Adequate timing of diagnostic tests for gastroesophageal reflux in children with esophageal atresia

OBJECTIVE

Recent guidelines made recommendations for the management of gastroesophageal reflux in patients with esophageal atresia (EA). However, the timing for some diagnostic tests remained somehow unclear. This investigation studied the tests for gastroesophageal reflux in children aged one year old and children aged two or three.

MATERIALS AND METHODS

Patients with EA who underwent Multichannel Intraluminal Impedance-pH monitoring (MII-pH) and endoscopy-histology were studied retrospectively. Patients aged one when the test was performed were the YO group and patients aged two or three years old formed the OL group. Substantially impaired MII-pH was defined as total number of reflux episodes >105 or >85 (depending on age), or reflux index >10%. Substantially impaired endoscopy was defined as erosive esophagitis or Barrett's esophagus. Substantially impaired histology was defined as moderate-severe esophagitis or Barrett's esophagus. Conventional parameters and substantially impaired values of the tests were compared.

RESULTS

Twenty-four patients were studied. Twenty-three MII-pH were performed (12 in YO and 11 in OL): percentages of abnormal conventional parameters of MII-pH were not significantly different in both groups. Twenty endoscopies with biopsies were performed (7 in YO and 13 in OL): percentages of esophagitis were not significantly different. Interestingly, 26.9% of all the tests performed in YO were substantially impaired vs. 10.8% of all the tests in OL (χ2 = 2.7; p = 0.1).

CONCLUSION

Considering the percentage of alarming results of diagnostic tests in the YO group it would be advisable that patients with EA undergo MII-pH and endoscopy-histology at one year of age.

[Applicability of a clinical score in patients with suspected foreign body aspiration]

OBJECTIVE

To validate the clinical score of Valdivieso et al. in the management of patients with suspected foreign body aspiration in a tertiary hospital. This score raises different scenarios according to the result: bronchoscopy, CT, observation or discharge.

MATERIAL AND METHODS

Retrospective study of patients who underwent a bronchoscopy due to suspected tracheobronchial foreign body between November-2015 and November-2018. The variables proposed by the score were collected (choking, stridor, wheezing, unilateral hypoventilation, altered chest X-ray and high-risk foreign body) and the score was calculated for each patient, analyzing the performance of the test using the ROC (Receiver Operating Characteristic) curve.

RESULTS

Bronchoscopy was performed in 81 patients with a mean age of 2.1 years (7 months-11 years), finding foreign body in 33.3%. The area under the ROC curve of the score was 0.803 (0.695-0.911). In 6 (22.2%) patients with confirmed foreign body the score initially indicated observation in 5 cases and discharge in 1. Excluding the 49 patients with unilateral altered auscultation or when there was a nut suspected, which in our environment are clear indications for bronchoscopy, the score correctly classified the remaining 32 patients, which would have reduced the rate of normal bronchoscopies from 66% to 45%.

CONCLUSIONS

The score in our sample presents a high diagnostic power but a non-negligible false negative rate. It has a special utility in patients who do not have unilateral altered auscultation and/or choking with nuts, allowing to reduce the rate of normal bronchoscopies.

[Splenectomy in hemolitic disorders. Influence of Gilbert's disease in the occurrence of biliary complications]

INTRODUCTION

In patients with hemolytic disorders (HD) splenectomy is recommended between 6-12 years. A higher risk of biliary complications (BC) has been described in those with associated Gilbert's disease (GD), but the ideal surgical age has not been stablished yet. Our aim is to quantify the risk of BC in patients with HD and GD to assess the benefit of early splenectomy.

MATERIAL AND METHODS

Retrospective study of splenectomies performed in patients with HD between 2000-2017. The incidence of BC, its clinical consequences (admission or invasive treatment) and time of onset were analyzed. Two groups were considered: patients with GD and without GD. Survival curves were obtained and compared with log-rank test.

RESULTS

Fourty-four patients underwent splenectomy, 15 of them (34.1%) with HD+GD. The median age at surgery was 10.3 years (range 5.4-14.8). Twenty-nine (65.9%) had BC. Half of the patients with GD had BC before 8 years vs. 10,5 years in the cases without GD (log-rank 3.9, p= 0.05). Patients with GD had more BC (86.7% vs. 55.2%; Chi²= 4.37, p= 0.037). In the HD+GD group, 8 cases (53%) required admission vs.8 patients (31%) in the group HD without GD (Chi²= 2, p= 0.1). Invasive treatment was performed in 2 patients (13%) in the HD+GD group and 2 others (7.6%) in the group HD without GD (Chi²= 0.3, p= 0.6).

CONCLUSIONS

In our series, the BC incidence was higher in patients with HD and GD. There was a trend towards an earlier presentation of BC in this group, but neither this data nor its clinical consequences allow us to recommend early splenectomy.

