Nissen fundoplication in the management of gastroesophageal reflux occurring after repair of esophageal atresia.

BACKGROUND/PURPOSE: Gastroesophageal reflux is a major cause of complications after esophageal atresia repair. The suitability of the Nissen fundoplication in these patients is still disputed. Therefore, the authors evaluated the results of their prospective treatment protocol in those patients who underwent a Nissen fundoplication. METHODS: From 1984 to 1996, 125 patients underwent anastomosis for esophageal atresia. A Nissen fundoplication was later performed in 29 patients. The prospective protocol included x-ray after 10 days, 6 weeks, 12 weeks, 6 months, and 12 months. Forty-eight-hour pH measurements were performed between 6 and 12 weeks. Mean postfundoplication follow-up was at least 5 years (range, 2 to 13 years). RESULTS: Two of the 29 patients died after the Nissen fundoplication from unrelated causes. A third patient was excluded from the study group. Nineteen of the remaining 26 patients showed severe stricture. pH-metry succeeded in 18 patients, showing pathological reflux in 17. In 24 patients the fundoplication was performed between 1 and 24 months (median, 4 months), in the other 2 patients much later. In 4 of the 26 patients(15%) the Nissen proved to be insufficient and had to be redone. The remaining 22 patients had no short-term or long-term complications. CONCLUSION: The authors' findings in this group of patients, comparing them with the results reported in the literature, indicate that there is no reason to change their prospective treatment protocol nor their policy to perform Nissen fundoplications at an early stage.

Gastroesophageal reflux and Barrett's esophagus in adults born with esophageal atresia.

OBJECTIVE: Postoperative morbidity after correction of esophageal atresia is partly determined by gastroesophageal reflux disease, which has been proven to affect from one-half to two-thirds of patients during childhood. We conducted a follow-up study to test our hypothesis that, if former patients still show gastroesophageal reflux at adult age, they are at high risk for developing Barrett's esophagus, which is considered to be premalignant. METHODS: Of 69 patients born between 1971 and 1978, all having undergone a primary anastomosis, 24 had died, five of them because of aspiration. Of the 45 survivors, 39 could be traced; they all completed a questionnaire inquiring after symptoms related to the esophagus. Of these patients, 34 underwent an additional esophagogastrocopy. RESULTS: Only nine of the 39 patients had no symptoms at all; 30 had mild to severe dysphagia symptoms, and 13 had mild to severe reflux symptoms. Esophagogastrocopy in 34 patients revealed that the anastomosis was still recognizable in all cases, but stenoses were not found. Six patients showed a small hiatal hernia, and one a large one. The incidences of reflux symptoms (13/39, p < 0.01), reflux esophagitis (9/34, p < 0.01) and Barrett's esophagus (2/34, p < 0.001) were significantly higher than in the normal population. CONCLUSIONS: This group seems to be at risk for developing Barrett's esophagus. As this is the first follow-up study of a consecutive group of adult esophageal atresia patients, we think it is advisable to perform an esophagogastroscopy in all patients at adulthood until more long term follow-up data are available.

Normal ranges of 24-hour pH-metry established in corrected esophageal atresia.

BACKGROUND: This study was undertaken to determine baseline values of 24-hour pH-metry in children who had undergone correction for esophageal atresia. METHODS: A 24-hour pH-metry without medication was conducted in 13 patients with an uncomplicated postoperative course after correction of esophageal atresia. The pH-metry was performed in the hospital with a flexible glass electrode. RESULTS: The mean reflux index was 4.08%, the mean total number of reflux periods with a pH less than 4 was 21, and the mean number of periods of pH less than 4 lasting longer than 5 minutes was 2.5. CONCLUSIONS: Twenty-four-hour pH-metry values in asymptomatic esophageal atresia patients are the same as in children from the same age group with normal anatomy.

Prospective medical and surgical treatment of gastroesophageal reflux in esophageal atresia.

