Impact of mentor guidance in surgical career selection

PURPOSE

The aim of this study was to survey graduates of a university general surgical residency training program to determine factors that influenced their selection of a specialty field.

METHODS

A 39-item questionnaire was mailed to 86 graduates of a university general surgery program who matriculated from 1975 to 1989. The impact of lifestyle, technology, clinical opportunity, and mentor guidance in the residents' selection of a specialty field and eventual clinical practice was assessed. Results were analyzed using Fisher's Exact test with significance determined at P less than.05.

RESULTS

The response rate was 65% (56 of 86). Eighty percent of respondents identified the most important aspect influencing their choice of specialty was interest in that field; additional factors included perception of prestige, presence of clinical opportunity, mentor influence, and family priorities. Sixty-six percent of respondents chose the same career as their mentor, attributing this to the mentor's skill (n = 36, 68%), achievements (n = 35, 66%), and verbal recommendations about their specialty field (n = 24, 45%), p < 0.05.

CONCLUSIONS

Surgical residents use many criteria in selecting a field of specialty with mentor guidance an important component. Knowledge of these influential areas should help training programs offer appropriate career guidance. J Pediatr Surg 36:1802-1804.

Down-regulation of decorin, a transforming growth factor-beta modulator, is associated with scarless fetal wound healing

PURPOSE

Transforming growth factor beta (TGF-beta) bioactivity has been implicated as a potential regulator of the transition from scarless healing to scar formation in fetal wounds. Decorin is an extracellular matrix proteoglycan that regulates TGF-beta bioactivity and assists in collagen fibrillogenesis. To determine its role in scarless repair, the authors examined decorin expression in fetal fibroblasts, skin, and wounds.

METHODS

A single, full-thickness, 2-mm open wound was created on the dorsal surface of fetal rats at 16.5 days (E16) and 18.5 days (E18) gestational age (term, 21.5 days [E21]). Wounds were harvested at 24 and 72 hours (n = 12 wounds per time-point). Nonwounded fetal skin at E17, E19, and E21 was harvested for analysis of decorin expression during skin development and as controls for wounds. In addition, fetal (E14, E18) and adult dermal fibroblasts were cultured for in vitro analysis. Reduced-cycle, specific primer, reverse transcriptase polymerase chain reaction was performed to quantitate decorin expression.

RESULTS

Decorin expression increased rapidly with increasing gestational age in both fetal fibroblasts and skin. Expression was increased 22-fold in E18 fibroblasts (P <.002) and 300-fold in adult fibroblasts (P <.001) compared with E14 fibroblasts. In skin, expression increased 74% (P <.01) during the fetal wound healing transition period between E17 and E19. However, in E16 wounds (scarless), decorin expression decreased 59% (P <.006) at 24 hours and 45% (P <.02) at 72 hours. Decorin expression did not change in E18 (scar) wounds at 24 and 72 hours (P >.05).

CONCLUSIONS

Early gestation fetal fibroblasts and fetal skin express decorin at lower levels than late gestation fetal and adult fibroblasts and skin. Decorin expression is down-regulated in scarless (E16) compared with scar (E18) wounds. Thus, increased decorin expression is associated with both skin development and scar formation. Conversely, decreased decorin expression is associated with scarless repair.

Ileoanal pouch procedures in children

PURPOSE

The aim of this study was to review the long-term experience with colectomy and the ileoanal pouch procedure (IAPP) in children from one hospital.

METHODS

Between 1977 and 2001, 168 children under 18 years of age underwent colectomy and IAPP. One hundred thirty-one had ulcerative colitis (UC). Twenty-six had familial colonic polyposis (FP), 9 had Hirschsprung's disease (HD), and 2 had colonic inertia. Ninety-seven had a J-pouch, 62 had a lateral pouch, and 9 had a straight pull-through (SP). The mean age was 13.9 years.

RESULTS

Complications within 2 years included pouchitis (16%), ileoanal strictures (14%), and adhesions (7%). There were no deaths. Fifty-six patients (33%) required reoperation, including 20 revisions of large pouches and 8 conversions of SP to pouches because of stool frequency. Six children (3.6%) had later pouch removal (3 had Crohn's disease). Stool frequency at 6 months was 3.8 (mean). At 6 months 5% had occasional soiling. Eighty-four percent can delay defecation over 1(1/2) hours; 82% can urinate without a bowel movement. With a mean follow-up of 11.2 years, 94.6% are functioning well.

CONCLUSIONS

Colectomy with IAPP is the preferred operation for children with UC, FP, and selected HD. The J-pouch is the preferred technique because of simplicity of construction and sparsity of complications.

Delayed disaccharidase development in a rabbit model of intrauterine growth retardation

Intrauterine growth retardation (IUGR) affects almost 10% of infants born in the United States. It may be responsible for delayed gastrointestinal function and is an important cause of perinatal morbidity and mortality. The New Zealand White rabbit provides an optimal model for the study of naturally occurring IUGR. At term, birth weight is determined by fetal position within the bicornuate uterus. The small intestinal disaccharidase enzymes are indicators of bowel maturity and function. To examine potential differences in disaccharidase development between normal and IUGR fetuses, this rabbit model was investigated. Jejunum was harvested at multiple stages in rabbit development including the third trimester fetus, neonate, and adult. Lactase, maltase, and sucrase enzyme activity, as well as total protein content, was determined. Results were analyzed by the 2-tailed t test and ANOVA. Lactase activity appeared in the mid-third trimester, peaked in the early neonatal period, then declined to adult levels. Maltase activity appeared in the early third trimester and gradually rose to adult levels. Sucrase remained at trace levels until the mid-neonatal period, reaching adult levels by weaning. Both lactase and maltase activity were depressed in IUGR fetuses compared with their normal littermates. This pattern of disaccharidase depression continued into the neonatal period until catch-up growth occurred at 2 wk when levels equalized. This report describes differential small intestinal disaccharidase development between normal and growth-retarded rabbit fetuses in a naturally occurring model of IUGR.

Methodology standards associated with quality reporting in clinical studies in pediatric surgery journals

BACKGROUND/PURPOSE

Reports of clinical trials often lack adequate descriptions of design and analysis; recent attention has focused on improving this omission so readers can properly assess the strength of the findings and draw their own conclusions. Similar analysis of study design and methodologic standards associated with quality reporting has not been carried out for pediatric surgery journals.

METHODS

All studies (n = 642) published in 1998 in Journal of Pediatric Surgery (JPS) and Pediatric Surgery International (PSI), were reviewed for demographic data and study design. The frequency of reporting of 11 basic elements of design and analysis was evaluated in randomized clinical trials (RCT), nonrandomized clinical trials (NRCT), and retrospective cohorts (RC) from JPS by consensus of 2 assessors.

RESULTS

Of the 642 studies, 17% of articles (111 of 642) were classified as clinical studies. Sixty-three were comparative studies and consisted of RC (n = 48), NRCT (n = 12), and RCT (n = 3). Two-thirds of articles published were either case reports or case series (431 of 642), and 16% were basic science articles. Demographic analysis showed a wide range of topics addressed, 4 authors per article, and multiple country of origin of authors. More than 66% of all RCT in JPS reported on eligibility criteria, admission before allocation, random allocation, method of randomization, patients' blindness to treatment, treatment complications, statistical analyses, statistical methods, loss to follow-up, and statistical methods; 2 elements of design and analysis, however, were poorly reported: blind assessment of outcome (33%) and power (17%).

CONCLUSIONS

There were few randomized, controlled trials in pediatric surgery journals, and further attention should be given to evaluate the causal factors. Nine elements of quality reporting were well reported; however, 2 others were poorly reported; this may improve if editors of pediatric surgical journals provide authors with guidelines on how to report clinical trial design and analysis.

Effect of acute anemia on the healing of intestinal anastomoses in the rabbit

BACKGROUND

Considering the potential deleterious effects of transfusion, the effect of severe, acute anemia on small intestine (SI) and large intestine (LI) anastomoses was evaluated.

METHODS

Thirty-six rabbits underwent segmental resection of the midileum and distal colon. Half underwent preanastomotic removal of 30% of their blood volume with crystalloid resuscitation. At 1 or 2 weeks, the anastomotic bursting pressure (ABP) and histologic grade of white blood cell influx, blood vessel ingrowth, fibroblast proliferation, and collagen deposition were assessed.