[Complicated omental cyst after a herniorrhaphy in an infant]

Omental cysts are uncommon benign masses localized in the abdomen. This article describes the case of a male infant who underwent surgery due to a left inguinal hernia. During the operation a small omental cyst was found inside the sac that was resected. The first postoperative days were uneventful but the infant came back to hospital seven days after. Subsequent imaging and operative findings revealed a complicated omental cyst. This cyst was removed and the histopathology report described an inflammatory pseudotumor. The postoperative evolution was satisfactory and the patient has remained asymptomatic since he was discharged from hospital. In conclusion, it is important to explore the contents of the hernial sac during inguinal hernia repair. The finding of a small omental cyst inside the sac should encourage to study other potential intraabdominal lesions.

[Successful conservative management of a multiple renal abscess in a child]

Renal abscesses are uncommon in children but their consequences could be serious, including sepsis, severe renal damage or loss of the kidney. The following report describes a three-year-old girl diagnosed of multiple renal abscess in the left kidney after a first episode of fever. The case is significant due to the uncommon presentation of a urinary tract infection as a multiple abscess, the extension of the injuries (there were 4 abscesses in the kidney) and the conservative therapy with intravenous antibiotics which was selected in order to preserve renal tissue.

[When a peritonitis does not seems like a peritonitis]

Acute pancreatitis should be considered in the differential diagnosis of acute abdominal pain. Although its incidence is low, it has increased in the last years; therefore, an accurate diagnosis is necessary to avoid inappropriate surgeries. The aim of this study is to describe acute pancreatitis in the context of acute abdominal pain, which suggests appendicitis. We performed a retrospective study of all the patients who were admitted in the emergency department due to suspected appendicitis but were finally diagnosed of acute pancreatitis since 2010. Five patients were included in the investigation. One of them underwent surgery and the diagnosis was made on the 5th postoperative day. Median age at diagnosis was 5 years (range from 8 month to 6 years). Median white blood cell was 16,600/microL (13,400-31,900/microL), Median differential count of white blood cell was 14,432/microL (11,400-29,348/microL) and Median PCR 11 mg/L (155-4.6 mg/L). Median serum amylase at diagnosis was 651 U/L (10-1,443 U/L). All cases were studied with ultrasound and computerized tomography or nuclear magnetic resonance. One case had recurrent episodes of pancreatitis and was complicated by the development of a pseudocyst and a pancreatic fistula, requiring an Y-en-Roux cysto-enteric anastomosis. The median follow up period was 10 months (range: 1 to 22). All patients are asymptomatic at the moment.

[Benefits of epidural analgesia in major neonatal surgery]

The aim of this paper is to describe and evaluate the benefits of epidural anesthesia in major surgery neonatal. We have performed a matched case-control (2:1) study of patients undergoing neonatal major surgery (NMSs) who received intra-and postoperative epidural anesthesia (EA) and controls with conventional general anesthesia. The matching criteria were age, weight and baseline pathology. EA was administered by caudal puncture and epidural catheter placed with ultrasound support. Levobupivacaine was selected as anesthetic drug. The time to extubation, intestinal transit time, type of analgesia and complications were studied. This study is based on 11 cases (2 esophageal atresia, 2 diaphragmatic hernias, 1 necrotizing enterocolitis, 3 intestinal atresia, 2 anorectal malformation and 1 bladder exstrophy) and 22 controls. We observed statistically significant differences in time to extubation (95% CI OR 12 1.99 to 72.35; Chi2 p = 0.004, Mann U Whytney p = 0.013) and intestinal transit time (Mann Whitney U p < 0.001, 100 Or, 95% CI 8.06-1 239; Chi2 p < 0.0001). There were no complications from epidural analgesia. Therefore we believe that the intra-and postoperative EA helps improve postoperative management in neonates and should be preferred in centers where this technique is available.

[Relation between packed red blood cell transfusion and severity of necrotizing enterocolitis in premature infants]

OBJECTIVE

It has been proposed recently that red blood cell transfusions (RBCT) might increase severity in infants with necrotizing enterocolitis (NEC). We intend to study if patients who have received red blood transfusions before the onset of NEC develop more severe forms of this entity.

METHODS

A retrospective study was carried out including prematures with NEC. Two groups were considered: with previous RBCT (TR) and without previous RBCT (No-TR). The main outcomes of the study were severity of NEC, according to the Bell stage (BS), surgical treatment and mortality. Patients who were treated with RBCT 48 hours prior to the onset of NEC symptoms were analysed separately afterwards. Comparison of groups was made with the Fisher test or the Chi square test for the BS, surgery, mortality and nominal variables; the U Mann-Whitney test was used for numeric variables.

