Gastrointestinal duplications

BACKGROUND/PURPOSE

The aim of this study was to review the presentations of gastrointestinal duplication (GID) and to assess the influence of prenatal diagnosis on treatment.

METHODS

Retrospective review of all GID at 2 pediatric hospitals from 1980-2002 was conducted.

RESULTS

Seventy-three patients (M43:F30) were identified: 21 neonates, 28 infants (1 to 24 months), 15 children (1 to 10 years), 9 adolescents (>/=11 years). GID location by frequency was ileum (31.5%), ileocaecal valve (30.2%), duodenum (9.6%), stomach (8.2%), jejunum (8.2%), colon (6.8%), and rectum (5.5%). In neonates and infants, vomiting and distension were the most common presentations. Volvulus, caused by a duplication, occurred in 23.8% of neonates and caused the death of one neonate. Intussusception was identified in 10.9% of patients. In older children and adolescents, pain and vomiting were the most common associations. Six of these patients were being treated for Crohn's disease, with the diagnosis of duplication made at laparotomy. Eighteen patients had a prenatal diagnosis by ultrasound scan, with 77.2% of these asymptomatic after birth. Most prenatal diagnoses occurred after 1991 (77.8%). When comparing an earlier period (1980 to 1991; 29 patients) with the current (1992 to 2002; 44 patients), a greater proportion of the latter patients were asymptomatic (36.4 v 13.8%) and had a lower incidence of complications (volvulus/intussusception).

CONCLUSIONS

GID can lead to life-threatening complications. Prenatal diagnosis should lead to expeditious postnatal investigation and treatment before the onset of symptoms or complications. GID in older children can mimic Crohn's disease. Laparoscopy/laparotomy should be considered in patients with atypical Crohn's disease or when the diagnosis of an intraabdominal mass is unclear.

Surgical resection and chemotherapy improve survival rate for patients with hepatoblastoma

BACKGROUND

The authors reviewed retrospectively their experience in 30 children with hepatoblastoma (HB). Despite an increased trend in the incidence of HB during the last 2 decades, an encouraging cure rate has been achieved with complete resection of the tumor and chemotherapy before or after surgery with cisplatin plus doxorubicin (Adriamycin) or cisplatin plus vincristine plus 5-Fluorouracil.

RESULTS

There were 10 female and 20 male patients. For the period from 1963 to 1980 there were 8 patients, and for the period from 1981 to 1998 there were 22 patients. Their mean age at surgery was 16 months (range, 3.5 months to 5.5 years). Tumors were localized to the right lobe in 10 (42%), to the left lobe in 7 (29%), and in both lobes in 7 (29%) of the resected patients. Tumors were greater than 10 cm in size in 16 (67%) of these patients. Twenty-four patients (80%), underwent liver resection before or after chemotherapy. One patient (3%) with an unresectable tumor received chemotherapy and a liver transplant. In 5 patients (17%) the hepatic involvement was too extensive for resection. The types of resection performed were right lobectomy in 7, left lobectomy in 6, right trisegmentectomy in 8, left trisegmentectomy in 2, and middle hepatectomy in 1. The overall survival rate for 35 years of the study was 60% (18 of 30). With the association of surgery and chemotherapy (1981 through 1998) survival rate is 82% (14 of 17). Overall median follow-up in our study is 8 years (range, 2.5 to 24 years).

CONCLUSIONS

There has been a dramatic improvement in the results of treatment of hepatoblastoma. Formerly, only 25% to 30% of patients were cured, whereas today, with combination of chemotherapy and surgery, 75% to 80% may be cured.

Repair of the huge umbilical hernia in black children

Surgical repair of large umbilical hernias may present a challenging surgical problem. The currently described surgical techniques often yield disappointing results. The authors describe a new technique that allows for the repair of the fascial defect and the creation, with the use of a square cutaneous flap, of a neoumbilicus with sufficient depth and a good cosmetic appearance.

Past and future of biliary atresia

BACKGROUND

With the advent of liver transplantation the outcome of children with biliary atresia (BA) has improved. Is Kasai hepatic portoenterostomy (KHPE) still a valuable option for the treatment of these patients?

METHODS

From 1974 to 1998, 77 patients with biliary atresia have been treated at our institution: 50 girls and 27 boys.

