheoesophageal fistula and eliminates the need for primary transthoracic fistula closure. A simple gastrostomy without division of the fistula has limited usefulness because of the possibility of reflux through the fistula into the lungs.

GASTROSTOMY IN THE PREMATURE NEWBORN INFANT. R. Cohn and P. Sunshine. .irch. Slug. 96:933 (June) 1968. The authors use gastrostomy in premature infants with repeated apnea periods requiring resuscitation by bag and mask. They feel that these infants tend to have stomachs full of air with increased instance of regurgitation and aspirations. A second indication is the ill infant with respiratory insufficiency that has to be artificially ventilated on a respirator. These infants have no epiglottic protection and may aspirate. A third indication is considered to be prior to and following surgery for trachea-esophageal fistula. Of interest is the fact that at Stanford University School of Medicine, Palo Alto, California, the gastrostomy is done in the isolette under local anesthesia with the operator and assistant working through the four openings in the plastic hood. If the stomach is not easily accessible in is distended with air which brings it readily into the wound. Stamm gastrostomy with two purse string sutures is employed with the second purse string suture being anchored to the peritoneum and the bag distended and placed in gentle traction. No serious infections occurred. The incision used is 1% to 2 cm. and placed in the left upper quadrant transversely. In only one of 65 patients was it necessary to surgically close a gastric fistula.--E. J. Bemun. NEONATAL GASTRIC PERFORATION. E&in son, Jr. Amer. J. Roentgen. 103:307-309 1968.

S. Wil-

(June )

In 1964 the total number of gastric perforations reported was 143. Only 39 survivors were among the group. A prompt diagnosis was the major factor in the survivors. Two cases are presented both of whom expired. The first was 5 lb., 3 oz. and did well for the first three days of lifr. On the fourth day the infant abruptly refused feed ings, became lethargic, and abdominal distention was noted. The infant expired 10 hours after the onset of symptoms. The diagnosis was made within that short period of time but the fulminant nature of the catastrophy prevented satisfactory intervention. The second case (a 4 lb., 6 oz. infant) developed symptoms during the third day. Diagnosis again was made promptly, supported by an upright film of the abdomen showing free air,

628

INTERNATIONAL

and a lesser gastric curvature perforation was found at surgery. This was repaired but the infant died suddenly in surgery. In the first child gastric perforation was found at post mortem examination but on the greater curvature. Microscopic sections showed incomplete muscular deveIopment in the gastric wall. The precise etiology of this entity is obscure. Focal aplasia of the gastric musculature, as in the first case, seems the most likely prediposing cause. Consideration of the true nature of the clinical problem should be made in a 3- or 4-day-old infant with the rapid onset of symptoms (lethargy, tachypnea, decreased temperature, and abdominal distention.) An unusually high number of these cases are in the premature infant.-W. L. Schey. COMBINED CONGENITAL GASTRIC AND DUODENAL OBSTRUCTION: PITFALLS IN DIAGNOSIS AND TREATMENT. .I. A. HalEer, Jr. and 1. L. Cahill. Surgery

63~503-506

(March)

1968.

A case of congenital prepyloric mucosal diaphragm in association with duodenal atresia is presented. The initial diagnosis was duodenal atresia proximal to the ampulla of Vater; the emesis was not bile-stained. Duodenojejunostomy was performed. Subsequently obstruction of the gastric outlet was observed and found later to be a mucosal diaphragm. This was corrected surgically and the patient recovered. The case was of interest because of the combined lesions and the difficulty in diagnosing the mucosal diaphragm.-D. T. Cloud. DUODENAL OBSTRUCTION IN THE NEWBORN DUE TO ANNLYLAR PANCREAS. E. A. Free and Barry Gerald. Amer. J. Roentgen. 103:321-325 (June) 1968. In 8 cases of annular pancreas by-pass procedures were performed and 7 survived. All had associated anomalies consisting of one or more of the following: agenesis of the lung, hemivertebrae, intestinal malrotation, Down’s syndrome, Hirschprung’s disease, imperforate anus, malrotated kidney, intervertebral disc calcification, microcephaly, and prematurity. Roentgen diagnosis prior to surgery suggested the possibility and likelihood of annular pancreas by demonstrating a “double-bubble.” Air was also noted beyond the site of apparent obstruction indicating the incomplete nature of the constriction.-W. L. Schey. ABNORMALITIES ASSOCIATED WITH NEONATAL DUODENAL OBSTRUCTION. D. G. Young and

A.

W.

ABSTRACXS OF PEDIATRIC SURGERY

Wilkinson.

Surgery

63:832-836

(May)

1968. The incidence of types of associated anomalies were studied in 157 infants with neonatal duodenal obstruction: malrotation (50) jaundice (49), Mongolism (33), annular pancreas (311, congenital heart disease (29), esophageal atresia (I7), other alimentary tract anomalies of the small bowel (16), and hindgut (7) were observed. In the Mongoloid babies with duodenal obstruction, the mortality rate was substantially higher than the average for the whole series. It was observed that 33 per cent of these infants did not have bile-stained vomitus. The authors stress that persistent vomiting in the neonate, bile-stained or not, suggests obstruction-D. 7’. Cloud. INTRALUMINAL DIVERTICULUM OF THE DUODENUM IN A Crrnn. Alex Newman and M. H. Nathan. Amer. J. Roentgen. 103:326329 (June) 1968. Intraluminal diverticulae have been reported previously in adults. The youngest was 22 years old. The present case, believed to be the only reported case in a child, demonstrated the typical radiographic findings of an intraluminal diverticUIUIU.

The child, an D-year-old female, was admitted for evaIuation complaining of cramping and abdominal pain throughout the abdomen for several days. The pain was present during the morning hours and was not associated with nausea or vomiting. No relief was obtained by intake of milk or liquids. She was prior to hospitalization.

treated

with

antispasmotics

An upper gastrointestinal examination revealed a sac-like structure hanging pendulously into the lumen of the duodenum. She was treated with “symptomatic” therapy and has remained without complaint.-W. L. Schey. THE

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