RESULTS

Forty-six patients were included for the investigation (28 in TR and 18 in No-TR). In the TR Group 20/28 neonates reached a BS II; 8/28 BS III; 10 were operated on and there were 7 deaths. In the No-TR group 14/18 patients were classified as EB II; 4/18 as BS III, 3 patients needed surgery and Idied. No relation was found between RBCT and BS (p = 0.39), RBCT and surgery (RR = 2.7; CI 95%: 0.64-11.97; p = 0.19), or RBCT and mortality (RR = 4.5; CI 95%: 0.6-36.6; p = 0.09). In those patients who received a RBCT 48 hours before the initial symptoms there were 3 EB II and 3 EB III; 4 infants required surgical treatment and there were 2 exitus. Comparing this subgroup and the rest of the sample there were only significant differences in the need of surgical treatment: patients who received a RBCT 48 hours before the onset of NEC were at an increased risk for surgery of 2.6 (CI 95%: 1.2-5.1; p = 0.045) but there were not different when surgical treatment and mortality were considered.

CONCLUSIONS

These results do not support clearly the hypothesis that there is a relation between previous treatment with RBCT and the severity of NEC.

[Estimation of the risk of upper digestive tract bleeding in patients with portal cavernomatosis]

PURPOSE

The aim of this study is to find out the risk of upper gastrointestinal bleeding (UGB) after the diagnosis of portal cavernoma in children, and to investigate several potential risk factors.

MATERIAL AND METHODS

We analyzed retrospectively 13 cases of portal cavernoma and estimated the risk of UGB with the Kaplan-Meier survival analysis. We calculated the incidence rate of the sample and the number of haemorrhages per year for each patient individually. From the moment of the diagnosis various parameters were recorded: age, platelets, leukocytes, hemoblobin, hematocrit, prothrombin time and number of bleedings. The relation between these parameters and the risk of bleeding was assessed with the Cox analysis.

RESULTS

The patients were followed for a median period of 7.1 years. 10 patients (77%) presented at least 1 episode of UGB after the diagnosis. The median survival time until the first haemorrhage was 314 days. After the diagnosis the incidence rate of the sample was 0.43 episodes of upper gastrointestinal bleeding per person-year. The number of individual bleedings per person had a range of 0-2.2 episodes per year.

CONCLUSIONS

There is very few data about the risk of bleeding in children with portal cavernoma. In our sample, we found out an incidence rate of 0.43 and a median survival time of 314 days until the first episode of bleeding after the diagnosis, but we were not able to find a statistically significant association between the studied variables and the risk of bleeding.

[Results of the use of laparoscopic anti-reflux procedure for the prevention of episodes of apnea, bradycardia and desaturation]

In 1986 the National Institutes of Health Consensus Developement Conference on Infantile Apnea and Home Monitoring defined the Apparent Life Threatening Events (ALTEs) as those frightening episodes for the observer which are determined by a combination of apnea (central or obstructive), changes in colour (cianosis, congestive pallor) and marked changes in muscular tone, asphyxia. Despite the fact that its cause still remains unknown, many centres relate ALTE with gastroesophageal reflux disease (GERD) and therefore recommend medical treatment of GERD to those patients with ALTE. However there are very few articles that proof the efficacy of surgical treatment in patients with ALTE and GERD. We carried out a retrospcective review between 2000 and 2008 of those patients with ALTE who underwent a laparoscopic antirreflux procedure. The study included the realization of contrast x-ray, pHmetry and laryngeal, digestive and bronchial endoscopy. During this period antirreflux (with either Nissen or D'Or technique) procedure was carried out by laparoscopic approach in the patients with ALTE and GERD. Median of gestational age was 32 week, mean birth weight was 1800 g, mean age at the time pof surgery was 217 days (range 32-410). All these patients had previously presented 3 or more events of ALTE and had been treated medically for GERD. pHmetric studies were no conclusive, In 6 out of 15 patients had different grades of arithemoid oedema. All the patients presented gastroesophageal reflux (grades II-III) in the constrast x-ray. Mean follow up was 1258 days. 7 from 8 patients presented clear improvement. Morbimortality derived from surgery was null.

[Nonpalpable testes: short, middle and long-term results with the use of an exclusively laparoscopic technique]

Non palpable testis (NPT) has an incidence of 20% and clinical relevance derived from the possibility of malignant degeneration, fertility disfunction. Recently the development of minimally invasive surgery (MIS) allowed more accurate diagnosis and has become a new therapeutic tool. We carried out a retrospective study that included all the patients who underwent laparoscopic orchidopexy between 1998 and 2008. 156 patients were reviewed, which represent 179 testis units (TU). In 65 occasions the testis was placed in the internal inguinal orifice and in 68 occasions the testis was purely intraabdominal. Testicular atrophy was evidenced in 32 cases (7%). Laparoscopic orchidopexy was carried out in 152 TUs except in those that developed agenesia or atrophy-. A prothesis was placed after removing the remaining testis. 18 cases required a FowlerStephens. Inmediate postoperative complications were oedema (18 cases) and escrotal hematoma (9 cases). Testicular atrophy appeared in 12 cases after descent and in 3 cases after the first stage of the FowlerStephens. In 8 cases it was necessary to proceed to a second descent because of ascent after surgery. Laparoscopic orchidopexy has proved to be an efficient technique for the management of NPT which unifies the advantages of MIS and the outcomes of the conventional opened approach.

