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Proximal gastric resection in the treatment of bleeding gastro-esophageal varices in patients with portal hypertension due to extrahepatic obstruction
ABSTFUCTS
84 the neck is achieved. Complications were frequent, and included anastomotic breakdowns, strictures, fistula between colon replacement and bronchus and obstruction by foreign bodies. Two children required a repeat replacement of the colon, five needed a revision of the anastomosis, cervical esophagus-to-colon and one had a revision of the colon-tostomach anastomosis. Despite the many surgical difhculties encountered, all children survived, and are reported to be swallowing without serious handicap.-C.
C. Ferguson.
RESPONSE OF THE ,GULLET TO GASTRIC REFLUX IN PATIENTS WITH HIATUS HERNIA AND ESOPHAGITIS. D. A. K. Woodward. Thorax
25:459-464
(July),
1970.
Esophageal motility and esophageal pH were simultaneously recorded in 33 patients with sliding hiatal hernias. This paper correlates findings with clinical symptoms and esophagoscopic appearance of the distal esophagus. Symptoms were noted only in those patients where esophageal pH levels dropped below 4. In general there was poor correlation between pH limits and symptoms. Poor motor function was associated with esophagitis and poor acid clearing from the distal esophagus. There was, however, no clear cut correlation between esophageal motor activity and clinical symptoms. The authors provide explanations for these findings.-W. K. Sieber. THE VALUE OF SIMPLE TESTS FOR PEFUSTALTIC ACTIVITY IN HIATUS HERNIA. S. J. A. Powis and J. Leigh Collis. Thorax 25:457458
(July),
1970.
PROXIMAL GASTRIC RESECTION IN THE TREATMENT OF BLEEDING GASTRO-ESOPHAGEAL VARICES IN PATIENTS WITH PORTAL HYPERTENSION DUE TO EXTRAHEPATIC OBSTRUCTION.R. L. Rothwell-Jackson and
Alan H. Hunt. Brit. J. Surg. 57z487-494 (July),
1970.
In the M-year period 1949-1965, 28 patients underwent the above procedure, the mean follow-up period being 10 years. Twelve were children of under 15 and 7 out of 16 adults had their first hemorrhage in childhood. Proximal gastric resection is performed through a left thoraco-abdominal approach. The esophagus is freed to the root of the lung. The proximal two thirds of the stomach is resected and the esophagus with a small cuff of stomach is anastomosed end to side to the distal stomach remnant, separate from the line of resection of the stomach. A pyloroplasty and feeding jejunostomy are also performed. Twenty two of the patients had been subjected to previous surgery for hemorrhage. Five had more than one type of operation. Two adults and two children died. One adult’s death was due to subphrenic abscess. The second adult and a child died 2% and 9 years after operation from massive hemorrhage. The second child died 3 years after her gastric resection from pneumococcal septicemia of unknown origin. The morbidity from this operation
was high.
Reflux esoph-
agitis occurred in 13. Recurrent hemorrhage also occurred in 13, 2 of whom died as the result of it. One of the cases bled from a duodenal ulcer and 2 from esophagitis following reflux. Five of the remaining 10
Esophageal peristalsis was studied in 184 patients (of all ages) by acidified barium esophagram. Included were normal control patients, those with proven hiatus hernia
cases had esophagitis as well as recurrent varices. Other serious complications were 2 empyemas, 4 anastomotic leaks and 9 strictures of the anastomoses. Six of these responded to dilatation, the remaining 3
with and without esophageal stricture, those with surgically repaired hiatus hernia and a group of patients with other types of esophageal pathology such as achaiasia and carcinoma. The timing of the first wave and the timing of clearance of barium from the esophagus were determined. No consistent correlation with specii?c pathology was possible. The authors conclude that such examinations are of no clinical diagnostic value. -W. K. Sieber.
required further surgery. The treatment of hemorrhage in patients with extrahepatic portal obstruction is unsatisfactory. A portal systemic anastomosis is often not feasible because of the caliber of vessels involved. For success the stoma should be more than 10 mm. The overall thrombosis rate is 36 per cent and only 16.5 per cent in adults. Operation of proximal gastric resection is recommended in ( 1) small children whose veins are too small for
85
ABSTRACTS a shunt,
(2)
patients who do not have suit-
able vessel for a shunt either because of extension of thrombosis to the splenic vein or because of previous splenectomy and (3 ) patients who continue to have recurrent hemorrhage in spite of previous surgery. The authors claim that in their hand this technique gives better results than other methods of direct attack on the esophagogastric vessels-J. Lari. A NASOJEJUNAL
TUBE FOR INFANT FEEDING.