BACKGROUND: Gastroesophageal reflux is a major cause of anastomotic complications after repair of esophageal atresia. For this reason, we evaluated a prospective, postoperative treatment protocol with the emphasis on comparing medical and operative treatment. STUDY DESIGN: From 1994 to 1995, 26 consecutive patients underwent correction of esophageal atresia in the Sophia Children's Hospital. These patients were enrolled in a decision-making protocol meant to establish the effect of medical treatment on gastroesophageal reflux and stricture formation, the relation between anastomotic tension and reflux, and the question of whether performing a Nissen fundoplication was justified. Patients who showed reflux on the first postoperative x-ray were given medical treatment. Reflux was assessed after 6-12 weeks by x-ray and 48-hour pH-metry (24 hours with and 24 hours without medication). Evaluations were repeated at 18 weeks, 6 months, and 1 year. Twenty-three patients were followed for > or = 1 year. RESULTS: Twenty-four patients had classic esophageal atresia combined with tracheoesophageal fistula. Two had isolated atresia and underwent a colonic interposition. One of the others died of severe cerebral hemorrhage early after the operation. Twenty-two of the remaining 23 showed reflux on the first postoperative x-ray and were given medical treatment. The mean 3.8% total mild reflux time (range, 0.0-11.0%) decreased to a mean of 1.47% (range, 0.0-6.8%). Medical treatment given according to protocol did not influence severe reflux. Eleven of 23 patients showed stricture formation, requiring a mean of four dilatation procedures (range, 1-9). Defining a real stricture as one needing three or more dilatations, as seen in seven patients, the following results were seen: four nonrefluxing patients (proved by x-ray and pH-metry) needed a mean of 4.2 dilatations (range, 3-7), and three refluxing patients (proved by x-ray and pH-metry) needed a mean of 7.3 dilatations (range, 5-9). Three of seven patients with anastomotic tension had proved gastroesophageal reflux; reflux was also diagnosed in 8 of 15 patients without any tension on the anastomosis. Nine of 23 patients underwent a Nissen fundoplication according to the protocol. In four of them, this was decided because of severe reflux-associated respiratory problems; in one, for resistant stenosis after a Livaditis procedure; and in one with normal pH-metry, the procedure was done on clinical grounds. The latter patient needed an aortopexy at a later stage. A late fundoplication was performed in two patients for persistent gastroesophageal reflux unresponsive to medical treatment, and in one for persistent stenosis and reflux. In all patients, the outcomes were successful, without complications. CONCLUSIONS: Medical treatment of gastroesophageal reflux after repair of esophageal atresia has a distinct effect on the duration of reflux and could have a positive effect on the occurrence and treatment of stenosis. There is no clear relation between the occurrence of reflux and tension on the anastomosis. Nissen fundoplication according to the protocol was done appropriately in eight of nine patients.

Function of pediatric Nissen-Rossetti fundoplication followed up into adolescence and adulthood.

BACKGROUND: We analyzed the very long-term results of the Nissen-Rossetti fundoplication performed in young children. Little has been reported about follow-up longer than 5 years in homogeneous populations. This study concerns a homogeneous group with a minimum follow-up of 10 years; these former patients, therefore, are now adolescents or adults. STUDY DESIGN: In 24 consecutive patients without other congenital or acquired anomalies of the esophagus or stomach, we evaluated the primary postoperative diagnoses, symptoms of recurrent reflux, and their state of health in 1994. RESULTS: After a median follow-up of 16 years, the result was excellent in 18 patients, good in 5, and poor in I (graded according to Visick). Patients with recurring reflux symptoms had evidence of failure of the fundoplication. All but 1 had been given a diagnosis of recurrent reflux within 2 years after the operation. The situation after 2 years seems predictive for the later outcome. CONCLUSIONS: In almost all cases, the Nissen-Rossetti fundoplication is a long-lasting, effective treatment for young children with symptomatic gastroesophageal reflux.

