Peri-operative high-dose V post-operative low dose steroid therapy in the management of biliary atresia: a preliminary report

The use of high-dose steroid therapy peri portoenterostomy may have a positive impact on the frequency of cholangitis and survival rate. A prospective study was conducted on two groups of patients [less than three months of age] suffering from biliary atresia from 1999 to 2005. The patients in group I [G I] were managed peri-operatively by high-dose methylprednisolone while the other group [G II] received low dose methylprednisolone only post-operatively [2mg/k/day for 1 month]. Infants in GI [n = 30] received methylprednisolone for 3 successive days before operation [10-8-6mg/kg/day], and 10 mg/k at the day of operation respectively. Thereafter the dose was tapered in the next successive 6 days by 8, 6, 5, 4, 3, and 2 mg/kg/day and continued for one month. Seventy two infants with biliary atresia were operated [39 girls and 33 boys]. Twenty-six of the 30 patients [86%] in G I became jaundice-free within 90 days after portoenterostomy while only seven [15%] of the 42 patients in G II had normal bilirubin [P < 0.0001]. Episodes of postoperative cholangitis in G I were 20% [6 of 30], and 53% [24 of 42] in G II [P < 0.005]. The difference in 3-year survival rate between the two groups is also remarkable: Eighty seven percent [26 of 30] in GI versus 29% [13 of 45] in G II [P < 0.005]. Death related to biliary atresia occurred in 1 [3.3%] patient in GI compared with 12 [29%] patients in G II [p < 0.005]. These results provide strong evidence that peri-operative high dose steroid therapy is not only safe in this patients population, but because of its anti-inflammatory and cholerrhetic effects has a positive impact on preventing recurrent cholangitis, and ultimately survival

Bowel movement patterns in children with acute appendicitis

Acute appendicitis is currently one of the most important causes of acute abdominal peritonitis and emergency laparatomy. Despite its low mortality, it remains a cause of concern for surgeons due to the postoperative complications of wound infection, sepsis, intrabdominal abscess and even bowel obstruction resulting from adhesions. High incidence of acute appendicitis provides a strong impetus for further studies. This study was conducted to determine the bowel movement patterns and dietary fiber consumption in pediatric patients with appendicitis in Shiraz, southern Iran. The study included 202 pediatric patients under the age of 18 years at Nemazee Hospital affiliated to Shiraz University of Medical Sciences, who had undergone appendectomy with the preoperative diagnosis of acute appendicitis from March 2003 to March 2004. Using a written semi-standard questionnaire, the variables recorded were age, gender, stool consistency, number of bowel movements, type of bread consumed, habit of fruit and vegetable consumption, clinical presentation [signs and symptoms] and the time taken from the onset of symptoms to arrival in hospital, the date of patients admission to the emergency room to the time of surgery, and the duration of postoperative hospitalization. The pathology of appendicitis was clarified and recorded. The patients aged from 3-18 years [mean: 11.2 +/- 3.6 years], with a male to female ratio of 2:4. Anorexia was the most common symptom, affecting 78.7% of patients. Of 31 patients with constipation, 58% did not report daily regular intake of fruits while the others had regular fruit intake. Only 3 patients [9.7%] had regular daily consumption of vegetables, and 27 patients [87.1%] had pathology reports of fecalith, while in the nonconstipated patients, only 1.2% had such reports. The abdominal pain was periumbilical in many patients [42.6%], which shifted to McBurny point in most [96%] patients. 134 patients [66.3%] visited a health center within 24 hours after the first symptoms. Surgeries were performed on 132 patients [65.3%] within 6 hours, on 67 patients [33%] within 6-12 hours, and on 3 patients [2%] in more than 12 hours. Our findings suggest a high rate of constipation in patients with lower fiber intake, which is consistent with the hypothesis indicating the role of dietary fibers in lowering the incidence of appendicitis

Plasma concentrations of oral metronidazole in the early post-laparotomy periods

The bioavailability of metronidazole after oral ingestion, in ordinary conditions, is quite similar to intravenous administration of the drug. However, the degree of its absorption is not known in the early periods after laparotomy. To determine plasma levels of metronidazole in pediatric patients following elective abdominal surgery. The study group was comprised of 25 pediatric patients with mean age of 8.25 years. They took 10 mg/kg metronidazole [ingested or taken via nasogastric tube] a few hours after operation, followed by every eight hours for a total of three successive doses. We obtained blood samples 1-2 hours after each drug intake. The mean +/- SD of plasma drug concentrations after the first, second and third doses were 1.43 +/- 0.81, 6.26 +/- 3.86 and 10.21 +/- 4.28 micro g/ml, respectively, showing a significant rise after each dose [p<0.001]. The majority of patients [84%] obtained a level equal to, or above the minimal bactericidal concentration [MBC] after the third dose. Ninety-two and 96% of patients achieved the plasma minimal inhibitory concentration or higher following the second and third doses, respectively, as compared to 4% after the first dose [p<0.00001]. Absorption of oral metronidazole after elective laparotomy is disturbed only temporarily, as in the majority of patients the drug attains an acceptable level before the second post-operative day. Therefore, parenteral metronidazole therapy, if necessary, is recommended only during the first 24 hours, and it may be replaced by oral preparation afterward

Hypothalamo-pituitary response before and after surgical stress [splenectomy] in Thalassemic patients

