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Ranitidine-enhanced 99mtechnetium pertechnetate imaging in children improves the sensitivity of identifying heterotopic gastric mucosa in Meckel's diverticulum
892
International Abstracts
infections and the risk of malignant transformation and can be safely performed between 3 and 9 months of life. The risk of infection is clearly more likely to occur with increasing age. Lobectomy remains the procedure of choice, possibly with minimal-access thoracoscopic surgery. Limited excision may lead to recurrence. Thoracotomy is well tolerated in infancy and early childhood. In this series, there were no significant complications. The authors found a direct correlation between the presence of respiratory compromise at age of surgery and the need for overnight or prolonged ventilation. The authors conclude that surgery can be safely performed after 3 months of age. An additional conclusion might be that if surgery is postponed longer in asymptomatic cases, infections could lead to more perioperative complications.—P. Schmittenbecher
Lung contusion-lacerations after blunt thoracic trauma in children Haxhija EQ, No¨res H, Schober P, et al. Pediatr Surg Int 2004 (June);20: 412-414. Serious chest injuries in children are infrequent, but they are an indicator of a high-energy trauma. Due to the elasticity of the chest, rib fractures are seldom seen. Pulmonary contusion-laceration is the most common reported injury. In adults, 4 years after pulmonary contusion, 70% showed a reduced functional residual capacity. In children, complete recovery is assumed. Between 1986 and 2000, 41 children with an age range from 1 to 17 years suffered from a traumatic lung injury. Twenty-seven patients were injured in connection with a motor vehicle accident (MVA); in 14 children, falls, sport injuries, and isolated compression trauma were reported. All but 2 children had associated extrathoracic injuries. Hemothorax was found in 37%, pneumothorax in 39%, and both in 25%, with bilateral contusion significantly more frequently seen in the MVA group. Traumatic pneumatocele occurred in three patients but resolved spontaneously by 3 to 4 months. In 8 cases, rib fractures were mentioned, but serial fractures occurred in 2 cases only. Rib fractures correlated with the occurrence of hemothorax. Chest tubes were used in 16 patients (14 with MVA). Two thoracic surgical interventions were performed for aortic dissection and for recurrent bilateral tension pneumothorax. Five children needed laparotomy, 15 stabilization of fractures (14 with MVA). Five died, all following MVA due to severe head trauma, cardiorespiratory insufficiency, and pneumonia. Follow-up investigations have been performed in 34 of 36 survivors 4.5 F 1 years after the injury. Lung function studies were normal in all but one asthmatic child. Hemothorax and chest tube were correlated with a lower maximal vital capacity. Most follow-up sequelae were related to associated injuries such as leg length discrepancies and hemiparesis. In children, detailed data about the late outcome after traumatic lung injury are lacking. It is shown that nearly all children had normal lung function but a lower maximal vital capacity following hemothorax. Other injuries than lung injuries are mainly responsible for mortality, but pulmonary contusion has been associated with 34% mortality in children with multiple injuries. Chest trauma remains a potent indicator of a high-energy trauma with higher risk of death in MVA. Children who recover do not suffer from significant late respiratory problems. — Peter Schmittenbecher
Alimentary Tract Manometric evaluation of the intrathoracic stomach after gastric transposition in children Gupta DK, Charles AR, Srinivas M. Pediatr Surg Int 2004 (June);20: 415 - 418. Gastric transposition has found wide acceptance as an esophageal substitute. The life expectancy is long and the function of the transposed stomach is of great importance. Residual gastric motility is not well studied. This study was designed to evaluate the intrathoracic stomach in patients with esophageal atresia by manometry. Eighteen babies underwent esophageal replacement by gastric transposition between 1993 and 2001. Group 1 had surgery during the newborn
period; group 2 were operated 4 to 15 months after birth. The manometric evaluation was done at mean age of 30.5 month with measurement of the pressure profile of the upper, mid, and lower portion of the transposed stomach. Sequential contractions at the three pressure sensors were judged as propulsive peristalsis, simultaneous contractions as mass contractions. No patient showed any propagated propulsive activity. Mass contractions were seen in two thirds of the children with a 78% appearance following neonatal transposition and a 56% in older patients. Peak pressures were higher following neonatal operation. Mass contractions appeared after swallowing. The transhiatal vs retrosternal transposition method made no difference. Gastric transposition will change gastric innervation, for example, by vagotomy. But some evidence exists that motor activity may recover and migrating motor complexes may be generated. None of the investigated children showed propulsive activity but a large number had mass contractions in response to swallowing. This swallow-related activity indicates functional integrity of the plexuses. Possibly, mass contractions will evolve into progressive peristalsis during long-term follow-up because electrical control activity in the normal stomach undergoes a maturation process and mass contractions were more often found in the newborn group. Multicentric studies are recommended to evaluate whether newborn operation implies a possible advantage in terms of motility. — P. Schmittenbecher