[Favorable results of percutaneous endoscopic gastrostomy in children in need of long-term tube feeding]. / Gunstige resultaten van percutane endoscopische gastrostomie bij kinderen die langdurig sondevoeding nodig hebben.

OBJECTIVE: Analysis of indications, weight and peroperative and postoperative complications in 32 consecutive children who underwent percutaneous endoscopic gastrostomy (PEG). DESIGN: Retrospective. SETTING: Sophia Children's Hospital, Rotterdam, The Netherlands. METHOD: Survey of medical records. RESULTS: In 26 children the indication for PEG was necessity of prolonged tube feeding on account of severe psychomotor retardation. The 6 others had no such retardation and had various indications. Mean hospital stay was 6.7 days, median 6 days. Three patients had immediate postoperative complications: two had leakage, one infection. In 22 patients there were no late complications. One patients died following status epilepticus. One patient had a late peritonitis, and two others gastroesophageal reflux severe enough to require surgical intervention. Six patients had mild long-term complications, mainly infectious. All children showed improvement of weight for length. CONCLUSION: The PEG procedure is well-tolerated, effective way of tube feeding in children, with a relatively low complication rate.

Neonatal transport by helicopter in The Netherlands: a 7-year overview.

In the Netherlands, neonatal intensive care is provided in 10 neonatal intensive care centres. Although antenatal transport is preferred, each year more than 1000 newborns are transported to the centres, in the majority of cases by ambulance. Transport by helicopter became available in 1987. From June 1987 till December 1993, 583 infants were transported by helicopter (median gestational age 32 weeks, range 24-43). Forty-four per cent had a gestational age of less than 32 weeks. Four hundred and forty-six infants were mechanically ventilated. No baby died in transfer. After admission, 101 infants died (18.4%). There were no accidents during transport Ten per cent of the requested flights was cancelled because of weather conditions. The mean transport time of the babies was 36 min (range 10-145), and the mean transport time of the transport teams was 128 min (range 20-345). The transports carried out from 1987 to 1989 were recalculated with regard to duration and cost, assuming they were carried out by ambulance instead of by helicopter: for the babies, the mean transport time by helicopter was 75% less than the calculated mean transport time by ambulance. However, the financial costs per transport were on average Dutch florins (DFL) 3000 higher by helicopter than by ambulance. In the Netherlands, the use of a helicopter for neonatal transport reduces the transport time, but doubles the costs.

Lyophylized dura patch repair of congenital diaphragmatic hernia: occurrence of relapses.

During an 8-year period, 71 neonates with congenital diaphragmatic hernia were admitted to the Sophia Children's Hospital. Seventeen patients died before surgery. The other 54 patients underwent either direct suture (18) or patch closure with lyophylized dura (36), depending on the size of the defect. Forty patients survived. In 16 of them the defect was closed by direct suturing. In the other 24 patients a patch was used. Five recurrences of the defect occurred, all of them among the latter group.

Incidence and management of gastroesophageal reflux after repair of congenital diaphragmatic hernia.

During a period of 6 years, 31 of 54 infants with congenital diaphragmatic hernia survived and were evaluated to study incidence and management of gastroesophageal reflux. At 6 months' follow-up 16 patients had gastroesophageal reflux proven by upper gastrointestinal series; at 12 months' follow-up 11 patients. Three patients having gastroesophageal reflux did not respond to medical treatment and underwent Nissen fundoplication. We conclude that after successful treatment, congenital diaphragmatic hernia is likely to be complicated by gastroesophageal reflux. We could not define a predictive feature for gastroesophageal reflux in the individual patient surviving congenital diaphragmatic hernia.

Long-term survival of a patient with congenital short bowel and malrotation.

Since 1969, reports of 16 patients presenting with the congenital short bowel and malrotation syndrome have been published. The prognosis of this malformation is poor; only two patients survived. We present the history of a third patient, successfully treated with long-term survival.