RESULTS

Seventy-four patients had a KHPE, and 3 patients had no KHPE because of delay in diagnosis. A total of 65 of 74 patients (88%) had undergone KHPE type I, 4 patients (5.4%) KHPE type II, 3 patients (4%) had a Suruga modification, and 2 patients (2.6%) had a portocholecystostomy. Among the 74 patients, 11 were lost to follow-up and their cases were considered failures. Seventeen of our patients are alive at long-term follow-up after KHPE. Among the 77 patients, 33 (43%) had an orthotopic liver transplantation (OLT). Successful KHPE patients underwent transplant at a mean age of 9 years, and KHPE failed at a mean age of 11 months. A total of 25 of 77 (32%) of patients are alive thanks to OLT. In the cohort, the overall survival rate for the KHPE plus OLT is 42 of 77 (55%). Mortality and morbidity rates were more frequent among the younger patients who had early OLT after KHPE failure. In our series, overall survival rate was improved when the patient had a successful KHPE (P < .001).

CONCLUSIONS

Kasai hepatic portoenterostomy (KHPE) continues to be a valuable procedure in the treatment of infants with biliary atresia (BA). Successful KHPE permits transplantation at an age at which mortality and morbidity are decreased leading to a better outcome.

Injection sclerotherapy in the treatment of rectal prolapse in infants and children

PURPOSE

The aim of this study was to examine the efficacy of injection sclerotherapy as treatment for persistent rectal prolapse.

METHODS

The records of 28 patients with rectal prolapse treated with injection sclerotherapy over a 16-year period were reviewed. Initial management included assessment and correction of predisposing factors. If rectal prolapse persisted or if the prolapse required repeat emergency or operating room reduction, injection sclerotherapy was performed. The sclerosing agent included D50W in 21 patients (sole agent in 15, combined with ethanolamine oleate in four, and with phenol 5% in two). Phenol 5% alone was used in six patients, and 25% saline was used in one patient. Number of injections, recurrences, and complications were reviewed.

RESULTS

Two patients were lost to follow-up, and one patient was cured once a polyp was recognized and removed. Of the remaining 25 patients, 21 were cured. Sixteen required one injection, three required two injections, and two required three injections (64% cure rate after one injection, 84% cure rate after three injections). There were 4 of 25 failures: two went on to low anterior resection after having failed two injections each; one patient was treated with Thiersch cerclage and injection after two failed injections; and one patient did not respond after three injections but had less severe prolapses. Of those injected with D50W alone, 13 of 14 were cured with injection sclerotherapy. Nine received one injection, two received two injections, and two received three injections (64% cure rate after one injection, 93% cure rate after three injections). The only complication was excessive oozing at the injection site in one patient. He was simply observed in hospital overnight. Follow-up averaged 33 months. The only significant underlying abnormality in our patient population was spina bifida in one patient. This patient was cured with injection therapy. Cystic fibrosis was ruled out by clinical examination and sweat chloride test in all patients. Constipation was the most common condition identified with the onset of rectal prolapse (15 of 28).

CONCLUSIONS

Injection sclerotherapy is simple and should be considered as the first line treatment of recurrent rectal prolapse after failure of conservative measures. D50W is effective, easily available, inexpensive, and associated with few complications.

Anticoagulation without catheter removal in children with catheter-related central vein thrombosis

Catheter-related central venous thrombosis is a serious and common problem among children. The traditional management has been anticoagulation and early catheter removal. Unfortunately, many patients require a new catheter, which is associated with complications that include possible further thrombosis. Although others have used thrombolytic agents in attempts to avoid catheter removal, the authors of the present study believe that the associated complications occur too frequently and are too serious. They have had success with standard anticoagulation in a limited number of patients. Between February 1991 and April 1994, 17 patients (6 weeks to 19 years of age) were treated for catheter-related deep venous thrombosis. Eight patients underwent early catheter removal accompanied by anticoagulation; two of them had intrinsic catheter problems that necessitated removal, and one had hemophilia. Nine others received anticoagulation without catheter removal. Of these, one required catheter removal after 10 days heparin administration failed to diminish the thrombosis. Another patient responded well to anticoagulation but required catheter removal several weeks later because of catheter-site infection. The other seven patients responded well to anticoagulation, and their catheters were retained. For patients with a functional catheter essential to their care, anticoagulation may safely prevent catheter removal.

Laparoscopic excision of a cystic lymphangioma

A 16-year-old female was evaluated for recurrent episodes of acute abdominal pain and distension. Initial abdominal radiographs were consistent with recurrent gastric volvulus. Following nasogastric tube decompression, reexamination revealed a mobile abdominal mass in the left upper quadrant. Contrast studies followed by computed tomography demonstrated a cyst measuring 9 X 7 X 6 cm with no obvious relationship to abdominal viscera. Laparoscopy was performed with a 10-mm port at the umbilicus and right upper quadrant,and a 5-mm port in the left lower quadrant. The cyst was excised from the mesentery of the proximal jejunum and placed in a laparoscopic sac. Controlled incision and drainage of the cyst within the sac facilitated its removal from the abdomen with neither enlargement of the trocar site nor intraabdominal spillage. To prevent recurrent gastric volvulus, a gastropexy was performed from the greater and lesser curvatures to the anterior abdominal wall. The histology was typical of a cystic lymphangioma. The patient was discharged on the third postoperative day without complication. Laparoscopic technique allowed the performance of both procedures without large incisions, This is the first reported laparoscopic excision of a cystic lymphangioma.