RESULTS

SI ABP was decreased in anemic rabbits at 2 weeks (190 +/- 6 mm Hg vs. 257 +/- 17 mm Hg). LI ABP was decreased at 1 week in anemic rabbits. In the test rabbits, histologic parameters were altered in both the SI and LI with decreased white blood cell infiltration, attenuated blood vessel ingrowth, and decreased collagen content at both 1 and 2 weeks. Decreased SI fibroblast proliferation was present at 1 week.

CONCLUSION

Acute anemia in the rabbit undergoing intestinal resection decreases the SI ABP at 2 weeks and alters histologic parameters of wound healing in both the SI and LI.

Surgical management of pectus carinatum: 30 years' experience

Pectus carinatum is an uncommon malformation that is often more symptomatic than the appearance suggests, and one that physicians often do not refer for surgical correction. Hospital records of 90 patients who underwent repair of pectus carinatum deformities between 1970 and 2000 were reviewed. During the same period another 445 patients underwent repair of excavatum deformities. Minimal deformity was observed before the age of 10 years for 81 of 90 patients; only 7 of the 90 underwent repair before age 11 years. All patients were symptomatic; 84 had exertional dyspnea and exercise limitation, 52 had frequent respiratory infections, 24 had asthma, and 38 had chest discomfort. The mean pectus severity score (width of chest divided by the distance between the sternum and spine) was 1.73 (the normal chest is 2.56). The type of repair varied with the type of deformity, consisting of subperiosteal resection of the deformed cartilages, transverse osteotomy of the anterior sternum with insertion of a cartilage wedge, and support with a steel strut for 4 to 6 months in 76 of 90. There were no deaths within 1 year after the repair. Complications included hypertrophic scar (n = 13), wound seroma (n = 5), pleural effusion (n = 3), and pneumothorax (n = 2). The mean blood loss was 78 ml, and the mean hospital stay was 2.6 days. With a mean follow-up of 12.8 years, all patients experienced alleviation of respiratory symptoms and chest discomfort and diminished exercise limitation; 88 of 90 patients experienced a very good to excellent long-term result. One patient required reoperation. Pectus carinatum often causes more severe respiratory symptoms and exercise limitation than is generally recognized. Repair in 90 patients with carinatum deformities has resulted in marked clinical improvement in all patients, with low morbidity and short hospitalization.

Surgical treatment of severe colonic inertia with restorative proctocolectomy

Patients with severe constipation due to colonic inertia who remain symptomatic after extensive medical therapy or partial colonic resection have occasionally been treated with ileostomy as a last resort. The hospital records of five patients with persistent symptomatic idiopathic colonic inertia were reviewed. Each of the patients had undergone extensive medical management, and eventually four underwent one or more colonic resections to relieve the recurrent abdominal distention and pain. Three of the patients eventually received a distal ileostomy, which functioned well. Anorectal manometric studies were within normal range for each of the five patients. Restorative proctocolectomy (J pouch) was therefore performed for each. With a mean follow-up of 42 months after restorative proctocolectomy each of the five patients was relieved of constipation and small bowel distention. The average number of bowel movements per 24 hours at 6 months was 4.8. All patients were able to discriminate flatus from stool, could hold back for up to 1.5 hours after the initial urge to defecate, and had total daytime continence. Each returned to work or school within 3 months, and each reported greater satisfaction with bowel function than with the ileostomy. Restorative proctocolectomy with a J pouch provides a satisfactory option for the management of patients with persistent abdominal distention and pain due to idiopathic colonic inertia.

Surgical aspects of dialysis in newborns and infants weighing less than ten kilograms

PURPOSE

Renal failure occurs in children with moderate frequency. Surgical aspects of establishing and maintaining dialysis access in small infants are exceptionally challenging. The purpose of this review is to evaluate the authors' experience with dialysis access for infants less than 10 kg, particularly with respect to the surgical care required.

METHODS

A retrospective review was conducted between 1991 and 1999 of all pediatric dialysis patients weighing 10 kg or less (n = 29). Age at start of dialysis, duration of dialysis, modes of dialysis, and complications specific to peritoneal (PD) and hemodialysis (HD) were examined.

RESULTS

The mean age at start of dialysis was 10.4 months and continued for an average duration of 16.3 months. Seventy-two percent of all patients required both modes of dialysis. HD and PD duration averaged 7.8 and 10.5 months, respectively. Catheter durability was 3.1 and 4.5 months per catheter for HD and PD, respectively. There was no significant difference in complications when comparing HD and PD. Patients who weighed 5 to 10 kg had significantly longer PD catheter durability than patients 0 to 5 kg (P = .001). Forty-one percent of patients terminated dialysis after transplantation, whereas 24% died awaiting transplantation.

CONCLUSION

Despite a large number of operations required, infants less than 10 kg can be bridged successfully, by surgical intervention and subsequent dialysis, to transplantation.

Pyloroplasty improves long-term gastric emptying in rats undergoing fundoplication

BACKGROUND

Conflicting reports exist regarding the permanence of improved gastric emptying (GE) after fundoplication for gastroesophageal reflux in children.

METHODS

Changes in gastric volume (GV) and GE of a radiolabeled mixed meal induced by a Nissen fundoplication (NF) were compared with those with a NF plus pyloroplasty (NF + P). GE was measured preoperatively, 15 and 30 days postoperation, in 24 Sprague-Dawley rats; 12 had NF alone, and 12 had NF + P Results were expressed as percent gastric retention at 90 minutes (GR90). GV was measured at the same time periods in 20 additional rats.

RESULTS

NF rats had enhanced GE with reduction of preoperative GR90 from 37.6% to 23.7% at 15 days (P < .05); however, at 30 days the GR90 increased to 34.3%. NF + P rats had enhanced GE with reduction in GR90 from 37.2% to 20.8% at 15 days (P< .05), which persisted at 30 days (20.4%). Mean GV decreased from (1.36 mL/100 g body weight) preoperation to 0.86 at 15 days (P< .05) at 15 days in the NF group, and returned to 1.29 at 30 days. Mean GV decreased from 1.36 to 0.91 at 15 days in the NF + P rats and persisted at 0.90 at 30 days.

CONCLUSION

In the rat model, NF enhances GE transiently, whereas NF + P produces long-term enhancement of GE.

The outcome of research training during surgical residency

BACKGROUND/PURPOSE

Graduates of a university surgical residency program were surveyed to identify the timing of specialty selection and the impact that studying in a research laboratory had on subsequent acceptance into a fellowship program.

METHODS

Between 1975 and 1990, 86 residents completed general surgery training at UCLA Medical Center. A survey was sent to all graduates to determine the focus of their previous laboratory research and when they selected their eventual surgical specialty. Responses were received from 67 of the 86 graduates (78%).

RESULTS

Forty-eight of the sixty-seven respondents (72%) took one or more years of surgical research during residency. Postresidency fellowship training was selected by 55 of 67 (82%); 50 applied to fewer than five programs; 49 of 55 (89%) received one of their top three choices. Twenty-seven of the sixty-seven residents pursued an academic career (40%). Residents who performed at least 2 years of research were more likely to become academicians (53%) than residents who did 1 year or less of research (22%). Only 39 of 67 residents (58%) had selected a specialty after 2 years of clinical training; 28 more made the selection after the third clinical year. All residents interested in cardiac surgery (n = 18) or plastic surgery (n = 4) prior to research were accepted into fellowships in those specialities, whereas only 37% of those who had an interest in other fields pursued the same specialty (P < 0.0001). Residents performing research in general surgery (n = 9), surgical oncology (n = 18), cardiac surgery (n = 14), and plastic surgery (n = 3) were more likely to practice in that specialty than those doing research in other specialty laboratories.

CONCLUSIONS

General surgery residents performing research in a specialty laboratory are likely to pursue fellowship training relating to that field. Those who select a career in cardiac or plastic surgery prior to research are most likely to enter into these fields as their eventual specialty. Residents who perform 2 or more years of laboratory research publish more papers and often pursue an academic career.

Comparison of loop versus end ileostomy for fecal diversion after restorative proctocolectomy for ulcerative colitis

BACKGROUND

The goal of this study was to compare the benefits versus complications of temporary loop ileostomies and end ileostomies in a consecutive series of patients undergoing colectomy and ileal pouch-anal anastomosis for ulcerative colitis.