Ranitidine-enhanced 99mtechnetium pertechnetate imaging in children improves the sensitivity of identifying heterotopic gastric mucosa in Meckel’s diverticulum Rerksuppaphol S, Hutson JM, Oliver MR. Pediatr Surg Int 2004 (May);20: 323-325. Meckel’s diverticulum is a gastrointestinal anomaly with an estimated prevalence of 1% to 4%. 99mTechnetium pertechnetate imaging is the most useful method of detection. The isotope is taken up and secreted by heterotopic gastric mucosa. The sensitivity of the test is reported with a range from 50% to 92%. The authors report their 5-year experience to show the usefulness of ranitidine for improving scan sensitivity. Thirty-seven children with histopathologically confirmed Meckel’s diverticulum were included in the study. They presented mainly with signs of bowel obstruction (n = 12), rectal bleeding (n = 9), inflammation-related symptoms (n = 8), and umbilical anomalies (n = 6). In 21 children (57%), heterotopic gastric mucosa was found, more commonly in patients with bleeding (89%) than in others (46%). The nine children with per rectal bleeding underwent 99mtechnetium pertechnetate imaging with successful demonstration of a diverticulum in 5 and a false negative scan in 4. After giving ranitidine 1 mg/kg IV 3 times every 8 hours or 150 mg orally twice every 12 hours, 2 further scans were positive. Therefore, the sensitivity increased from 62.5% (5/8 patients) to 87.5% (7/8 patients). Heterotopic gastric mucosa in a Meckel’s diverticulum is the precondition for a positive technetium pertechnetate scan. It is found in 50% to 62% of all symptomatic patients and in 95% to 100% of children with bleeding. The cumulative sensitivity of the scan from multicenter studies is 85% but varies between 50% and 92%. H2-receptor antagonists prior to Meckel’s scan seem to enhance the sensitivity because the release of pertechnetate from the mucous and/or parietal cells is delayed. This was confirmed by the authors in a small patient cohort. They suggest a large multicenter trial to definitively assess the effect of H2-antagonist pretreatment. If that is a fact, the pharmacological enhancement should be the standard procedure. — P. Schmittenbecher
Surgery for necrotising enterocolitis: primary anastomosis or enterostomy? Hofman FN, Bax NMA, Zee van der DC, et al. Pediatr Surg Int 2004 (July);20:481-483. Necrotising enterocolitis (NEC) is the most common life-threatening gastrointestinal emergency in newborns. Treatment involves resecting
International Abstracts
infections and the risk of malignant transformation and can be safely performed between 3 and 9 months of life. The risk of infection is clearly more likely to occur with increasing age. Lobectomy remains the procedure of choice, possibly with minimal-access thoracoscopic surgery. Limited excision may lead to recurrence. Thoracotomy is well tolerated in infancy and early childhood. In this series, there were no significant complications. The authors found a direct correlation between the presence of respiratory compromise at age of surgery and the need for overnight or prolonged ventilation. The authors conclude that surgery can be safely performed after 3 months of age. An additional conclusion might be that if surgery is postponed longer in asymptomatic cases, infections could lead to more perioperative complications.—P. Schmittenbecher
Lung contusion-lacerations after blunt thoracic trauma in children Haxhija EQ, No¨res H, Schober P, et al. Pediatr Surg Int 2004 (June);20: 412-414. Serious chest injuries in children are infrequent, but they are an indicator of a high-energy trauma. Due to the elasticity of the chest, rib fractures are seldom seen. Pulmonary contusion-laceration is the most common reported injury. In adults, 4 years after pulmonary contusion, 70% showed a reduced functional residual capacity. In children, complete recovery is assumed. Between 1986 and 2000, 41 children with an age range from 1 to 17 years suffered from a traumatic lung injury. Twenty-seven patients were injured in connection with a motor vehicle accident (MVA); in 14 children, falls, sport injuries, and isolated compression trauma were reported. All but 2 children had associated extrathoracic injuries. Hemothorax was found in 37%, pneumothorax in 39%, and both in 25%, with bilateral contusion significantly more frequently seen in the MVA group. Traumatic pneumatocele occurred in three patients but resolved spontaneously by 3 to 4 months. In 8 cases, rib fractures were mentioned, but serial fractures occurred in 2 cases only. Rib fractures correlated with the occurrence of hemothorax. Chest tubes were used in 16 patients (14 with MVA). Two thoracic surgical interventions were performed for aortic dissection and for recurrent bilateral tension pneumothorax. Five children needed laparotomy, 15 stabilization of fractures (14 with MVA). Five died, all following MVA due to severe head trauma, cardiorespiratory insufficiency, and pneumonia. Follow-up investigations have been performed in 34 of 36 survivors 4.5 F 1 years after the injury. Lung function studies were normal in all but one asthmatic child. Hemothorax and chest tube were correlated with a lower maximal vital capacity. Most follow-up sequelae were related to associated injuries such as leg length discrepancies and hemiparesis. In children, detailed data about the late outcome after traumatic lung injury are lacking. It is shown that nearly all children had normal lung function but a lower maximal vital capacity following hemothorax. Other injuries than lung injuries are mainly responsible for mortality, but pulmonary contusion has been associated with 34% mortality in children with multiple injuries. Chest trauma remains a potent indicator of a high-energy trauma with higher risk of death in MVA. Children who recover do not suffer from significant late respiratory problems. — Peter Schmittenbecher