Vascular complications after pediatric liver transplantation

From February 1986 to July 1994, 81 hepatic transplantations were performed in 73 children, with an overall patient survival rate of 83%. Forty-two patients received whole-liver grafts (WLG) and 39 had reduced-size grafts (RSG). The mean patient weight was 19.7 kg, with 29 patients weighing less than 10 kg. Seventeen vascular complications (21%) occurred in 13 children: 8 (10%) had hepatic artery thrombosis (HAT), 5 (6%) had portal vein thrombosis (PVT), 1 had both HAT and PVT (1%), and 3 (4%) had aortic conduit perforation (ACP). There was no significant difference in the incidence of HAT between RSG (5%) and WLG (14%) or between children weighing less than 10 kg (10%) and those weighing more than 10 kg (10%). The site of arterial reconstruction, end-to-end to the recipient common hepatic artery or end-to-side to the infrarenal aorta, had no significant effect on the occurrence of HAT (7% v 8%), but HAT occurred in 2 of 6 cases (33%) in which an aortic conduit was used. PVT documented in 5 cases (6%) was associated with technical complications (2), preduodenal portal vein (2), and a circulating cardiolipid antibody (1), and required thrombectomy, with no graft loss. Combined HAT and PVT was found in one patient 2 years postretransplantation for HAT. Although graft function is normal, portal hypertension persists. The aortic conduit, used in six patients, led to arterial perforation (3), HAT (2), and death (2). Of the 8 cases of HAT, 1 was diagnosed during autopsy and 7 occurred within 30 days and required retransplantation (6) or thrombectomy with rearterialization (1).(ABSTRACT TRUNCATED AT 250 WORDS)

Imperforate anus, malrotation and Hirschsprung's disease: a rare association

The association of imperforate anus with anomalies of rectal innervation is very rare. Moreover, malrotation only rarely accompanies these malformations. We report 2 patients with this unusual triple association and its impact on their management. Retrospectively both patients presented at birth with the same radiological picture of distended distal colon and right-sided small bowel location. We discuss the importance of a systematic search for associated intestinal malformations in cases of imperforate anus in order to avoid serious complications and to choose the optimal operative strategy.

Results and complications of Toupet partial posterior wrap: 10 years' experience

A 270 degrees posterior wrap, described by Toupet, was performed in 112 patients with medically refractory gastroesophageal reflux (GER) over a 10-year period. The mean age was 39 months (range, 2 months to 19 years). Thirty percent of the patients were neurologically impaired (NI). The approximation of the crura, the posterior fixation of the wrap, and the posterior partial fundoplication were performed with nonabsorbable sutures, over a bougie. Thirty percent of the NI and 15% of the neurologically normal (NN) children underwent a gastrostomy. Early postoperative complications were found in 24% of NI and 18% of NN children; these were treated medically, except for two bowel obstructions. Eight patients died for reasons unrelated to surgery, and nine were lost to follow-up. The mean follow-up period for the 95 remaining patients was 3.5 years for NI and 4.9 years for NN children. The evaluation showed that 6 patients had temporary dysphagia and two had food impaction. Nine wrap herniations (10%) were found; three of them without symptoms were noted by routine upper gastrointestinal series and received no treatment. Six wrap herniations with recurrent reflux were reoperated on successfully. With 90% of patients free of symptoms, the results of the Toupet procedure compare favorably with those of the Nissen fundoplication because of the retained ability to belch or vomit.

Surgical and metabolic aspects of liver transplantation for tyrosinemia

Tyrosinemia is the diagnosis of a very small percentage of patients undergoing liver transplantation worldwide. Tyrosinemia is endemic within our referral area however, and fully one-third of the liver transplantations at our institution are done for this disease. Since 1986, 15 patients with tyrosinemia (TYR) and 31 patients with various other indications (non-TYR) have undergone a total of 51 liver transplantations. The 36-month actuarial survival for TYR patients is 87%, compared with 74% for non-TYR patients. Liver transplantation for hereditary tyrosinemia and other metabolic disorders without portal hypertension or previous portohepatic operations is notably easier to perform. Intraoperative blood loss was less, length of hospital stay was shorter, and incidence of infections was lower in TYR than in non-TYR patients. Less than 10% of TYR patients had foci of hepatocellular carcinoma at the time of transplantation. For this reason, and while most patients with tyrosinemia will eventually require liver transplantation, our results do not support systematic early transplantation before the age of two years.