STUDY DESIGN

A retrospective review was performed of all patients undergoing restorative proctocolectomy with diverting ileostomy for ulcerative colitis at the UCLA Medical Center during a 4-year period. An end ileostomy (EI) was used for 38 patients and a loop ileostomy (LI) for 39. All patients had a J pouch, with all EI patients having a hand-sewn ileoanal anastomosis, and 33 LI patients having a double-stapled anal anastomosis. EI closure was performed through a laparotomy, and LI closure was performed through a periileostomy incision.

RESULTS

The mean operative time for EI closure was 157 minutes, and for LI closure was 103 minutes. The wound infection rate after EI closure was 5.3% and after LI was 10.3%. For EI patients, 2 of 38 patients required reoperation, compared with 5 of 39 for LI. The mean hospital stay after EI closure was 6.7 days, and after LI closure was 7.1 days. Peristomal skin irritation was more severe, more prolonged, and occurred in more than twice as many LI as EI patients. Home ostomy nurse care was necessary for a mean of two visits for EI patients and five visits for LI patients. The cost ofostomy supplies and care was more than double for LI patients compared with those with EI. Patient satisfaction and ability to resume physical and social activities early after ileostomy construction were much more favorable for EI than LI patients.

CONCLUSIONS

The benefit of shorter operating time for LI closure compared with EI closure is often outweighed by the complications and costs of LI stomal care and patient dissatisfaction. EI should be considered more frequently for temporary ileal diversion after restorative proctocolectomy.

Functional and morphologic changes of the ileal mucosa after ileoanal pouch procedure

BACKGROUND

Restorative proctocolectomy is used widely for treatment of ulcerative colitis and familial polyposis coli. Limited information is available regarding the morphologic and functional adaptation of the mucosa in a functioning ileoanal pouch.

STUDY DESIGN

Ileal pouch specimens from patients who underwent pouch reconstruction (mean 7.5 years postcolectomy, n = 12) were compared with normal ileum (n = 15) and normal colon (n = 5). Amino-oligopeptidase (AOP) and maltase activity were measured as parameters of normal ileal function. Histologic samples were examined for the presence of neutrophils and plasma cells, the villus to crypt height ratio, and the degree of crypt hyperplasia, villus blunting, and goblet cell mass. Data were analyzed by analysis of variance.

RESULTS

The AOP activity in the normal ileum was 73 +/- 32 units of enzymatic activity per gram of mucosal protein; the AOP activities of the pouch and colon were 21 +/- 22 and 16 +/- 10, respectively. The maltase activity of the normal ileum measured 254 +/- 116 units of enzymatic activity per gram of mucosal protein, and the maltase activities of the pouch and colon were 57 +/- 71 units and 29 +/- 25 units, respectively. The ileal pouch mucosa demonstrated little acute inflammation and varying degrees of chronic inflammation. Morphologically, the ileal pouch mucosa demonstrated a range of adaptations, including villus blunting and crypt hyperplasia. Several specimens contained immature epithelial cells.

CONCLUSIONS

The AOP and maltase activities in mucosa from ileoanal pouches and colon were significantly lower than those in normal ileal mucosa. Ileoanal pouch mucosa from humans undergoes adaptive changes to resemble colonic mucosa both morphologically and functionally.

Repair of pectus excavatum deformities: 30 years of experience with 375 patients

OBJECTIVE

To review the surgical experience with pectus excavatum chest deformities at UCLA Medical Center during a 30-year period.

BACKGROUND

Pectus excavatum is a relatively common malformation that is often symptomatic; however, children's physicians often do not refer patients for surgical correction.

METHODS

Hospital records from 375 patients who underwent repair of pectus excavatum deformities between 1969 and 1999 were reviewed. Decrease in stamina and endurance during exercise was reported by 67%; 32% had frequent respiratory infections, 8% had chest pain, and 7% had asthma. The mean pectus severity score (width of chest divided by distance between posterior surface of sternum and anterior surface of spine) was 4.65 (normal chest = 2.56). All patients had marked cardiac deviation into the left chest. Repair was performed with subperiosteal resection of the abnormal cartilages, transverse wedge osteotomy of the anterior sternum, and internal support with a steel strut for 6 months. Repair was performed on 177 children before age 11 years; 38 adults with severe symptoms underwent repair.

RESULTS

The mean hospital stay was 3.1 days. With a mean follow-up of 12.6 years, all patients with preoperative respiratory symptoms, exercise limitation, and chest pain experienced improvement. Vital capacity increased 11% (mean) within 9 months in 35 patients evaluated. There were no deaths. Complications included hypertrophic scar formation (35), atelectasis (12), pleural effusion (13), recurrent sternal depression (5), and pericarditis (3). More than 97% had a very good or excellent result.

CONCLUSION

Pectus excavatum deformities can be repaired with a low rate of complications, a short hospital stay, and excellent long-term physiologic and cosmetic results.

Reoperation after esophageal replacement in childhood

BACKGROUND

Esophageal replacement is associated with significant morbidity that may lead to operative interventions. This study reviews the management and outcome of children who underwent reoperation after esophageal replacement.

METHODS

Eighteen patients who underwent esophageal replacement from 1985 to 1997 were reviewed retrospectively. Ten patients underwent reoperation. Patient management, perioperative morbidity, and the dietary intake at follow-up were recorded for each patient.

RESULTS

Of the reoperated patients, 7 had esophageal atresia, 2 had caustic ingestion, and 1 had achalasia. Nine patients received a colon interposition, and 1 received a reverse gastric tube as the initial esophageal replacement. Seven patients required revision of the anastomoses. Three patients required complex esophageal reconstruction: 1 underwent gastric transposition, 1 underwent free jejunal graft, and 1 underwent gastric transposition combined with free jejunal graft. Seven patients were eating well at follow-up. Two patients still required partial gastrostomy tube feeding. One patient died 6 months postoperatively from aspiration pneumonia.

CONCLUSIONS

Esophageal replacement continues to be a challenging operation associated with significant complications. Most reoperative procedures were directed toward strictures and persistent fistulae. Complete graft failure can be managed by gastric transposition or free jejunal graft. Despite the perioperative morbidity, most patients have good functional outcome.

Interposition of a jejunal segment between esophagus and pylorus for treatment of multirecurrent gastroesophageal reflux

Here the authors report the clinical experience with placement of an isolated jejunal segment between the esophagus and pylorus for treatment of multirecurrent gastroesophageal reflux (GER) in a child. A 6-year-old neurologically normal girl experienced severe symptomatic GER after 3 previous well-constructed Nissen fundoplications that failed over a 4-year period. The gastric cardia was closed, and a 16-cm isolated segment of proximal jejunum was placed in an isoperistaltic direction between the distal esophagus and an incision through the pylorus, extending onto both the antrum and duodenum. A gastrostomy was used for 3 months. The patient recovered from the operation without complications and has been completely relieved of reflux symptoms during the 15 months postoperation. She has gained over 6.5 kg in weight and 3.2 cm in height during this period and has not experienced difficulty swallowing solid foods. Esophagogastric dissociation with placement of an isolated jejunal segment between the esophagus and pylorus may have a useful role in the surgical management of multirecurrent symptomatic GER as a "rescue procedure" with low risk compared with other options.

Simplifying the Waterston's stratification of infants with tracheoesophageal fistula

The survival of infants with tracheoesophageal fistula was stratified by David J. Waterston et al. in 1962. This classification has been used as a guide to direct the timing of operative intervention in these infants. This study examines the current applicability of this classification system. The hospital records of 64 infants with esophageal atresia and/or tracheoesophageal fistula were reviewed. The survival rate was analyzed as a function of the infants' risk stratification, birth weight, and additional anomalies. Twenty-three infants were in Waterston Group A, 20 infants in Group B, and 21 infants in Group C. The survival of all infants was 81 per cent. Six infants died after recognition of severe anomalies and withdrawal of care, four infants died of cardiopulmonary arrest, and two infants died of sepsis. The survival of infants in both Groups A and B was 100 per cent, in contrast to 43 per cent survival in Group C. Only infants who weighed <1800 g or had severe additional anomalies were at risk of dying. Therefore, the classification of infants with esophageal atresia and/or tracheoesophageal fistula may be simplified by combining Waterston's Groups A and B into a single risk stratum.

The influence of gestational age and mode of delivery on infants with gastroschisis

BACKGROUND/PURPOSE

It has been proposed that preterm and prelabor cesarean section may improve the outcome of infants with gastroschisis. The purpose of this study is to examine the impact of gestation and delivery method on infants with gastroschisis.

METHODS

The medical records of 60 infants with gastroschisis treated at a tertiary care center from 1985 through 1995 were reviewed retrospectively. The gestational age, the mode of delivery, the type of operative repair, and the length of hospital stay were recorded for each patient.

