Preterm elective caesarean section and early enteral feeding in gastroschisis.

AIMS: To evaluate the effect of elective caesarean section (CS) before term and early enteral nutrition on length of parenteral nutrition and hospital stay in infants with gastroschisis. METHODS: Retrospective review of all infants with gastroschisis treated in a regional level III hospital from 1993 to 2008. During 1993-97, there was no established standard for management of pregnancy or delivery while a protocol on close foetal monitoring and early elective CS was adhered to for 1998-2008. Introduction of human milk on the first day after complete closure of the abdominal wall and rapid increase was the policy during the whole period. RESULTS: With early elective CS, no foetal deaths occurred after 28-week gestational age (GA). Ten infants were born during the first period and 20 during the second period at a median GA (range) of 36.5 (34-40) and 35 (34-37) weeks (p = 0.013). Seven and 20, respectively, were born by CS. Median (range) days before full enteral feeds and hospital stay were 11.5 (7-39) and 13.0 (7-46) (p = 0.85), and 17.5 (12-36) and 22.5 (13-195) (p = 0.67), respectively. One child died of volvulus after discharge. CONCLUSION: Close surveillance of pregnancy, elective preterm caesarean section, early surgery and active approach to primary closure and early enteral feeds appears to be a safe and effective line of management in gastroschisis.

Gastro-oesophageal reflux and chronic respiratory disease in infants and children: surgical treatment.

BACKGROUND: Many infants have chronic respiratory symptoms related to gastro-oesophageal reflux. The reflux seems to be due to a motility disorder, possibly because of an immature neuro-hormonal system. Most infants outgrow the disorder. Infants and children with severe symptoms and poor response to medical treatment may benefit from operation. Nissen fundoplication is the most commonly used procedure. In some children it is necessary to add a pyloroplasty to the fundoplication because of slow gastric emptying. METHODS: From May 1991 to March 1993 eight children with severe gastro-oesophageal reflux disease were operated on using the Nissen fundoplication procedure. RESULTS: Seven to 29 months after the operation all children are much better. CONCLUSIONS: Children who do not respond to 6 weeks with aggressive medical treatment should be referred to surgery.

[Conservative treatment of blunt liver injuries]. / Konservativ behandling av stumpe leverskader.

15 patients with blunt liver injuries were treated without operation. The extent of the injury was evaluated by computed tomography and median score was 3 (according to Mirvis and co-workers) (range 2-4). The mean lowest haemoglobin concentration was 10.4 g/100 ml (range 7.0-15.8). Two patients needed blood transfusion and two developed complications, one of which was related to the liver injury (cyst). No patient died, and mean hospitalization time was 11 days. This encouraging experience prompted the introduction of a treatment programme formalizing initial investigation and observation in such patients. Most patients with blunt liver injuries can be treated non-operatively. Surgery is indicated only if bleeding leads to haemodynamic instability or if other intraabdominal injuries are suspected.

Surgical treatment as a principle in patients with advanced abdominal carcinoid tumors.

Seventy-five patients with advanced abdominal carcinoid tumors (65 midgut, 10 others) have been examined retrospectively to evaluate the role of surgical treatment as a principle, irrespective of stage of disease. Eighteen of 52 patients (35%) exhibited the carcinoid syndrome. Two or more primaries were found in 39% of patients with midgut lesion, 81% of these patients had regional metastases, 5% of these patients had distant lymph node metastases, and 74% of the patients had liver secondaries. All patients underwent operation, an additional 34% of the patients had a further reoperation, 9% of the patients had a second reoperation, 3% of the patients had a third reoperation, and one patient (2%) had a fourth reoperation. Intraoperative debulking (liver excluded) was performed in 33% of the patients, and 48% of the patients had treatment (resection, hepatic artery ligation, embolization) directed at the liver. The postoperative mortality rate was 2% after the primary operation for midgut lesions. The median survival for midgut tumors was 92 months, compared to 40 months for other lesions (not significant). A significantly higher survival rate was revealed for those patients with midgut lesion who were undergoing intraabdominal debulking procedures (liver excluded); median survival was 139 months versus 69 months without debulking. For those patients with liver metastases, median survival after intervention was 216 months and 48 months without such treatment (p less than 0.001). It is concluded that resection of intraabdominal carcinoid tumor masses can be performed in a high proportion of patients. Despite the retrospective, uncontrolled nature of this study, the difference in survival probabilities in favor of aggressive surgical therapy is so marked that it is not unreasonable to conclude that surgery has played a role in prolonging life in these patients.