Biliary tract complications in pediatric orthotopic liver transplantation

Biliary tract complications are reported in 15% to 30% of orthotopic liver transplantations (OLTs). Since 1986, 53 OLTs were done in 48 children with a mean age and weight of 5.3 years and 18.9 kg, respectively. Twenty-seven transplantations (51%) were reduced liver grafts (RLG) and 26 (49%) were whole liver grafts (WLG). Since 1988, 70% of transplantations have been RLG. Choledochocholedochostomy (mean weight, 25 kg) with a T-tube (CC) or choledochojejunostomy (CJ) (mean weight, 14.5 kg) were done in 24 (45%) and 29 (55%) cases, respectively. The overall mortality was 19% but none of the deaths were related to biliary problems. There were 13 biliary tract complications (24.5%) in 11 patients including 7 leaks, 5 obstructions, and 1 intrahepatic biloma. Leaks leading to bile peritonitis were managed with simple suture and drainage and were related to the T-tube (4), to the Roux-en-Y loop (2), and to the transection margin of a RLG (1). Obstruction was documented in 5 cases with none associated with hepatic artery thrombosis (HAT). Stenosis after CC reconstruction (2) required conversion to CJ. Two patients had revision of CJ because of kinking of the common bile duct after a left lateral segment graft and an anastomotic stricture 46 months after OLT. The last patient developed a vanishing bile duct syndrome 4 months posttransplant and is awaiting retransplantation. One patient had multiple episodes of cholangitis after HAT and was retransplanted. Neither the type of grafts (RLG 25.9% v WLG 23.1%) nor the type of biliary reconstruction (CC 25% v CJ 24%) influenced the rate of biliary complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Diaphragm of the gallbladder: a case report

Gallbladder anomalies are rare and normally affect its shape, size, and position. We report on a 3-year-old boy with a gallbladder divided transversally by a windsock-type diaphragm, isolating the fundus from the rest of the biliary tree. Bilobed and multiseptated gallbladder have been described before, but this is the first isolated case of a congenital hourglass gallbladder.

Neonatal gastrointestinal perforations

Neonatal gastrointestinal perforation has been associated with mortality rates of 40% to 70%. Over the past 20 years, 81 infants (46 boys and 35 girls) were treated for a gastrointestinal perforation at this institution. Perforation occurred from birth to 50 days (average, 8.2 days). Etiologies included necrotizing enterocolitis (NEC) (68%), meconium ileus (10%), and idiopathic gastric perforation (7%). Seventy-six infants underwent surgical exploration and five infants, considered too small or too sick to withstand a laparotomy, were treated with peritoneal lavage only. There were 29 deaths, an overall mortality of 36%. Ninety percent of the death occurred in patients with NEC, while all patients with gastric perforations survived. There has not been a significant improvement in survival in recent years, partly because of an increase in the proportion of NEC-related perforations. However, there is a narrowing of the mortality gap between low birth weight and normal weight infants. As the risk inherent to laparotomy in neonates is decreasing, other factors, such as the underlying etiology or the site of perforation, play a more important prognostic role.

Pneumatosis and pneumoperitoneum in chronic idiopathic intestinal pseudoobstruction

Chronic idiopathic intestinal pseudoobstruction is a diagnosis of exclusion for the rare patient with severe small bowel atony without any demonstrable organic cause. The very poor prognosis associated with this disease has been somewhat improved with the advent of parenteral nutrition; nevertheless, these patients follow a stormy course characterized by malnutrition, recurrent obstruction, infection, hemorrhage, and perforation. We describe a 16-year-old boy with this disease who presented to us with vague abdominal pain and pneumoperitoneum. Laparotomy showed pneumatosis cystoides intestinalis without intestinal perforation. The presence of free air in the abdominal cavity is an almost pathognomonic sign of intestinal perforation. Pneumatosis cystoides intestinalis is one of the very few nonsurgical causes of pneumoperitoneum. Beyond the neonatal period, in which it is the hallmark of necrotizing enterocolitis, it has been described in patients with severe obstructive lung disease, in collagenous disorders, and in the short-bowel syndrome. In the present case, it may have resulted from chronic intestinal distension, allowing air under pressure to dissect through the bowel wall. The challenge of such a unique association of conditions lies in the avoidance of unnecessary surgery in a chronic, essentially nonsurgical disease while avoiding unnecessary delay in a possibly acute surgical event.