RESULTS

Infants born vaginally were more likely to require silo stage repair than those delivered by cesarean section (21 of 29 v. 11 of 31, P<.01). Infants born vaginally also had longer hospital stay than those delivered by cesarean section (53 v. 39 days, P = .19). Infants born before 33 weeks' of gestation stayed longer in the hospital than those born after 33 weeks. After 33 weeks' gestation, infants had similar hospital stay regardless of the gestational age.

CONCLUSIONS

Cesarean section delivery was beneficial for infants with gastroschisis. Preterm delivery did not shorten the length of hospital stay. The role of elective cesarean section delivery at term should be considered for infants with gastroschisis diagnosed antenatally.

Gastric emptying after fundoplication is dependent on changes in gastric volume and compliance

BACKGROUND/PURPOSE

Nissen gastroesophageal fundoplication (GEF) increases gastric emptying (GE); however, the duration and the mechanisms for this improvement in GE remain unclear. The aim of this study was to evaluate the effects of a GEF on GE of a mixed meal, and to determine the correlation between GE and changes in intragastric pressure (IGP) and compliance.

METHODS

Using a radiolabeled mixed meal, GE was measured preoperatively 15 and 30 days after operation in 24 Sprague-Dawley rats divided into SHAM and GEF groups. Results were expressed as percent gastric retention at 90 minutes (GRg90), and time to evacuate 50% of the isotope meal (T1/2). Changes in IGP and compliance were determined at the same time-points using a different set of 20 rats.

RESULTS

Fifteen days after surgery, GR90 and T1/2 in the GEF group were reduced significantly when compared with preoperative values but returned to near preoperative values 30 days postoperation. In contrast, rats from the SHAM group showed no change in GR90 and T1/2 at 15 days and 30 days postoperation. Immediately after GEF, maximal distension of the stomach resulted in pressures 65% higher than those recorded before operation (20.2 v 11.7 mm Hg; P< .05), which persisted on the 15th postoperative day (17.7 v 10.7 mm Hg; P<.05). On the 30th postoperative day, however, there was no difference in the IGP between rats undergoing GEF compared with those undergoing a SHAM operation (11.7 v 12.0 mm Hg; P < .05). Similarly, mean gastric compliance decreased significantly immediately after and 15 days after GEF, but returned to preoperative levels 30 days after the operation.

CONCLUSIONS

In a rat model, GEF produces a transitory increase in GE, which is related to a simultaneous decrease in gastric volume and compliance. However, 30 days after GEF, associated with an elevated IGP, gastric volume increases and GE returns to preoperative levels.

Antireflux surgery in children under 3 months of age

PURPOSE

The aim of this study was to analyze the indications and results of fundoplication in 110 infants under 3 months of age.

METHODS

A retrospective review was conducted on the charts of all infants operated on for gastroesophageal reflux disease (GERD) at the UCLA Medical Center from January 1980 to December 1997. There were 59 boys and 51 girls. Recurrent emesis was the indication for operation in 62 of 110 infants, and respiratory symptoms in 85 of 110, with 54 of 110 having both. Neurological impairment was present in 32%. Prematurity was present in 21%; 35% had associated anomalies. Overall, 81 of 110 infants (73.6%) had one or more associated major malformations or disorders. Reflux was confirmed by upper gastrointestinal series findings in 63 of 78, esophageal pH monitoring in 60 of 62, and endoscopy in five of seven.

RESULTS

Mean age at operation was 1.8+/-0.1 months and mean weight was 3,686+/-90.2 g. A Nissen fundoplication was performed on 104 children, and six underwent a Thal procedure. Thirty-one had a gastric emptying procedure for delayed gastric emptying. Complications occurred in 7 infants. Emesis was controlled in 57 of 62 patients, aspiration in 38 of 48, and apneic spells in 54 of 57. Follow-up greater than 6 months was available for 73 patients. There were nine late deaths, all related to severe associated malformations. Seven patients required a redo fundoplication for recurrent reflux.

CONCLUSIONS

Nissen fundoplication can be performed safely in symptomatic infants under 3 months of age with low mortality and morbidity rates and with resolution of the presenting symptoms in 79% of infants.

Reconstruction for chronic dysfunction of ileoanal pouches

OBJECTIVE

A retrospective review was performed to determine the results after surgical reconstruction for chronic dysfunction of ileal pouch-anal procedures for ulcerative colitis and familial colonic polyposis at a university medical center.

METHODS

During the 20-year period from 1978 to 1998, 601 patients underwent colectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, familial colonic polyposis, or Hirschsprung's disease. A J pouch was used for 351 patients, a lateral pouch for 221, an S pouch for 6, and a straight pull-through for 23. Acute complications after pouch construction have been detailed in previous publications and are not included in this study. Chronic pouch stasis with diarrhea, frequency, urgency, and soiling gradually became more severe in 164 patients (27.3%), associated with pouch enlargement, an elongated efferent limb, and obstruction to pouch outflow, largely related to the pouch configuration used during the authors' early clinical experience. These patients were sufficiently symptomatic to be considered for reconstruction (mean 68 months after IPAA). Transanal resection of an elongated IPAA spout was performed on 58 patients; abdominoperineal mobilization of the pouch with resection and tapering of the lower end (AP reconstruction) and ileoanal anastomosis on 83; pouch removal and new pouch construction on 7; and conversion of a straight pull-through to a pouch on 16.

RESULTS

Good long-term results (mean 7.7 years) with improvement in symptoms occurred in 98% of transanal resections, 91.5% of AP reconstructions, 86% of new pouch constructions, and 100% of conversions of a straight pull-through to a pouch. The average number of bowel movements per 24 hours at 6 months was 4.8. Complications occurred in 11.6% of reconstructed patients. Five of the 164 patients (3.1%) required eventual pouch removal and permanent ileostomy. The high rate of pouch revision in this series of patients undergoing IPAA is due to a policy of aggressive correction when patients do not experience an optimal functional result, or have a progressive worsening of their status.

CONCLUSIONS

Although occasionally a major undertaking, reconstruction of ileoanal pouches with progressive dysfunction due to large size or a long efferent limb has resulted in marked improvement in intestinal function in >93% of patients and has reduced the need for late pouch removal.

Repair of pectus excavatum and carinatum in adults

BACKGROUND

There is sparse published information regarding the repair of pectus chest deformities in adults. This report summarizes our clinical experience with the surgical repair of pectus excavatum and carinatum deformities in 25 adults.

METHODS

During the past 11 years, 25 patients 20 years of age or older (mean 31) with symptomatic pectus excavatum (23) or carinatum (2) deformities underwent surgical repair using a temporary internal sternal support bar.

RESULTS

Each of the patients with decreased stamina and endurance or dyspnea with exercise experienced marked clinical improvement within 4 months postoperation. Exercise-induced asthma was improved in 6 of 7 patients; chest pain was reduced in each of 9 patients. Postoperative complications included pneumothorax (1), keloid (2), and discomfort from sternal bar (2). The sternal bar was removed 7 to 10 months postoperation in 19 patients; there has been no return of preoperative symptoms or recurrent depression in any patient with a mean follow-up of 4.8 years.

CONCLUSIONS

For adults who have symptoms and activity limitations related to uncorrected pectus chest deformities, surgical repair can be performed with low morbidity, low cost, minimal limitation in activity, and a high frequency of symptomatic improvement. The operation in adults is more difficult than in children, although the results are similar.

Gastric emptying procedures decrease the risk of postoperative recurrent reflux in children with delayed gastric emptying

PURPOSE

Although several centers often perform gastric emptying procedures (GEP) together with fundoplication for gastroesophageal reflux (GER) and delayed gastric emptying (DGE), the benefit of GEP is controversial. The present study addresses the question of whether adding a GEP in children with preoperatively diagnosed GER and DGE affects the recurrence rate of GER after Nissen fundoplication (NF).

METHODS

A retrospective chart review was performed on all children under the age of 16 years, operated on for GER from 1980 to 1997, who had a preoperative diagnosis of DGE, and at least 6 months of follow-up. Gastric retention of more than 50% of a radiolabeled meal at 90 minutes was considered DGE. Recurrent reflux was defined as reappearance of GER symptoms, confirmed by postoperative esophagram or 24 hours of pH monitoring.