James Rhea and John Kilby. Pediatrics 46:36-40 l._Tulv) . 1970. _,I
An alternative method to nasogastric feeding was attempted in 48 infants wherein a limp polyvinyl tube was passed from the stomach through the pylorus into the jejunum. Full enteric infant feedings for 3-4 weeks without complications were accomplished. Daily volumes of 150 cc. milk/Kg. in small, but frequent feedings were well tolerated
but the authors
attention
to the osmolarity
stress that careful is necessary
to
formation
has been seen in oblique
mosis performed
on baby
rabbits.
anastoNygaard
(1967) has pointed out that cutting the circular muscle in constructing an equal lumen in an end-to-side or oblique end-toend anastomosis produces a potentially weak area, which could predispose to diverticulum formation. Although blind pouch syndrome is more likely to occur in side-to-side anastomosis, there is, however, a slight risk of this occuring in end-to-end anastomosis--J. Lari. INTUSSUSCEPTION AFTER MAIOR ABDOMINAL OPERATIONS IN CHILDREN.-F. M. G&man, J. C. Duchasme and P. P. Co&n. Canad. J.
Surg.
13:427-433
(October),
1970.
The authors report five children who suffered from intussusception in the postoperative period following revision of a cervical jejuno-esophageal anastomosis; an abdominoperineal pull-through; an adrenalectomy; a Soave pull-through; and the construction of an ileal bladder.
prevent diarrhea and/or hypovolemic shock as fluid is mobilized in the gut--C. Rubin.
Since the symptoms and signs of intussusception in this situation are always bizarre, it is emphasized that surgeons should be
DIVERTICULUM FORMATION AFTER OBLIQUE END-TO-END ANASTOMOSIS FOR JEJUNOILEAL ATRESIA. S. M. L. Nade and I. A. S.
aware of this complication and suspect it in any infant presenting with the clinical pic-
Dickson. Brit. J. Surg. 57:54Q-543
(July),
ture of early postoperative mechanical tinal obstruction-c. C. Ferguson.
intes-
1970. Three patients are presented who developed a diverticulum at the anastomosis after successful treatment for small bowel atresia. Two followed an oblique end-to-end anastomosis and one Roux-en-Y anastomosis with ileostomy. In the first two there was no blind end and in the third the blind end (ileostomy) had been excised at the age of 7 months. Their main features at presentation, aged 4 to 6 years, were bleeding per rectum, anemia and “failure to thrive.” All three were treated successfully by resection of the segment containing the diverticulum. The anemia was due to congestion and ulceration of the diverticulum and the adjacent bowel. The “failure to thrive” was assumed to be due to stasis with disordered absorptive power and altered bacterial flora in the adjacent bowel. There was no evidence of mechanical obstruction in any. The mechanism of diverticulum formation is not known but (Nixon 1960) diverticular
MANAGEMENT OF INTUSSUSCEPTION BY BARIUM ENEMA VERSUS SURGERY. R. K. Leoick. Clin. Pediat. 9:457-462 ( August ), 1970. This paper deals mostly with the technical aspects of barium enema reduction of intussusception as done at the Children’s Hospital Western Bank, Sheffield. The author states that when the interval between the onset of symptoms and the attempted tion was under 24 hours the success
reducrate of
barium enema reduction was 70 per cent. However, if the interval was over 24 hours, the success rate dropped to 25 per cent. According to age groups, successful barium reduction was obtained in 33 per cent of children under 6 months, and 72 per cent in children over 6 months. Irrespective of the duration of symptoms, the main decision against use of the barium enema is the child’s general condition. Thus a shocky child is considered an immediate surgical case, with an occasional enema done only for
84 the neck is achieved. Complications were frequent, and included anastomotic breakdowns, strictures, fistula between colon replacement and bronchus and obstruction by foreign bodies. Two children required a repeat replacement of the colon, five needed a revision of the anastomosis, cervical esophagus-to-colon and one had a revision of the colon-tostomach anastomosis. Despite the many surgical difhculties encountered, all children survived, and are reported to be swallowing without serious handicap.-C.