Meckel's diverticulum in children: a 20-year review

Meckel's diverticulum occurs in 2% of the population and may present at any age. Its management, when found incidentally at laparotomy, remains controversial, particularly in the pediatric population. From 1970 to 1989, a Meckel's diverticulum was discovered in 164 children at laparotomy. There were 120 boys and 44 girls with a mean age of 5.2 years (range, 0 to 18 years). Forty-seven cases were asymptomatic, representing an incidental finding at laparotomy, 25 were resected, and ectopic gastric mucosa was present in 7 specimens (28%). Three postoperative deaths (6%) that were not related to the resection and 2 complications (4%) (postoperative leak and wound infection) occurred in this group. Of the 117 symptomatic patients, 49 (42%) presented with bowel obstruction, 45 (38%) had rectal bleeding, 16 (14%) had diverticulitis, and 7 (6%) had umbilical pathology. Volvulus (20) and intussusception (19) were the most common causes of obstruction. Predisposing factors for bowel obstruction were fibrous bands to umbilicus or mesentery (37%) and ectopic mucosa (35%). Severe painless rectal bleeding occurred in 45 patients, 30 of whom (67%) required blood transfusion. A nuclear medicine Meckel scan was positive in 32 of 37 patients (85%). Contrast studies were not diagnostic; colonoscopy and gastroscopy ruled out other causes of bleeding. Patients with diverticulitis (16) presented with acute abdominal pain compatible with appendicitis. In the symptomatic group, ectopic mucosa was present in 61% of the resected specimens. Gastric (88%), pancreatic (7%), and gastric with pancreatic (3%) were the most common ectopic tissue. Postoperative morbidity and mortality for symptomatic patients was 8.5% and 0%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Benign liver tumors in children: a 25-year experience

The most common benign liver tumors are hemangiomas and hamartomas, both of mesenchymal origin. Mortality for patients with these tumors has traditionally been substantial despite benign histology. Between 1965 and 1989, 22 patients were treated for a benign liver tumor. This represents 42% of all primary neoplasms of the liver observed during this period. Incidental findings of liver tumors at autopsy were excluded from this series. There were 9 boys and 13 girls with a mean age at presentation of 2.3 years (range, birth to 14 years). Sixteen had hemangiomas and presented earlier in life (mean age, 4.4 months). In this subgroup, high-output cardiac failure was present in 58% of the newborns. Seven hemangiomas were resected, four were observed, three were treated with digitalis, diuretics, and steroids, and one received epsilon-aminocaproic acid. Nonhemangiomatous tumors included four hamartomas, one focal nodular hyperplasia, and one nodular transformation. All six were resected. There was one death early in the series. At a mean follow-up of 38 months, 21 of the 22 patients are cured or asymptomatic. In the past, mortality rates of close to 90% have prompted many investigators to advocate resection of every symptomatic hemangioma. With the availability of more sophisticated imaging techniques and refinements in the treatment of cardiac failure, surgery can be used more selectively. Hepatic resections, once considered heroic, can now be performed with minimal morbidity and virtually no mortality. The 96% survival in this series of benign liver tumors contrasts with high mortality rates reported in the literature and illustrates the spectacular improvements that have been made in the diagnosis and management of these once ill-reputed tumors.

Gracilis muscle transposition for anal incontinence in children: long-term follow-up

We report a series of 7 patients, aged 6.5 to 19 years (mean, 12.9), who have been treated for uncontrollable fecal incontinence since 1976: 5 had imperforate anus and multiple subsequent operative procedures, 1 had a low myelomeningocele with bi-sphincteric incontinence, and 1 had a traumatic destruction of the sphincter apparatus. A modified Pickrell procedure was performed, with the gracilis muscle transposed subcutaneously, without constructing a pulley through the median raphe as originally described. All patients were evaluated by anorectal manometry preoperatively and post-operatively. They were followed-up for a period of 0.5 to 12.5 years (mean, 4.4). All patients were continent at follow-up, with a normal defecation pattern and no enemas required. None of the patients had evidence of fibrosis of the muscle or anal canal, and tension in the transposed muscle was maintained. Voluntary contractions remain efficient in all cases. Age was thought to be an important factor: personal motivation and compliance with physiotherapy, essential for a good outcome, is unlikely to be present in the younger child. We conclude that the gracilis sling procedure is an excellent long-term alternative for total fecal incontinence when time and other therapeutic measures have failed.