[Short term evaluation of transanal pull-through with automatic suture]

For the last ten years many centres have adopted transanal pull-through (TP) as the first choice technique for the treatment of Hirschsprung's Disease (HD) affected children. We present our experience, based on the endorectal pull-through with autosuture, which has not been reported up to now. According to our HD management programme, TP with autosuture should be performed in rectosigmoid forms of HD which are easily handled with outpatient care. Seven patients with HD whose ages ranged from 5-months-old to 5-years-old underwent EP with autosuture. We present the short term results of the evolution of our patients. Firstly, a laparoscopic procedure is carried out in order to obtain a biopsy from the transition zone. The second stage consists of the TP following the De La Torre technique, modified by the 21 mm circular autosuture. No new surgical operation was necessary. Passage of stools started between the second and fourth postoperative day. The most frequent complication was abdominal distention, found in an 85.7% of patients and resolved before being discharged. Hospital discharge took place between the fourth and the tenth postoperative day. Oral feeding was started in the 2nd-7th postoperative day. Medium term outcomes show a single case of complications: a patient Developer a skin stricture due to the low suture, which has been treated conservatively with rectal dilatations. Patients older than three (42.8%) are continent, although one presents occasional fecal soiling. The rest of the children present normal stools for their age. Automatic suture involves several advantages such as celerity and safety. We ought to point out that this method should not be used in children under 5 months because the autosuture size does not allow to do so.

Antibodies to factor VIII in plasma of patients with hemophilia A and normal subjects

Non-neutralizing factor VIII (FVIII) antibodies (FVIII-Ab) in hemophilia A may be associated with an abnormal clinical response to FVIII concentrates. Patients with FVIII inhibitors may develop noncoagulation FVIII-Ab after the induction of immunotolerance. Natural FVIII-Ab may be detected in the plasma of some healthy subjects. The aim of this study was to analyze the presence of FVIII-Ab in the plasma of 53 normal blood donors and 124 patients with hemophilia A (18 patients had a previous history of FVIII inhibitor, but only 12 had inhibitor at the moment this study was performed). FVIIII inhibitor was measured using the Bethesda method. FVIII-Ab were analyzed by a specific ELISA assay using purified FVIII from a monoclonal concentrate and a standard plasma containing 26 Bethesda units (BU) of FVIII inhibitor. Purified FVIII was used to coat wells of a microtiter plate and was incubated with dilutions of plasma to be tested. Bound human IgG FVIII-Ab were detected by incubation with polyclonal sheep anti.human IgG alkaline phosphatase conjugate, and the OD405 was quantitated. A linear fit was obtained (by plotting FVIII-Ab positivity [OD 405nm] versus BU titer) when serial dilutions of this standard inhibitor plasma, containing titers of 0.5 BU or higher, were used. Four different levels of FVIII-Ab positivity [OD 405nm] were distinguished in this assay: Negative levels (-) were obtained with dilutions of the standard inhibitor containing < 0.5 BU. Mild levels (+) were obtained with dilutions of 0.5-5 BU. Moderate levels (+2) were obtained for dilutions ranging from 5-25 BU. Maximum positivity (+3) was obtained for dilutions of titers > 25 BU. FVIII-Ab positivity was detected in eight of the normal subjects (15%): three were found to be moderately positive (+2) and five mildly positive (+). No inhibitory activity was detectable when whole plasma was used. All the hemophilic patients with a presence of FVIII inhibitor at the time of the study were found to be positive for FVIII-Ab. In addition, the level of positivity correlated with the corresponding BU. Four of the six patients who had a history of inhibitory were negative and two positive. Twenty additional patients (16.12%) in whom no inhibitory activity was detected were found to be positive for FVIII-Ab: 16 + and four +2. The mean age of patients with FVII-Ab positivity was significantly higher than that of patients of the FVIII-Ab negative group (p < 0.005). In conclusion, FVIII-Ab positivity in patients with hemophilia A was 17.7% higher than the level of positivity detected by an inhibitory assay. We propose that this method for FVIII-Ab analysis could be used for patients with hemophilia A, at least to complement the functional inhibitor assay. FVIII recovery or half-life should be assessed in patients who test positive for FVIII-Ab and who show no evidence of inhibitor.