Obstructive jaundice caused by placement of a nasoenteric feeding tube.

Nasoenteric feeding tubes are a safe and effective means for providing nutritional support to the critically ill patient. Serious complications have been reported, but usually are the result of an improper path of the tube during placement. The authors report a case of ampullary obstruction and jaundice caused by a nasoenteric feeding tube, presumably caused by coiling of the tube in the duodenum. This report represents the first such case in the literature.

Fetal midgut volvulus presenting at term.

This report describes a rare case of intrauterine midgut volvulus that presented at term. The pregnancy was uncomplicated. There were no signs of fetal distress or polyhydramnios, and the child was delivered vaginally. This patient had the unusual presentation in that at the time of delivery, the patient was distended and acidotic. She immediately required an extensive resection of gangrenous small bowel. Comparing this case to the 10 other cases of fetal intestinal volvulus that have been reported, it seems this child was particularly fortunate that the volvulus occurred at a point in gestation when she was mature enough to tolerate birth and surgery. This case is also the first demonstration that volvulus can present with abdominal distension in the immediate newborn period.

Repair of pediatric pectus deformity and congenital heart disease as a combined procedure.

Coexisting pectus deformity and congenital heart disease is not uncommon. Traditionally, the approach to this problem has been to repair each one with a separate surgical procedure because of fear of increased complications from bleeding, infections, and anesthesia. More recently, many reports of successful combined repair have been published, particularly in adults with coronary artery or aortic pathology. The authors wished to determine the feasibility of this combined procedure in younger patients, particularly those with a severe pectus deformity. Three patients underwent repair, including a 17 year old with Marfan's syndrome and a severe pectus excavatum deformity. The postoperative course was smooth for these patients, and all had good short- and long-term (over 18 months) results.

Percutaneous peritoneal drainage in the management of acute intestinal perforation.

This case series describes the use of percutaneous peritoneal drainage when it is performed as the definitive treatment for acute intestinal perforation. Seven extremely low birth weight neonates who were admitted to a neonatal intensive care unit of a regional center between March 1987 and October 1992 had acute intestinal perforation. Six neonates were initially treated with percutaneous peritoneal drainage while they were under local anesthesia. Despite reports that percutaneous peritoneal drainage alone can be curative in intestinal perforation, this approach without adjunctive surgery can delay the recovery of bowel integrity.

Primary extrarenal Wilms' tumor in the inguinal canal: case report and review of the literature.

Inguinal and scrotal Wilms' tumors are extremely rare; only 15 cases have been reported to date. The authors report a case of inguinal Wilms' tumor (stage III), which occurred in a previously healthy 3 1/2-year-old boy who was staged and treated according to currently accepted National Wilms' Tumor Study III criteria. The exact embryological origin of this tumor has not been determined. However, there is evidence that the origin is more primitive than that of intrarenal Wilms' tumor.

Fundoplication and gastrostomy in familial dysautonomia.

Fundoplication with gastrostomy has become a frequent treatment for patients with familial dysautonomia, so we evaluated the use of both procedures in 65 patients. Although patients differed widely in presenting signs and age, from 5 weeks to 40 years, gastroesophageal reflux was documented in 95% of patients by cineradiography or pH monitoring. Panendoscopy was a useful adjunct. Preoperative symptoms of gastroesophageal reflux included vomiting, respiratory infections, and exaggerated autonomic dysfunction. Severe oropharyngeal incoordination frequently coexisted and resulted in misdirected swallows with aspiration, dependence on gavage feedings, or poor weight gain and dehydration. Follow-up after surgical correction ranged from 3 months to 11 years; 55 patients (85%) were available for a 1-year postoperative assessment. We had no instances of surgical death. The long-term mortality rate was 14%, primarily related to severe preexisting respiratory disease. Beyond the first postoperative year, 30 patients had pneumonia attributed to continued aspiration, exacerbation of preexisting lung disease, or recurrence of gastroesophageal reflux. Of 11 patients who vomited postoperatively, six had recurrence of reflux. Recurrence of gastroesophageal reflux was documented in eight patients (12%), and we revised the fundoplication in three patients. The number of patients with cyclic crises was reduced from 18 to 7; retching replaced overt vomiting in all but two of these seven patients, neither of whom had recurrence of reflux. Because oropharyngeal incoordination was prominent, concomitant use of gastrostomy and an antireflux procedure was especially effective in the treatment of younger patients with familial dysautonomia, before the development of severe respiratory disease. Despite the development of severe morning nausea in 15 patients, the combination procedure resulted in significantly improved nutritional status, decreased vomiting, and decreased respiratory problems. Appropriate use of gastrostomy feedings also contributed to success of the operation. The generally good outcome of fundoplication with gastrostomy confirms the benefit of this procedure in familial dysautonomia.