Infectious complications of pediatric liver transplantation

Twenty-five pediatric orthotopic liver transplantations (OLTs) performed in 22 patients at Sainte-Justine Hospital were reviewed for infections complications. One patient died within 12 hours posttransplantation and is excluded. The patients had an average age of 6.1 years (range, 1.25 to 19 years) and an average weight of 20.4 kg (range, 11 to 55 kg). Two patients (9%) were cytomegalovirus (CMV) seropositive and 9 of 19 patients (48%) were Epstein-Barr virus (EBV) seropositive preoperatively. Five of the donors (20%) were CMV seropositive. The most common indications for OLT were biliary atresia (8) and tyrosinemia (7). There were 4 deaths, for an overall mortality rate of 19%. In 3 patients, deaths were related to infection (CMV hepatitis and duodenitis with aortoduodenal fistula, adult respiratory distress syndrome [ARDS] with Streptococcus viridans pneumonia, Escherichia coli cholangitis with progressive hepatic failure). Fifteen patients (72%) had 41 major infections, most of them bacterial, during the first month posttransplantation. These include pneumonia (25%), line sepsis (17%), cholangitis (14%), and tracheitis (14%). There was only one major viral infection, a CMV hepatitis that occurred in the first month posttransplantation. Three patients had fungal infections (8%) associated with hepatic artery thrombosis and recurrent cholangitis. All three patients required retransplantation. There was only one protozoal infection (Pneumocystis carinii pneumonia) causing life-threatening respiratory failure, from which patient recovered without sequelae. Infection still remains a serious complication of OLT. Bacterial infection is common and is usually associated with technical complications. The low rate of CMV infection is related to low incidence of CMV in the donor pool and the minimal use of strong immunosuppressants.

Diagnosis and treatment of gastroesophageal reflux in 500 children with respiratory symptoms: the value of pH monitoring

Gastroesophageal reflux (GER) usually presents with digestive symptoms, failure to thrive, and/or respiratory symptoms. During the 8-year period from 1981 to 1989, 1,153 children underwent 20-hour pH monitoring to assess GER. All patients were graded using the scoring system of Euler and Byrne. Patients were classified as severe (score greater than 50), moderate (score 25 to 50), and normal (score less than 25). Five hundred (43.3%) of these patients presented with respiratory symptoms including apnea, cyanosis, or "near miss" sudden infant death syndrome (36%), poorly controlled asthma (28%), recurrent bronchopneumonia (13%), bronchiolitis (9%), and miscellaneous symptoms such as intermittent dyspnea, chronic cough, and stridor (12%). Eight patients (2%) had cystic fibrosis. The ages ranged from 1 month to 20 years (mean, 19.5 months). Twelve patients had technically inadequate studies and were excluded. Severe reflux was present in 156 patients (31%) and moderate reflux in 159 patients (31%). All patients were treated initially by medical therapy for a minimum of 8 weeks. The majority of patients (81%) had resolution of their symptoms with change in position, thickened feedings, and, when indicated, additional therapy with metoclopramide, cisapride, or domperidone. Most of these patients were found to have a specific position, usually prone, which decreased reflux. The remaining 57 patients had documentation of persistent reflux by pH monitoring and underwent an antireflux procedure. Of those patients undergoing surgery 51 had severe reflux and 6 had moderate reflux. Forty-four patients had a posterior 270 degrees wrap (Toupet), 10 had a 360 degrees wrap (Nissen), and 3 had an anterior 180 degrees wrap (Boix-Ochoa).(ABSTRACT TRUNCATED AT 250 WORDS)

Aberrant cervical thymus in children: three case reports and review of the literature

Aberrant migration of thymic tissue occurs with ectopic thymus in the mediastinum, base of the skull, tracheal bifurcation, and cervical region. A recent review of the literature showed a total of 76 reported cases of aberrant thymus or thymic cysts in patients who presented with primary neck masses. We report three additional cases of ectopic cervical thymus. All three patients presented with asymptomatic cervical masses, and preoperative diagnosis included branchial cleft cyst, cervical lymphangioma, and cervical teratoma. All patients underwent complete surgical resection of the masses. Aberrant cervical thymus rarely produces symptoms because it does not invade contiguous strictures. Despite its rarity, it should be considered in the differential diagnosis of asymptomatic neck masses in children.