RESULTS

Of the 183 patients with DGE, 92 were available for long-term follow-up. Of these, 20 had no gastric emptying procedure performed (no-GEP group) and 72 had a GEP performed together with an NF (GEP group). Groups were comparable as to age at operation, mean follow-up time, male to female ratio and prevalence of associated anomalies. A higher prevalence of neurological impairment (NI) was present in the GEP group (48.6% v20.0%). Mean preoperative gastric retention was significantly higher in the GEP group (69.9 +/- 1.3%) than in the no-GEP group (61.4 +/- 2.2%). No complications resulted from the GEP. Recurrent reflux rate was 18.1% in the GEP group (13 of 72) versus 35.0% (7 of 20) in the no-GEP group. Actuarial analysis disclosed a marginally significant difference in the rate of recurrent reflux between the groups (P = .057) and estimation of the relative risk showed a 1.94 increase of recurrent reflux risk in the no-GEP (0.89<RR<4.20).

CONCLUSIONS

Children with DGE, who did not have GEP, had twice the frequency of recurrent reflux as those who had a GER Preoperative screening for DGE, as well as operative correction of DGE at the time of fundoplication, is therefore recommended.

Glucose uptake in dilated small intestine

BACKGROUND/PURPOSE

The development of dilated small intestine in patients with short bowel syndrome results in increased mucosal surface area. This study examines whether the incremental increase in surface area leads to a proportional increase in absorptive function of the small intestine.

METHODS

Partial obstruction of the small intestine was created in rats by placing an intussusception valve in the proximal jejunum. Rats that underwent sham operations served as controls. One week postoperatively, the small intestine proximal and distal to the valve was removed. The intestinal diameter proximal and distal to the obstruction was measured. The rate of glucose uptake was measured by the everted sleeve technique. The results were analyzed by analysis of variance (ANOVA).

RESULTS

The intestine proximal to the valve was significantly dilated and thickened when compared with the intestine distal to the valve. The wet mass per centimeter of the dilated segment was 2.5 times that of the control group (P<.001). The glucose uptake capacity of the dilated segment was slightly higher than that of the control group (540 v 420 nmol/min/cm, P<.05). However, the specific glucose uptake rate was reduced significantly in the intestine proximal to the valve (247 v 335 nmol/min/cm2, P<.01).

CONCLUSIONS

Although the partial obstruction of small intestine resulted in a substantial increase in the intestinal surface area, the absorptive capacity of the dilated intestine per unit surface area was decreased significantly. This translated ultimately into a slight increase in the overall functional absorptive capacity of glucose in the small intestine. These results suggest that dilated small intestine may not enhance mucosal absorption.

Surgical ligation of patent ductus arteriosus in very low birth weight infants: is it safe?

We evaluated the outcome of a combined medical and surgical treatment of patent ductus arteriosus (PDA) in newborns weighing less than 1500 g. Charts were retrospectively reviewed for 76 newborns with a PDA between 1993 and 1997. Thirteen infants had pre-existing conditions prohibiting the use of indomethacin; eight were managed surgically, five medically. The remaining 63 infants received indomethacin therapy. Thirty-two medical failures occurred, requiring surgical ligation of the PDA. Those requiring surgery had a lower average birth weight (847 versus 997 g) and gestational age (26 versus 28 weeks; P < 0.05). Indomethacin treatment was successful in 27 infants. There were only three operative complications: a small pneumothorax, wound bleeding, and a small aortic tear. All recovered uneventfully and no deaths were attributable to the surgical procedure itself. There was no difference in the incidence of respiratory distress syndrome, duration of intubation, sepsis, neonatal enterocolitis, renal dysfunction, bleeding disorders, or intraventricular hemorrhage among both groups. Surgical ligation of a PDA is associated with a high success rate, a low incidence of complications, and no additional morbidity than indomethacin alone. We propose that surgical ligation should be regarded as a first line therapy for very small premature infants who are at higher risk of medical failure.

In vivo growth of transplanted genetically altered intestinal stem cells

PURPOSE

Intestinal stem cell transplantation is a potential method of delivering genes to the small intestine. The authors have previously demonstrated the survival of transfected intestinal stem cells implanted into the rat small intestine. This study examines the growth of genetically altered intestinal stem cells that were grown on a polycarbonate membrane and implanted into the rat small intestine.

METHODS

The IEC6 rat intestinal cell line serves as a model for intestinal stem cells. A subclone of the IEC6 cells was developed that stably expresses the lac Z gene introduced by a retroviral vector. The transfected cells were seeded at 500,000 cells/cm2 on a polycarbonate membrane. In 15 male Sprague-Dawley rats, a 0.75-cm enterotomy was created on the antimesenteric side of the small intestine 5 cm distal to the ligament of Treitz. A 0.5-cm2 segment of the membrane was sutured over the enterotomy with the cells facing away from the intestinal lumen. A segment of the omentum was wrapped around the patched enterotomy and sutured to the serosa. Three and 7 days after implantation, the implanted cells were retrieved, then fixed and stained with an X-gal solution. The number of cells was determined from the intensity of the X-gal staining. In five of the rats, frozen sections of the enterotomy sites were examined after staining with X-gal.

RESULTS

All 15 rats survived the implantation procedure. Initially, 0.32 +/- 0.11 million cells were implanted. At both 3 and 7 days, the enterotomy site still contained viable transfected cells. The number of viable cells increased substantially to 1.52 +/- 0.46 and 3.52 +/- 1.87 million cells at 3 and seven days, respectively (P < .05).

CONCLUSIONS

The polycarbonate membrane served as a good vehicle to efficiently deliver genetically altered intestinal stem cells to the small intestine. The transplanted cells continued to grow and stably expressed the gene product. This ex vivo approach to gene therapy has considerable therapeutic potential.

Surgical treatment of gastroesophageal reflux in children: a combined hospital study of 7467 patients

OBJECTIVE

To review retrospectively the combined clinical experience with the surgical treatment of persistently symptomatic gastroesophageal reflux (SGER) in childhood from seven large children's surgery centers in the United States.

DESIGN

During the past 20 years, 7467 children <18 years of age underwent antireflux operations for SGER at the seven participating hospitals. Fifty-six percent were neurologically normal (NN) and 44% were neurologically impaired (NI). The most frequent diagnostic studies were upper gastrointestinal series (68%), esophageal pH monitoring (54%), gastric emptying study (32%), and esophagoscopy (25%). The age at operation was under 12 months in 40% and 1 to 10 years in 48%. The type of fundoplication was Nissen (64%), Thal (34%), and Toupet (1.5%). A gastric emptying procedure was performed on 11.5% of NN patients and 40% of NI patients. Laparoscopic fundoplication was performed on 2.6% of patients.

RESULTS

Good to excellent results were achieved in 95% of NN and 84.6% of NI patients. Major complications occurred in 4.2% of NN and 12.8% of NI patients. The most frequent complications were recurrent reflux attributable to wrap disruption (7.1%), respiratory (4.4%), gas bloat (3.6%), and intestinal obstruction (2.6%). Postoperative death occurred in 0.07% of NN and 0.8% of NI patients. Reoperation was performed in 3.6% of NN and 11.8% of NI patients. The results and complications were similar among the participating hospitals and did not seem related to the type of fundoplication used.

CONCLUSION

The excellent results (94% cure) and low morbidity with gastroesophageal fundoplication with or without a gastric emptying procedure from a large combined hospital study indicate that operation should be used early for SGER in NN children and to facilitate enteral feedings and care in NI children.

The outcome of research training during surgical residency

BACKGROUND/PURPOSE

The exposure to research during residency is currently an integral part of most academic surgical training programs. In this study, graduates of two surgical programs were surveyed to characterize their research experience and to determine the effects on their careers.

METHODS

Between 1975 and 1990, 86 and 61 residents completed general surgical training programs at UCLA Medical Center and at Harbor-UCLA Medical Center, respectively. An anonymous survey was sent to each graduate regarding his research experience and current practice.

RESULTS

Of the graduates who spent 2 years in research, 47% now hold academic positions, compared with 23% for those who spent less than 2 years (P = .18). When the graduates were segregated according to their desire to enter the laboratory, 49% of graduates who requested research time hold academic positions, whereas only 13% of those who would not request research are in academic positions (P = .01).

CONCLUSIONS

Residents who strongly desire a period of research during surgical residency are also more productive in the laboratory. This information should be considered in selecting residents for research training in the current era of academic budget restriction and managed health care.