Multiple endocrinopathy is a common manifestation in thalassemia. Although the response of the stress hormones to induced hypoglycemia has been studied in these patients, the impact of surgical stress is not yet determined. The hypothalamo-pituitary-adrenal axis of 27 thalassemic patients [TP], [4-15 years old [y.]] admitted for splenectomy, was evaluated before and after surgical stress during 1996-8. Blood samples for measurement of ACTH, cortisol, growth hormone [GH], thyroid stimulating hormone [TSH] and prolactin [PRL] were taken a day before and also approximately two hours after surgical insult. For comparison, 22 non-thalassemic patients [NTP] [3.5-14 y.] admitted for elective laparotomy, were selected as the control group. The cortisol response after surgical stress was significantly higher than baseline in both the TP [17.4 +/- 6.3 vs 30.81 +/- 11.49 micro g/dl; P<0.001] and the NTP [20.65 +/- 9.1 vs 36.87 +/- 11.08 micro g/dl; P<0.001]. NTP showed a significant elevation of ACTH upon surgical stress [P<0.001], while the difference between pre- and post-stress ACTH was not statistically significant in TP [P=0.123]. However, the ACTH concentration before operation in TP. was significantly higher than that of NTP [P<0.042] with no remarkable difference after surgical stress between the two groups [P=0.261]. GH increased significantly after operation in TP and NTP [P< 0.016 and <0.05, respectively]. A significant change in TSH [P< 0.03] and PRL [P< 0.004] was also observed in TP after operation. The hypothalamo-pituitary as well as the pituitary-adrenal axes are usually intact and responsive in TP. It is concluded that, the remarkable increase in ACTH concentration before operation may be due to a decreased adrenal reserve. Thus, the possibility of primary partial adrenal insufficiency, particularly under stress situations, should be considered in every thalassemic patient

Modified duhamel operation using a newly designed crushing clamp

Using a newly-designed crushing clamp, modified Duhamel Operation [MDO] was performed in 15 children aged between 2 to 8 years with Hirschsprung's disease. Post-operative recovery was uneventful in all patients. No clamp-related complication was observed. Complete bed rest was not necessary for more than 3-4 days. The clamp was passed spontaneously 8-11 days after operation. Endoscopy 3-4 weeks later did not reveal any colo-rectal septum in the neo-rectum in any patient. Performing MDO using this instrument is convenient to the patient. More importantly, with equal efficacy, it is more cost-effective as compared to the currently used GIA stapler

Ano-rectal anomaly associated with Hirschsprung's disease

Two hundred and eighty-one patients with ano-rectal malformation [ARM] were treated between September 1983 and August 1994. The criteria for consideration of the patient as a probable case of Hirschsprung's disease [HD] in the absence of anal stenosis were: 1] constipation unresponsive to medical therapy; 2] anastomotic leakage following closure of colostomy after ano-rectoplasty. Posterior ano-rectal myectomy [PARM] was carried out as a diagnostic step. If the patient was still symptomatic and the myectomy specimens showed histologic signs of HD, a definitive procedure was performed. Eighteen patients [6.4%] proved to have HD. No instance of HD was observed in high type malformations [28 patients] and cloacal anomalies [3]. However, 13 of 123 patients with low ARM [10.5%] and 5 of 127 patients with intermediate anomalies [3.93%] had HD [P< 0.05]. FARM was therapeutic in the 5 patients with ultrashort HD, all of whom had low ARM. The remaining 13 patients [8 low, 5 intermediate] had to undergo a definitive procedure. In conclusion: 1. association of HD with ARM, especially low types, is not uncommon. 2. biopsy of the rectal wall is recommended at the time of correction of low and intermediate ARM. 3. PARM may be therapeutic in HD, especially if associated with low type anomalies

Does oral metronidazole reduce complications in acute appendicitis?

In order to determine the effect of oral metronidazole [OM] in acute appendicitis, a prospective study was carried out in 305 adult patients [age: 15 - 50 yrs, mean: 25.5 yrs], randomly divided into a study group [SG] and a control group [CG]. In uncomplicated cases, the SG received OM 500 mg 2 hours pre-operatively and starting 5-6 hours post-operatively every eight hours for a total of three doses. The same dose schedule was continued for another three to five days in the SG if the appendicitis was complicated. A routine combination of penicillin, chloramphenicol and gentamicin was administered for the CG in complicated cases. No drug reaction was observed. The rate of wound infection was similar in both groups presenting with the same degree of pathology. There was no intra-abdominal collection. Length of hospitalization was one day shorter and hospital cost per day was 50% less in complicated cases in the SG as compared to the CG. In conclusion, OM is a safe and cost-effective drug that can be used both in simple and complicated appendicitis

Medical and surgical management of intestinal malacoplakia

During the last 7 years diagnosis of intestinal malacoplakia [MP] has been confirmed in 5 children and one adult, either by colonoscopy with tissue biopsy or fine needle aspiration [FNA]. All children had chronic abdominal pain, bloody diarrhea, low grade fever and irregular abdominal mass with signs of partial intestinal obstruction. The adult patient had the same symptoms with no mass. Complete resection was possible in only one child with no evidence of recurrence. The adult patient developed recurrence in the ileum and rectum 2 years after total colectomy and ileo-proctostomy. Four patients had unresectable tumors, all of whom also had hydronephrosis. Of these patients who were all handled by ileo-sigmoidostomy as a bypass, ileostomy or right transverse colostomy, 2 died 1-3 months later. In the presence of abdominal mass, diagnosis is feasible by FNA. However, colonoscopy is mandatory for appropriate decision and management. Intestinal MP should be managed seriously because of its aggressive nature. If diagnosed early, MP may be cured by medical therapy alone or by resection with or without adjuvant medical therapy. An underlying immunosuppressive disorder should also be looked for