Pediatric liver transplantation: the Montreal experience

The introduction of cyclosporine A in 1980 greatly improved the survival of children with end-stage liver disease undergoing orthotopic liver transplantation. The average 1-year survival rate following hepatic transplantation increased from 30% in 1963 to 70% in 1980. This report summarizes the initial experience of two pediatric hospitals in Montreal--Hôpital Ste-Justine and Montreal Children's Hospital. Since December 1985, 13 orthotopic liver transplantations have been performed in 11 patients: six females and five males. The median age was 18 months (range, 13 months to 17 years) and the median weight was 10 kg (range, 8.5 to 38 kg). The indications for transplantation were biliary atresia (5 patients), tyrosinemia (2 patients), biliary hypoplasia (1 patient), Amerindian cirrhosis (1 patient), Crigler-Najjar syndrome, type I (1 patient), and fulminant non-A, non-B hepatitis with grade IV encephalopathy (1 patient). Immunosuppression was ensured by cyclosporine A, azathioprine, and steroids. The function of 11 grafts was immediate following revascularization of the grafts. One graft had delayed function due to preservation injury, and one had primary nonfunction. Surgical complications included bile peritonitis (1), ruptured aneurysm of an aortic conduit (1), and thrombosis of the hepatic artery necessitating retransplantation (2). Three of our patients died, one from postoperative cerebral edema, one of primary nonfunction of the graft, and one of ruptured aneurysm of an aortic conduit. Our overall survival rate was 72% with a follow-up of 3 to 32 months. Pediatric liver transplantation can now provide successful treatment and cure of liver diseases considered, until recently, dismal and hopeless.

Esophageal leiomyoma in children: two case reports and review of the literature

Leiomyoma of the esophagus is not uncommon in the adult population but is rarely seen in children; only 20 cases have been reported in the pediatric population. In this paper we describe two cases of esophageal leiomyoma in female patients aged 6 and 13 years and review previous reports. Several differences were noted between the pediatric and adult population. The mean age in children is 14 years (range, 4 to 20 years). Leiomyoma appears 1.71 times more often in females than in males. Localized lesions are found in only 9%, whereas the diffuse form predominates in 91%. The entire esophagus may be involved 35% of the time, and encroachment on the cardia or upper stomach occurs in 70%. Leiomyomas associated with familial syndromes (familial leiomyoma and Alport's syndrome) occur in 22% of the cases. Major symptoms include dysphagia (86%), dyspnea (36%), vomiting (27%), retrosternal pain (27%), and coughing (22%). The initial diagnosis following contrast studies is most often achalasia. The diagnosis of leiomyoma is made only with subsequent endoscopy. Enucleation was performed in only 11% of the cases; surgical resection (including part of the stomach) was necessary in 78% with a 21% postoperative mortality. Esophageal leiomyoma should be considered in the differential diagnosis of mediastinal masses and esophageal obstruction. Accurate preoperative diagnosis is desirable in order to plan proper surgical treatment.

Isolated complete transection of the common bile duct due to blunt trauma in a child, and review of the literature

A case of isolated complete transection of the common bile duct due to blunt abdominal trauma in a 3-year-old child is presented. The rarity of this injury and its initial presentation as a pancreatic pseudocyst warrant its description. This patient, the fifteenth child to be reported in the literature, was diagnosed as having a biliary injury following ultrasound-guided percutaneous drainage. Choledochal transection was documented at laparotomy and was successfully treated by proximal cholecystostomy and choledochojejunostomy with Roux-en-Y reconstruction. Delayed diagnosis is common, but this injury should always be kept in mind. Early diagnosis is feasible with the use of the HIDA scan. A review of the literature, modes of diagnosis, and techniques for surgical repair are described.

Partial splenectomy for benign cystic lesions of the spleen

Cystic lesions of the spleen are uncommon, about 600 cases being reported in the world literature. This report concerns three pediatric patients treated by partial splenectomy for benign cyst. In the world literature most of the cystic lesions of the spleen are treated by splenectomy and more recently by partial splenectomy. The infected lesions are treated by splenectomy or by incision and drainage only. Partial splenectomy has evident advantage over splenectomy. Although in the world literature we have not found a single case of infected splenic benign cyst treated by partial splenectomy, we believe that this procedure also has an advantage over drainage as the infected and necrotic part of the cyst is removed, thereby reducing morbidity and further possible complications.

Tracheal growth after resection and anastomosis in puppies

Tracheal morphology, morphometric changes, and growth and histologic changes were studied in puppies submitted to tracheal resection and anastomosis. Fifteen mongrel puppies about 12 weeks old and weighing on an average 5.5 kg were operated under general anesthesia using fluothane. A median cervicotomy incision was made in ten puppies (experimental group, EG) and the proximal 14 tracheal rings were resected (average length 5.08 cm or about 35% to 38% of total tracheal length). One layer anastomosis was done using vicryl 4.0 maintaining the average tension of 1,450 g. Five puppies (control group, CG) were submitted to tracheal transection and anastomosis and the following parameters were studied. Tracheal morphology the trachea of the EG was a rounded triangle whereas in the CG it was oval in shape, there was increase in the intercartilageneous spaces in the EG, no granulation tissue was present, two mucous webs were seen in the EG and one in the CG. Morphometric changes average tracheal length EG 13 cm, CG 17.7 cm, intercartilagenous space EG 3.08 mm, CG 1.3 mm, intercricothyroid space EG 1.2 cm, CG 0.53 cm, sagittal and transverse tracheal thickness at the anastomosis EG 2.6 and 3.3 mm, CG 2 and 1.5 mm, sagittal and transverse diameter reduced on an average 2 mm in EG. Histology Moderate fibrosis was found at the level of anastomosis with no modification of chondrocytes at the cartilagenous rings in the EG. Even with high anastomotic tension, the dogs had normal tracheal growth without stenosis; the sagittal and transverse growth at the anastomosis in the EG was 90% and 85%, respectively, when compared with the CG.