Long-term quantitative results following fundoplication and antroplasty for gastroesophageal reflux and delayed gastric emptying in children

BACKGROUND

The operative management of children with combined gastroesophageal reflux and delayed gastric emptying is controversial. This study measures the long-term follow-up of gastric emptying in children who have undergone gastroesophageal fundoplication combined with antroplasty.

METHODS

Fifteen randomly selected children with gastroesophageal reflux and scintigraphically demonstrated delayed gastric emptying underwent fundoplication and antroplasty. Each patient had another gastric emptying scintigraphic study performed an average of 3.6 years postoperation.

RESULTS

All patients reported improvement of their symptoms compared with before the operation, and none required further medical therapy for gastroesophageal reflux or experienced dumping syndrome. Eleven of the 15 patients had significant long-term improvement of their gastric emptying postoperatively. The mean percent of isotope meal remaining in the stomach at 90 minutes improved from 72% preoperatively to 40% postoperatively (P = 0.0005).

CONCLUSIONS

Gastric emptying in children with gastroesophageal reflux and delayed gastric emptying is significantly improved for several years in three-fourths of patients after fundoplication and antroplasty. Fundoplication and concomitant antroplasty are recommended for symptomatic children with documented gastroesophageal reflux and delayed gastric emptying.

Relationship of esophageal anastomotic tension to the development of gastroesophageal reflux

BACKGROUND/PURPOSE

Gastroesophageal reflux (GER) is a common occurrence after repair of congenital esophageal atresia and is believed to be more frequent when the esophageal anastomosis is performed under tension. This study documents that esophageal anastomotic tension correlates directly with the severity of acid reflux into the esophagus in the rabbit model.

METHODS

Eight adult rabbits underwent complete esophageal transection with immediate reanastomosis (EA) and 12 underwent resection of a 1-cm segment of the midesophagus with reanastomosis under mild tension (EAT). Three-weeks postoperation continuous lower esophageal pH (LEpH) values were recorded for a 24-hour period for each rabbit, and compared with five normal unoperated rabbits.

RESULTS

The normal rabbit's average LEpH is 7.7. EA rabbits had LEpH values below 5.0 for a mean of 56 min/24 hr (3.8% of monitored time). EAT rabbits had LEpH values below 5.0 for a mean of 328 min/24 hr (25.5% of monitored time; P < .05). EA rabbits had a mean of 8.8 reflux episodes under 5.0/24 hr, whereas EAT rabbits had a mean of 29.6 reflux episodes under 5.0. All EAT rabbits had moderate to severe anastomotic strictures; no EA rabbits had strictures. There were no anastomotic leaks.

CONCLUSIONS

Esophageal anastomosis with mild tension in the rabbit causes severe GER with resultant anastomotic strictures in almost all rabbits, in contrast to rabbits undergoing esophageal anastomosis without tension in whom strictures did not develop and had only small reduction in esophageal pH values.

Improved survival of infants with omphalocele

BACKGROUND

The surgical management of patients with omphalocele has evolved over the past 4 decades. Despite many improvements in care, the reported mortality has been over 10%.

METHODS

This study reviewed the characteristics, management, and outcome of 31 patients with omphalocele who underwent surgical care between 1980 and 1995 at a single hospital.

RESULTS

Twenty-five patients had additional congenital anomalies. All but 1 patient underwent operative repair; 13 of these patients with large defects had a silo chimney constructed initially. Fourteen patients underwent primary fascial and skin closure at the initial operation. Only 1 patient died perioperatively; another patient died without operation due to other major malformations.

CONCLUSIONS

The results following surgical repair of omphalocele defects depend on the degree of visceroabdominal disproportion and on the severity of associated anomalies. The operative mortality for staged omphalocele repair with limited elevation of intraabdominal pressure is low, and the long-term quality of life of these patients is good.

Combination of "patch, drain, and wait" and home total parenteral nutrition for midgut volvulus with massive ischemia/necrosis

The successful use of a combination of "patch, drain, and wait" (PDW) and home total parenteral nutrition (TPN) in the management of a case of acute, catastrophic midgut volvulus in a 2-year-11-month-old boy with near-total ischemia/necrosis of his small intestine is reported. The PDW approach to the highly effective management of acute midgut ischemia/necrosis in infancy and childhood (necrotizing enterocolitis and midgut volvulus) involves maximum gut salvage by avoidance of resection, stoma formation, or both through the use of extensive peritoneal cavity drainage by Penrose drains, TPN, and broad-spectrum antibiotics. The extensive peritoneal drainage fosters capture of enteric fistulas with the formation of enterostomies at drain exit sites, while adhesions and ischemia/inflammation-induced hypervascular obliteration of the peritoneal cavity diminish the potential for peritonitis (no peritoneal cavity, no peritonitis) and facilitate impressive salvage of seemingly hopelessly lost ischemic/necrotic gut (a simulation of the in utero ischemic gut process leading to atresias and some varying, but generally mild, gut loss) while simultaneously contributing to the resorption of absolutely non-salvageable gut and the creation of a remarkably clean and adhesion-free peritoneal cavity resembling that of a newborn infant with midgut intestinal atresia.

Epidermal growth factor selectively enhances functional enterocyte adaptation after massive small bowel resection

After massive small bowel resection, the intestine adapts to compensate. In addition to proliferation, enterocytes also undergo selective functional adaptation. In this study we examined the effect of intraperitoneal administration of epidermal growth factor (EGF) on the expression of the brush border dissacharidase sucrase, the sodium glucose cotransporter (SGLT1), and the sodium-potassium ATPase pump (NaK ATPase) by enterocytes in the remnant intestine after massive small bowel resection. Adult Lewis rats underwent either ileal transection or 70% proximal intestinal resection. These animals were subdivided into groups that received either saline or EGF intraperitoneally for 1 week. Ilea from each group were harvested 4 weeks postoperatively. Enterocytes were separated from these segments by calcium chelation. The total protein from the isolated cells was subjected to Western blot analysis. Administration of EGF to animals that underwent transection did not significantly alter the expression of sucrase, SGLT1, or NaK ATPase. After intestinal resection, the expressions of sucrase and SGLT1 were significantly increased. The combination of EGF administration and intestinal resection resulted in a further increase in SGLT1 expression. The intraperitoneal administration of EGF selectively enhanced the expression of SGLT1 by enterocytes after massive small bowel resection. Administration of EGF to sham-operated animals did not have similar effects. These results suggest that EGF augments the adaptive response and may therefore have a therapeutic role in the management of patients with short bowel syndrome.

Management of peritoneal dialysis-induced hydrothorax in children

Continuous ambulatory peritoneal dialysis (CAPD) is a safe and effective treatment for children with end-stage renal failure. Approximately three per cent of patients develop a large hydrothorax as a result of a dialysate leak from the peritoneal cavity through an occult diaphragmatic eventration or attenuation of the pleuroperitoneal membrane. Previously, such patients often discontinued CAPD and were placed on hemodialysis even though the complications, expense, and limitation of activity with hemodialysis are undesirable in children. During the past 15 years, 6 of the 193 children (3%) undergoing CAPD at UCLA Medical Center developed a hydrothorax. Three patients were male and three were female. Four patients were treated surgically with diaphragmatic plication, one was treated by reducing the dialysate volume, and one was switched to hemodialysis in preparation for a renal transplant. Each of the four surgically-treated children was able to return to full-volume peritoneal dialysis and has not experienced recurrence of the hydrothorax. Therefore, diaphragmatic plication permits children to quickly resume full-volume CAPD and avoid hemodialysis.

Long-term results after colectomy and ileoanal pull-through procedure in children

OBJECTIVE

To review the clinical experience with colectomy and ileoanal pull-through procedure in children from 1 hospital.

DESIGN

Since 1977, 116 children 18 years of age or younger underwent colectomy and ileoanal pull-through procedure at University of California-Los Angeles Medical Center. Ninety-four children had ulcerative colitis, 17 had familial polyposis coli, and 5 had Hirschsprung disease. Sixty-two children had a lateral pouch, 47 a J-pouch, and 7 a straight pull-through. A diverting ileostomy was used for 4 months for all patients except 9 with polyposis coli and 2 with Hirschsprung disease. During the same period, an additional 414 patients older than 18 years underwent the ileoanal pull-through procedure.

RESULTS

Forty-eight children (41%) developed complications; the most common was pouchitis, which occurred in 18 patients with ulcerative colitis. Forty-two children underwent reoperation; 38 had ulcerative colitis. There were no deaths. Six children (5.2%) (3 with Crohn disease) required a permanent ileostomy. Six straight pull-throughs were converted to J-pouches because of stool frequency; 19 patients with lateral pouches underwent pouch reconstruction or spout resection because of stasis. With a mean follow-up of 7.1 years, 107 children (92.2%) were progressing well.