Alimentary Tract Manometric evaluation of the intrathoracic stomach after gastric transposition in children Gupta DK, Charles AR, Srinivas M. Pediatr Surg Int 2004 (June);20: 415 - 418. Gastric transposition has found wide acceptance as an esophageal substitute. The life expectancy is long and the function of the transposed stomach is of great importance. Residual gastric motility is not well studied. This study was designed to evaluate the intrathoracic stomach in patients with esophageal atresia by manometry. Eighteen babies underwent esophageal replacement by gastric transposition between 1993 and 2001. Group 1 had surgery during the newborn
period; group 2 were operated 4 to 15 months after birth. The manometric evaluation was done at mean age of 30.5 month with measurement of the pressure profile of the upper, mid, and lower portion of the transposed stomach. Sequential contractions at the three pressure sensors were judged as propulsive peristalsis, simultaneous contractions as mass contractions. No patient showed any propagated propulsive activity. Mass contractions were seen in two thirds of the children with a 78% appearance following neonatal transposition and a 56% in older patients. Peak pressures were higher following neonatal operation. Mass contractions appeared after swallowing. The transhiatal vs retrosternal transposition method made no difference. Gastric transposition will change gastric innervation, for example, by vagotomy. But some evidence exists that motor activity may recover and migrating motor complexes may be generated. None of the investigated children showed propulsive activity but a large number had mass contractions in response to swallowing. This swallow-related activity indicates functional integrity of the plexuses. Possibly, mass contractions will evolve into progressive peristalsis during long-term follow-up because electrical control activity in the normal stomach undergoes a maturation process and mass contractions were more often found in the newborn group. Multicentric studies are recommended to evaluate whether newborn operation implies a possible advantage in terms of motility. — P. Schmittenbecher
Ranitidine-enhanced 99mtechnetium pertechnetate imaging in children improves the sensitivity of identifying heterotopic gastric mucosa in Meckel’s diverticulum Rerksuppaphol S, Hutson JM, Oliver MR. Pediatr Surg Int 2004 (May);20: 323-325. Meckel’s diverticulum is a gastrointestinal anomaly with an estimated prevalence of 1% to 4%. 99mTechnetium pertechnetate imaging is the most useful method of detection. The isotope is taken up and secreted by heterotopic gastric mucosa. The sensitivity of the test is reported with a range from 50% to 92%. The authors report their 5-year experience to show the usefulness of ranitidine for improving scan sensitivity. Thirty-seven children with histopathologically confirmed Meckel’s diverticulum were included in the study. They presented mainly with signs of bowel obstruction (n = 12), rectal bleeding (n = 9), inflammation-related symptoms (n = 8), and umbilical anomalies (n = 6). In 21 children (57%), heterotopic gastric mucosa was found, more commonly in patients with bleeding (89%) than in others (46%). The nine children with per rectal bleeding underwent 99mtechnetium pertechnetate imaging with successful demonstration of a diverticulum in 5 and a false negative scan in 4. After giving ranitidine 1 mg/kg IV 3 times every 8 hours or 150 mg orally twice every 12 hours, 2 further scans were positive. Therefore, the sensitivity increased from 62.5% (5/8 patients) to 87.5% (7/8 patients). Heterotopic gastric mucosa in a Meckel’s diverticulum is the precondition for a positive technetium pertechnetate scan. It is found in 50% to 62% of all symptomatic patients and in 95% to 100% of children with bleeding. The cumulative sensitivity of the scan from multicenter studies is 85% but varies between 50% and 92%. H2-receptor antagonists prior to Meckel’s scan seem to enhance the sensitivity because the release of pertechnetate from the mucous and/or parietal cells is delayed. This was confirmed by the authors in a small patient cohort. They suggest a large multicenter trial to definitively assess the effect of H2-antagonist pretreatment. If that is a fact, the pharmacological enhancement should be the standard procedure. — P. Schmittenbecher
Surgery for necrotising enterocolitis: primary anastomosis or enterostomy? Hofman FN, Bax NMA, Zee van der DC, et al. Pediatr Surg Int 2004 (July);20:481-483. Necrotising enterocolitis (NEC) is the most common life-threatening gastrointestinal emergency in newborns. Treatment involves resecting