Surgical treatment of Crohn's disease

Of 93 children with Crohn's disease treated at the Hôpital Sainte-Justine between 1967 and 1979, 39 were operated on. Ten had abscesses and anal fistulas drained and in 29 the bowel was resected. The mean age of the children was 13 years. The average time between onset and diagnosis for both the medical and surgical groups was 13 months. Medical treatment failed in 25 patients after an average time of 22 +/- 17 months. Fourteen patients had an initial laparotomy, with a false diagnosis of appendicitis in 8, abdominal tumour in 2 and Meckel's diverticulum in 1. Indications for operation were: intestinal obstruction, bowel fistula, intra-abdominal abscess, gastrointestinal hemorrhage, growth failure and toxic megacolon. There were no deaths and only two postoperative infections. Crohn's disease seems to be becoming more frequent, more severe and starting earlier in life. Three to 6 weeks of preoperative preparation with enteral and parenteral nutrition allows operation to be performed under safer conditions. Although the recurrence rate after operation is still high, there is no doubt that the children enjoy a better quality of life, growth and a 50% chance of being disease-free 10 years later.

[Kasai's operation for extrahepatic bile duct atresia: a cure or palliative treatment?]

The only surgical treatment currently available for patients with extrahepatic biliary atresia is portoenterostomy or portocholecystostomy, the Kasai operation. Seventeen such patients were operated upon at the Hôpital Sainte-Justine; 11 had bile excretion. Eight are still alive 12 to 60 months after operation. They have good to fair bile excretion. Twelve of the 17 patients had infectious or hemorrhagic complications and hepatic deficiency is evident in 6 of the 8 living patients. The progressive deterioration of liver function in the majority of the patients still alive raises the question of whether the Kasai procedure should be considered a curative or only a palliative procedure.

[Portal hypertension of extra-hepatic origin in children (author's transl)]

From 1960 to 1981, 31 children, 18 boys and 13 girls, have been treated at Ste-Justine Hospital for extra-hepatic portal hypertension. Age at the onset of gastro-intestinal bleeding 3 1/2 months and 13 years. Splenomegaly with hypersplenism, hematemesis and melena have been the most frequent clinical manifestations. Percutaneous splenoportography be coelio-mesenteric arteriography confirmed the diagnosis of cavernomatous transformation of the portal vein. Among the 31 children, 28 bled from their varices, the 3 others did not to date. Among the 28 patients with active bleeding complication, 7 have been treated conservatively, 11 had sclerotherapy (sclerosing injections of varices). On the surgical point of view, 7 had ligation of varices with intra-thoracic transposition of the spleen in 5 of them. Portosystemic shunts were performed in 10 patients, 3 central spleno-renal and 7 cavo-mesenteric shunt. Each of these 28 patients had an average of 9,5 episodes of gastro-intestinal bleeding, 8.7 hospitalizations, and received 7.5 liter of blood. Medical treatment, sclerotherapy, ligature of varices and intra-thoracic transposition of the spleen are palliative measures. Nevertheless the procedures are time and life savers, allowing improvement and development of natural porto-systemic shunts. Follow up of unshunted patients on a period of 8 to 17 years revealed a decreasing frequency and intensity of the hemorrhagic manifestations. Operative risks and morbidity of recurrent bleeding should be the guidelines for surgery. Natural course of illness and possible neuro-psychiatric consequences of a porto-caval shunt should also be considered.

The pathogenesis of intestinal atresia

The records of 28 patients with duodenal and 31 with jejunoileal intestinal atresia or stenosis were studied. Vomiting and abdominal distention were the most prominent symptoms; an unusual colon may be present in jejunal as well as ileal obstruction and is not pathognomonic for ileal obstruction. Intestinal atresia is associated with a high incidence of preterm babies but with a low incidence of intrauterine growth retardation. Fifty-three infants were operated upon; the overall survival rate was 79 per cent. The high percentage of mortality in duodenal obstruction is due to associated malformations. Theories of the pathogenesis of intestinal atresia do not seem to fit current clinical and experimental evidence in all patients. Possibly, different factors play a role in separate situations.