CONCLUSIONS

Ulcerative colitis is a more severe disease in children. The ileoanal pull-through procedure is the preferred operation for children with ulcerative colitis, polyposis coli, and selected patients with Hirschsprung disease. The J-pouch is preferred because of simplicity of construction and scarcity of complications.

Current management of the undescended testis

True undescended testes are unilateral in approximately 80% of cases, are rarely corrected by human chorionic gonadotropin (hCG), and should be treated by orchiopexy before the patient reaches the age of 3 years to permit optimal tubular development and sperm function. A cryptorchid testis does not mature normally after the age of 2 years and may produce adverse effects on the contralateral descended testis. The higher a cryptorchid testis resides above the scrotum, the more dysgenetic the morphology is likely to be. Hypoplastic cryptorchid testes should be removed early, and high-positioned testes that have not been surgically placed into the scrotum before midadolescence generally should be removed.

Delayed effects of epidermal growth factor after extensive small bowel resection

Epidermal growth factor (EGF) is produced in the gastrointestinal tract and has been shown to have a transient stimulatory effect on mucosal growth and uptake of glutamine. This study investigated the delayed effects of EGF on mucosal brush-border membrane enzymes and glutamine uptake after extensive small bowel resection. Twenty-four New Zealand White rabbits underwent a 50% to 60% midjejunoileal enterectomy. One group of 12 had a subcutaneous osmotic pump inserted, delivering EGF at 0.3 microgram/kg/h for the first 7 postoperative days. The other group of 12 served as controls. Six rabbits from each group were killed at 3 weeks, and the remaining 12 were killed at 6 weeks. Six additional rabbits served asd nonsurgical controls. There was a twofold increase in mucosal dry weight at 3 weeks without EGF, and an almost fourfold increase with EGF, over control rabbits. This effect of EGF on the mucosa persisted for 6 weeks. Enzymatic activity per gram of protein in each group of rabbits was similar between the four groups of rabbits, although maltase activity increased approximately fourfold over that of nonoperative control animals. However, enzyme capacity of maltase and aminooligopeptidase (AOP) increased threefold and twofold (respectively) at 3 weeks without EGF, and sixfold and fourfold with EGF. Functional capacity is a measure of the load of nutrients that the intestine can digest and absorb, and therefore the derivable benefit to the animal. Glutamine uptake capacity increased 60% in 3 weeks without EGF, then declined by 6 weeks. However with EGF it increased 200% by 3 weeks, and further increased 400% by 6 weeks over control levels. The authors conclude that EGF markedly increases the functional capacity of the small intestine in rabbits that have undergone extensive small bowel resection; this effect persists for up to 6 weeks after a small initial dosage of EGF.

Gastroesophageal reflux in childhood

Gastroesophageal reflux (GER) is one of the most frequent symptomatic clinical disorders affecting the gastrointestinal tract of infants and children. During the past 2 decades, GER has been recognized more frequently because of an increased awareness of the condition and also because of the more sophisticated diagnostic techniques that have been developed for both identifying and quantifying the disorder. Gastroesophageal fundoplication is currently one of the three most common major operations performed on infants and children by pediatric surgeons in the United States. Normal gastroesophageal function is a complex mechanism that depends on effective esophageal motility, timely relaxation and contractility of the lower esophageal sphincter, the mean intraluminal pressure in the stomach, the effectiveness of contractility in emptying of the stomach, and the ease of gastric outflow. More than one of these factors are often abnormal in the same child with symptomatic GER. In addition, in patients with GER disease, and particularly in those patients with neurologic disorders, there appears to be a high prevalence of autonomic neuropathy in which esophagogastric transit and gastric emptying are frequently delayed, producing a somewhat complex foregut motility disorder. GER has a different course and prognosis depending on the age of onset. The incompetent lower esophageal sphincter mechanism present in most newborn infants combined with the increased intraabdominal pressure from crying or straining commonly becomes much less frequent as a cause of vomiting after the age of 4 months. Chalasia and rumination of infancy are self-limited and should be carefully separated from symptomatic GER, which requires treatment. The most frequent complications of recurrent GER in childhood are failure to thrive as a result of caloric deprivation and recurrent bronchitis or pneumonia caused by repeated pulmonary aspiration of gastric fluid. Children with GER disease commonly have more refluxing episodes when in the supine position, particularly during sleep. The reflux of acid into the mid or upper esophagus may stimulate vagal reflexes and produce reflex laryngospasm, bronchospasm, or both, which may accentuate the symptoms of asthma. Reflux may also be a cause of obstructive apnea in infants and possibly a cause of recurrent stridor, acute hypoxia, and even the sudden infant death syndrome. Premature infants with respiratory distress syndrome have a high incidence of GER. Esophagitis and severe dental carries are common manifestations of GER in childhood. Barrett's columnar mucosal changes in the lower esophagus are not infrequent in adolescent children with chronic GER, particularly when Heliobacter pylori is present in the gastric mucosa. Associated disorders include esophageal dysmotility, which has been recognized in approximately one third of children with severe GER. Symptomatic GER is estimated to occur in 30% to 80% of infants who have undergone repair of esophageal atresia malformations. Neurologically impaired children are at high risk for having symptomatic GER, particularly if nasogastric or gastrostomy feedings are necessary. Delayed gastric emptying (DGE) has been documented with increasing frequency in infants and children who have symptoms of GER, particularly those with neurologic disorders. DGE may also be a cause of gas bloat, gagging, and breakdown or slippage of a well-constructed gastroesophageal fundoplication. The most helpful test for diagnosing and quantifying GER in childhood is the 24-hour esophageal pH monitoring study. Miniaturized probes that are small enough to use easily in the newborn infant are available. This study is 100% accurate in diagnosing reflux when the esophageal pH is less than 4.0 for more than 5% of the total monitored time.

Superior and inferior vena caval occlusion in infants receiving total parenteral nutrition

During the past 23 1/2 years, 510 infants under 12 months of age had 756 Broviac central venous catheters inserted. At first catheter insertion 51 per cent of patients were less than 1 month old. Catheter function ranged from 3 to 1080 days (mean = 90 days). Sites of insertion were saphenous 85 per cent, external jugular 7 per cent, internal jugular 5 per cent, subclavian 2 per cent, cephalic 0.7 per cent, and transthoracic azygos 0.5 per cent. Eighty-nine patients had malabsorption syndromes, 86 had short bowel syndrome, 74 had intractable diarrhea, and 261 required nutritional support for other reasons. Vena caval thrombosis developed in 35 infants; 23 had inferior vena cava (IVC) occlusion (4.5% at risk); six had isolated superior vena cava (SVC) occlusion (11% at risk), and six had both SVC and IVC thrombosis. No major symptoms or complications resulted from isolated IVC thrombosis, whereas all infants with SVC occlusion developed head and neck swelling, 50 per cent developed pleural effusions, and two died. Each of six infants with combined IVC and SVC occlusion died within 6 months. We conclude that SVC occlusion is a very serious complication in infants receiving total parenteral nutrition (TPN) solutions and that infusion via the IVC has fewer and less serious complications.

Adaptation of rabbit small intestinal brush-border membrane enzymes after extensive bowel resection

Short lengths of small intestine may be resected without significantly affecting the digestive and absorptive capacity; however, extensive resection produces varying degrees of malnutrition. This study was undertaken to define the adaptive changes in the remaining small intestine of two of the jejunal and ileal mucosal brush-border membrane enzymes after extensive small bowel resection in rabbits. Thirty adult New Zealand White rabbits underwent a 50% to 60% jejuno-ileal-enterectomy with end-to-end anastomosis. Maltase activity (UE/g protein) increased from 152 (preoperative) to 392 at 3 weeks in the proximal segment and from 85 to 259 in the distal segment; these levels decreased to 222 and 155 in the respective segments at 6 weeks. AOP activity (UE/g protein) increased from 154 (preoperative) to 171 in the proximal segment and 171 to 256 in the distal segment at 3 weeks, and was 131 and 288 in the respective segments at 6 weeks. This marked increase in the mucosal brush-border enzymatic activities at 3 weeks postoperatively was associated with a 28% increase in bowel length. By 6 weeks the enzyme levels had decreased slightly; however, there was a persistent 41% increase in bowel length over that immediately postoperation. The mucosal surface area increased from 295 mm2 immediately postoperation to 5,337 mm2 at 3 weeks and 7,635 mm2 at 6 weeks, a 250% increase. The authors conclude that there is an immediate compensatory increase in villus length as well as brush-border enzymatic expression in the remaining intestine that gradually declines as the small intestinal surface area continues to increase and the bowel lengthens with time.