C. Ferguson.
RESPONSE OF THE ,GULLET TO GASTRIC REFLUX IN PATIENTS WITH HIATUS HERNIA AND ESOPHAGITIS. D. A. K. Woodward. Thorax
25:459-464
(July),
1970.
Esophageal motility and esophageal pH were simultaneously recorded in 33 patients with sliding hiatal hernias. This paper correlates findings with clinical symptoms and esophagoscopic appearance of the distal esophagus. Symptoms were noted only in those patients where esophageal pH levels dropped below 4. In general there was poor correlation between pH limits and symptoms. Poor motor function was associated with esophagitis and poor acid clearing from the distal esophagus. There was, however, no clear cut correlation between esophageal motor activity and clinical symptoms. The authors provide explanations for these findings.-W. K. Sieber. THE VALUE OF SIMPLE TESTS FOR PEFUSTALTIC ACTIVITY IN HIATUS HERNIA. S. J. A. Powis and J. Leigh Collis. Thorax 25:457458
(July),
1970.
PROXIMAL GASTRIC RESECTION IN THE TREATMENT OF BLEEDING GASTRO-ESOPHAGEAL VARICES IN PATIENTS WITH PORTAL HYPERTENSION DUE TO EXTRAHEPATIC OBSTRUCTION.R. L. Rothwell-Jackson and
Alan H. Hunt. Brit. J. Surg. 57z487-494 (July),
1970.
In the M-year period 1949-1965, 28 patients underwent the above procedure, the mean follow-up period being 10 years. Twelve were children of under 15 and 7 out of 16 adults had their first hemorrhage in childhood. Proximal gastric resection is performed through a left thoraco-abdominal approach. The esophagus is freed to the root of the lung. The proximal two thirds of the stomach is resected and the esophagus with a small cuff of stomach is anastomosed end to side to the distal stomach remnant, separate from the line of resection of the stomach. A pyloroplasty and feeding jejunostomy are also performed. Twenty two of the patients had been subjected to previous surgery for hemorrhage. Five had more than one type of operation. Two adults and two children died. One adult’s death was due to subphrenic abscess. The second adult and a child died 2% and 9 years after operation from massive hemorrhage. The second child died 3 years after her gastric resection from pneumococcal septicemia of unknown origin. The morbidity from this operation
was high.
Reflux esoph-
agitis occurred in 13. Recurrent hemorrhage also occurred in 13, 2 of whom died as the result of it. One of the cases bled from a duodenal ulcer and 2 from esophagitis following reflux. Five of the remaining 10
Esophageal peristalsis was studied in 184 patients (of all ages) by acidified barium esophagram. Included were normal control patients, those with proven hiatus hernia
cases had esophagitis as well as recurrent varices. Other serious complications were 2 empyemas, 4 anastomotic leaks and 9 strictures of the anastomoses. Six of these responded to dilatation, the remaining 3
with and without esophageal stricture, those with surgically repaired hiatus hernia and a group of patients with other types of esophageal pathology such as achaiasia and carcinoma. The timing of the first wave and the timing of clearance of barium from the esophagus were determined. No consistent correlation with specii?c pathology was possible. The authors conclude that such examinations are of no clinical diagnostic value. -W. K. Sieber.
required further surgery. The treatment of hemorrhage in patients with extrahepatic portal obstruction is unsatisfactory. A portal systemic anastomosis is often not feasible because of the caliber of vessels involved. For success the stoma should be more than 10 mm. The overall thrombosis rate is 36 per cent and only 16.5 per cent in adults. Operation of proximal gastric resection is recommended in ( 1) small children whose veins are too small for
85
ABSTRACTS a shunt,
(2)
patients who do not have suit-
able vessel for a shunt either because of extension of thrombosis to the splenic vein or because of previous splenectomy and (3 ) patients who continue to have recurrent hemorrhage in spite of previous surgery. The authors claim that in their hand this technique gives better results than other methods of direct attack on the esophagogastric vessels-J. Lari. A NASOJEJUNAL
TUBE FOR INFANT FEEDING.