[A Norwegian polyposis family. From catastrophe to prevention]. / En norsk polyposeslekt. Fra katastrofe til profylakse.

A Norwegian polyposis family (PP29) including ten affected cases over five generations is reported with clinical case histories. In the first three generations one patient died in her thirties of "tuberculosis" and the other five affected patients died of gastrointestinal cancer. Of 12 at risk in the 4th generation, three had polyposis and underwent prophylactic colectomies, six were normal at regular follow-up rectoscopies till 35-40 years of age and three avoided examination. One of four at risk persons in the 5th generation had polyposis and underwent colectomi with ileoanal anastomosis. DNA-typing using D5S71 (p11c11) showed segregation which confirmed linkage and almost ruled out the possibility of any of the three non-controlled at risk persons being polyposis gene carriers. Another family (PP11) illustrates how typing, using the probe D5S71, may allow early and prenatal diagnosis.

Pancreatic duct occlusion in the rat: report and assessment of a new technique.

Temporary reduction of the exocrine pancreatic secretion may be desirable in various experimental models. In the rat this can be achieved by obstructing the connection between the pancreas and the duodenum. A new, simple technique of pancreatic duct occlusion using metal hemostatic clips is described. The reduction of secretion produced by the procedure was assessed by measuring duodenal protein, amylase, and trypsin during stimulation with cholecystokinin. Stimulated duodenal amylase activity 1 and 4 weeks following duct occlusion was reduced by approximately 80% compared with sham-operated controls, whereas proteolytic activity was reduced by 96 and 60%, respectively. The magnitude and duration of pancreatic insufficiency achieved by this technique is equivalent to that achieved with more complicated methods.

Influence of pancreatic secretion on late radiation enteropathy in the rat.

In female Wistar rats a 10 cm long exteriorized mid small intestinal segment was roentgen irradiated 3 weeks after a pancreatic duct-occluding operation/sham operation. Roentgen doses were 19 and 21 Gy as single exposures. Radiation injury was assessed 2, 8 and 26 weeks after irradiation using one macroscopic and 7 histopathologic parameters. The parameters were graded according to severity, and a radiation injury score was calculated by adding the scores for the individual parameters. Two and 8 weeks following irradiation there was no difference between pancreatic duct-occluded and sham operated animals. Twenty-six weeks after irradiation all parameters of radiation injury except the extent of vascular sclerosis were less marked in pancreatic duct-occluded rats than in controls. It is concluded that exocrine pancreatic secretions may influence the development of late changes following irradiation, and that these changes seem to be mainly independent of the degree of vascular sclerosis.

The effect of guar gum and fiber-enriched wheat bran on gastric emptying of a semisolid meal in healthy subjects.

The effect of physiological doses of guar gum (Guarem), 5 g, and fiber-enriched wheat bran (Fiberform), 10.5 g, on gastric emptying was studied by two different methods in healthy subjects: by a simple isotope localization monitor placed over the upper part of the abdomen and by gamma camera. The fiber preparations were added to a semisolid meal consisting of wheatmeal porridge and juice, using technetium-99 DTPA as a marker. The gamma camera showed no effect of fiber on gastric emptying. The isotope localization monitor, however, indicated that Fiberform prevented a postprandial accumulation of the meal within the upper part of the stomach. The simple isotope localization monitor cannot be recommended for measurements of gastric emptying.