Effect of intraamniotic dexamethasone administration on intestinal absorption in a rabbit gastroschisis model

Infants with gastroschisis experience delayed intestinal motility and absorption for several weeks after birth. This intestinal dysfunction is believed to occur primarily in the third trimester and to be largely caused by the prolonged exposure of the intestine to amniotic fluid. Previous studies have shown that prenatal steroid administration will enhance mucosal disaccharidase activity and nutrient uptake. The present study evaluates the effects of dexamethasone on intestinal function in a rabbit fetal gastroschisis model. Thirty-four fetuses from 10 New Zealand white rabbits were divided into three groups: (1) gastroschisis group (GSC, n = 10), gastroschisis was created on gestational day (GD) 24 (term = 31 to 33 days); (2) dexamethasone group (GSD, n = 10), after the creation of gastroschisis, a small osmotic pump was placed into the rabbit doe for dexamethasone infusion into the fetal amniotic cavity for 7 days (0.2 microgram/g/d); (3) normal group (NF, n = 10), unoperated littermates from the GSC group. There were no maternal deaths, and fetal survival rate was 85%. The fetal small intestinal disaccharidase enzyme, lactase (UE/g protein), was markedly decreased in GSC fetuses. It was increased 70% in the GSD group but lower than in normal fetuses (GSC = 10.0 +/- 1.6; GSD = 17.3 +/- 1.6 [GSD versus GSC, P < .05]; NF = 48.0 +/- 6.7). Maltase activity in the GSD group was significantly increased (GSC = 7.2 +/- 1.1; GSD = 13.9 +/- 1.8 [GSD versus GSC, P < .05]; NF = 12.2 +/- 1.3).(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of epidermal growth factor on mucosal function after ileal resection

Since epidermal growth factor (EGF) enhances gut mucosal regeneration, the present study was undertaken to evaluate the effect of EGF on brush-border membrane enzyme activity and glutamine uptake in the intestinal remnant following extensive small bowel resection. Twenty-four adult male New Zealand White rabbits were divided into three groups: Group 1 (n = 12) served as controls. Groups 2 and 3 (n = 6 each) underwent a 50-60% mid-jejunoileal resection with anastomosis of the remaining intestine, leaving 90 cm between the pylorus and the ileocecal valve. Group 3 rabbits had a subcutaneous osmotic pump implanted to deliver EGF for 7 days at 0.3 micrograms/kg/hr. Rabbits from Groups 2 and 3 were sacrificed 3 weeks postoperation. Mucosa from the proximal and distal segments of the remaining intestine was analyzed for wet/dry weight, maltase and aminooligopeptidase activity, and glutamine uptake. There was a twofold increase in mucosal dry weight/cm of intestine in rabbits without EGF at 3 weeks (Group 2) and a fourfold increase in those given EGF (Group 3). The maltase enzyme capacity (UEnzyme/rabbit) increased from 37 +/- 10 in controls (Group 1) to 167 +/- 30 without EGF and 207 +/- 30 with EGF. The aminooligopeptidase enzyme capacity (UEnzyme/rabbit) increased from 55 +/- 10 to 147 +/- 20 and 226 +/- 30 in Groups 1, 2, and 3, respectively. Glutamine uptake capacity (microM glutamine/min) also increased significantly, from 63 +/- 19 in Group 1 to 88 +/- 6 without EGF and 162 +/- 18 with EGF (P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery for pediatric ulcerative colitis

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the "gold standard" operation for treatment of ulcerative colitis refractory to medical therapy. The J-pouch is the simplest to construct, produces the fewest complications, and is used most commonly. Long-term function with the IPAA is good in approximately 90% of cases, and patient satisfaction is high. Controversial aspects of the operation include 1) whether mucosectomy and hand-sewn IPAA is better than anal transition zone preservation and stapled anastomosis, 2) whether a temporary diverting ileostomy should be used, 3) the role for IPAA in the treatment of indeterminate colitis, 4) the etiology and the most effective treatment for pouchitis, and 5) the best method for salvaging the failed pelvic pouch.

A combined hospital experience with fundoplication and gastric emptying procedure for gastroesophageal reflux in children

BACKGROUND

Operative treatment of symptomatic gastroesophageal reflux (GER), often together with neurologic feeding disorders, is very common in infancy and childhood. Delayed gastric emptying (DGE) has been observed frequently in association with GER in children.

STUDY DESIGN

A retrospective review was performed on 1,200 consecutive patients 18 years of age and younger operated upon for symptomatic GER or neurologic feeding disorders, or both, at two pediatric surgery centers in widely separated geographic areas in the United States of America, to compare the results after fundoplication with or without a gastric emptying procedure (GEP).

RESULTS

Operations included gastroesophageal fundoplication (GEF) alone (871 patients), GEF plus GEP (286 patients), reoperative GEF plus GEP (30 patients), and GEP alone (13 patients). Thus, 27 percent of the total and 40 percent of the last 494 children with reflux had a GEP. Delayed gastric emptying with retention of more than 60 percent of an isotope meal appropriate for age at 90 minutes was present in 241 of the 451 children with reflux studied. Major neurologic disorders were present in 219 (25 percent) of 871 children who underwent GEF alone and in 247 (75 percent) of 329 children who had a GEP. All patients operated upon from both hospitals were relieved of recurrent emesis, and those with failure to thrive showed significant weight gain; pulmonary symptoms were relieved in 94 percent. Recurrent GER developed in 47 (5.2 percent) of 901 children who had GEF alone, but in only four (1.2 percent) of 329 patients who had a GEP.

CONCLUSIONS

The excellent clinical results with low morbidity in this largest reported clinical experience with GEP in childhood suggest that a GEP should be combined with GEF for symptomatic children who have both GER and DGE. Minimal investigative studies are necessary for most neurologically impaired children who require a feeding gastrostomy.

Infectious and catheter-related complications in pediatric patients treated with peritoneal dialysis at a single institution

Continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD) are the predominant dialytic modalities for the majority of children while awaiting transplantation. Wide acceptability of peritoneal dialysis is hindered by infectious complications. A retrospective review of 367 pediatric patients treated with CAPD/CCPD for at least 3 months from September 1980 through December 1994 revealed that the peritonitis incidence ranged from 1.7 to 0.78 episodes per patient-year. No differences in peritonitis rates were observed between patients treated with CAPD or CCPD. Gram-positive organisms were responsible for the majority of peritonitis episodes. Age, sex, race, primary renal disease, presence of nephrotic syndrome, and serum albumin level were not associated risk factors. Longer time on treatment and diminished serum IgG level were associated with increased peritonitis incidence. Treatment was successfully completed at home in most cases. Almost half of the catheter losses were caused by Staphylococcus, Pseudomonas, and fungal peritonitis and tunnel/exit-site infections. Infectious complications are still the major causes of morbidity and treatment failure in patients treated with CAPD/CCPD. Thus, controlled studies are needed to assess methods for prevention or improvement of peritonitis rates in this patient population.

Effect of prenatal dexamethasone administration: fetal rabbit intestinal nutrient uptake and disaccharidase development

To examine the effect of prenatal steroids on fetal intestinal maturation, eight pregnant rabbits received either dexamethasone (Dex) or saline (Cont) on Days 25-27 of a 31-day gestation. As the rabbit provides a model of growth retardation based on uterine position, fetuses were identified as favored (Fav) or runt (Runt), generating four study groups: ContFav, ContRunt, DexFav, and DexRunt. On Day 31 the small intestinal uptake of glucose and proline was measured by an everted sleeve technique. Additionally, lactase and maltase activity was determined. Small intestinal length and nutrient uptake was significantly increased in the Dex fetuses. Control runts had a trend to decreased levels of nutrient uptake when compared to their favored counterparts. This trend reversed in the Dex fetuses with runt nutrient uptake surpassing that of the favored fetus. A trend to increased enzyme activity of both lactase and maltase was demonstrated. This report provides the first description of maternal steroid administration causing a marked increase in fetal small intestinal length and glucose and proline absorption in an in vivo model of intrauterine growth retardation.