Stenting of the ureterovesical anastomosis in pediatric renal transplantation.

From January 1985 to July 1989, 36 children received a renal transplant at our hospital. Their ages ranged from 2 to 18 years. All patients had a standard neoureterocystostomy according to Lich-Grégoir. In the first 18 patients, no transanastomotic stent was placed. In the latter 18, a transanastomotic stent with or without suprapubic bladder drainage was performed. In the nonstented group, six severe urological complications occurred, two of which eventually resulted in loss of the transplant. In the stented group, only one severe urological complication occurred. No kidneys in this group were lost due to urological complications. The number of urinary tract infections in the nonstented group was the same as in the stented group.

Total parenteral nutrition associated cholestasis: a predisposing factor for sepsis in surgical neonates?

Of 496 neonates and infants less than 1 year of age admitted to the paediatric surgical intensive care unit (PSICU) over a 5 year period (1983-1987), 94 required total parenteral nutrition (TPN) for more than 14 consecutive days, generally due to congenital anomalies of the digestive tract. Cholestasis occurred in 15 of them and 12 of these patients developed sepsis. In contrast, of the 79 patients on TPN that remained free from cholestasis, only 23 developed sepsis. The mortality rate for the TPNAC-group was substantially higher than for the group without TPNAC. It is suggested that development of TPNAC might lead to impairment of non-specific cellular immunity in neonates.

Total colectomy and ileorectal anastomosis in the treatment of total colonic aganglionosis: a long-term follow-up study of six patients.

Six patients with total colonic aganglionosis (TCA) with ileal involvement were treated with a total colectomy and ileorectal anastomosis according to Rehbein. Follow-up lasted from 1 to 7 years and showed no mortality. Postoperative management consisted of total parenteral nutrition initially, followed by gradual introduction of oral feeding beginning with a low-osmolarity low-residue diet, the use of loperamide, an adequate oral intake of salt, and regular bowel deflation. Major postoperative complications disappeared and all patients demonstrated weight gain by the end of the first postoperative year, with normal feeding and two to three soft stools per day.

Congenital diaphragmatic hernia: impact of preoperative stabilization. A prospective pilot study in 13 patients.

In case of congenital diaphragmatic hernia (CDH), survival generally depends not on prenatal diagnosis, planned delivery, and immediate postnatal operation, but on the gravity of pulmonary hypoplasia and persistent hypertension (PPH). Many vasoactive drugs have become available for lowering PPH, but the mortality rate for CDH still amounts to 40% to 70%. Preoperative stabilization might prevent or at least reduce the risk of PPH. This method was evaluated in a pilot study lasting 15 months and involving 13 patients. All were admitted to the pediatric surgical intensive care unit within six hours of birth, all requiring mechanical ventilation. Continuous suction of the stomach and bowel proved successful in reducing the mediastinal shift. Study parameters were alveolar-arterial oxygenation differences ((A-a)DO2), mean airway pressure (MAP), oxygenation index (OI), and ventilation index (VI), measured on admission and at set times before and after surgery. Eight patients did not survive, but in two cases death was not directly related to CDH. The following conclusions were reached: (1) satisfactory ventilation parameters on admission will remain good during the preoperative stabilization phase and will not be affected by its duration or by subsequent surgery, spelling survival; (2) unsatisfactory ventilation parameters on admission may improve with preoperative stabilization, giving these patients a better chance of survival; and (3) poor ventilation parameters on admission that fail to improve with preoperative stabilization will not improve with surgery or postoperatively, spelling death.

Double-sided psoas abscess in a young infant: sonographic and radiographic findings.

Psoas abscess is rare in children and is exceptional in the neonatal period. A sonographically and radiographically well-documented case of double-sided primary psoas abscess in a few-week-old infant is presented. To our knowledge this is the first description of a case of double-sided psoas abscess in a neonate.