James Rhea and John Kilby. Pediatrics 46:36-40 l._Tulv) . 1970. _,I
An alternative method to nasogastric feeding was attempted in 48 infants wherein a limp polyvinyl tube was passed from the stomach through the pylorus into the jejunum. Full enteric infant feedings for 3-4 weeks without complications were accomplished. Daily volumes of 150 cc. milk/Kg. in small, but frequent feedings were well tolerated
but the authors
attention
to the osmolarity
stress that careful is necessary
to
formation
has been seen in oblique
mosis performed
on baby
rabbits.
anastoNygaard
(1967) has pointed out that cutting the circular muscle in constructing an equal lumen in an end-to-side or oblique end-toend anastomosis produces a potentially weak area, which could predispose to diverticulum formation. Although blind pouch syndrome is more likely to occur in side-to-side anastomosis, there is, however, a slight risk of this occuring in end-to-end anastomosis--J. Lari. INTUSSUSCEPTION AFTER MAIOR ABDOMINAL OPERATIONS IN CHILDREN.-F. M. G&man, J. C. Duchasme and P. P. Co&n. Canad. J.
Surg.
13:427-433
(October),
1970.
The authors report five children who suffered from intussusception in the postoperative period following revision of a cervical jejuno-esophageal anastomosis; an abdominoperineal pull-through; an adrenalectomy; a Soave pull-through; and the construction of an ileal bladder.
prevent diarrhea and/or hypovolemic shock as fluid is mobilized in the gut--C. Rubin.
Since the symptoms and signs of intussusception in this situation are always bizarre, it is emphasized that surgeons should be
DIVERTICULUM FORMATION AFTER OBLIQUE END-TO-END ANASTOMOSIS FOR JEJUNOILEAL ATRESIA. S. M. L. Nade and I. A. S.
aware of this complication and suspect it in any infant presenting with the clinical pic-
Dickson. Brit. J. Surg. 57:54Q-543
(July),
ture of early postoperative mechanical tinal obstruction-c. C. Ferguson.
intes-
1970. Three patients are presented who developed a diverticulum at the anastomosis after successful treatment for small bowel atresia. Two followed an oblique end-to-end anastomosis and one Roux-en-Y anastomosis with ileostomy. In the first two there was no blind end and in the third the blind end (ileostomy) had been excised at the age of 7 months. Their main features at presentation, aged 4 to 6 years, were bleeding per rectum, anemia and “failure to thrive.” All three were treated successfully by resection of the segment containing the diverticulum. The anemia was due to congestion and ulceration of the diverticulum and the adjacent bowel. The “failure to thrive” was assumed to be due to stasis with disordered absorptive power and altered bacterial flora in the adjacent bowel. There was no evidence of mechanical obstruction in any. The mechanism of diverticulum formation is not known but (Nixon 1960) diverticular
MANAGEMENT OF INTUSSUSCEPTION BY BARIUM ENEMA VERSUS SURGERY. R. K. Leoick. Clin. Pediat. 9:457-462 ( August ), 1970. This paper deals mostly with the technical aspects of barium enema reduction of intussusception as done at the Children’s Hospital Western Bank, Sheffield. The author states that when the interval between the onset of symptoms and the attempted tion was under 24 hours the success
reducrate of
barium enema reduction was 70 per cent. However, if the interval was over 24 hours, the success rate dropped to 25 per cent. According to age groups, successful barium reduction was obtained in 33 per cent of children under 6 months, and 72 per cent in children over 6 months. Irrespective of the duration of symptoms, the main decision against use of the barium enema is the child’s general condition. Thus a shocky child is considered an immediate surgical case, with an occasional enema done only for