Major neonatal surgery under local anesthesia: a cohort study from Bangladesh.

BACKGROUND: Surgeons and anesthetists must respond to the perioperative mortality associated with general anesthesia in developing countries. The safety of performing major neonatal surgery under local anesthesia is one pragmatic response. This study describes and evaluates such practice in a tertiary pediatric surgery center in Bangladesh. METHODS: Seven hundred and twenty neonates were admitted for major surgery during a 3.5-year study period. Hundred and fifty two neonates died pre-operatively, and 568 underwent major neonatal surgery. 352 (62.0%) neonates were operated under general anesthesia, while the 216 most fragile neonates (38.0%) were operated with local infiltrative anesthesia alone. Medical files were reviewed; data were collected prospectively; mortality risk factors were assessed by univariate and multivariate analysis. RESULTS: Two hundred and sixteen procedures were performed under local anesthesia: sigmoid colostomies (37.5%), laparotomies with anastomosis (21.3%), anoplasties (18.1%), laparotomies with enterostomy (8.3%), closures of abdominal wall defects (6.9%), fixations of silastic bags (3.7%), peritoneal tube drainage (2.3%), and gastrostomies (1.9%). Median weight was 2,400 g (2,200-2,460), median gestational age was 37.0 weeks (36.0-38.0), and median age at surgery was 5.0 days (3.0-14.7). In-hospital postoperative mortality was 10.6% among those selected for local anesthesia, and 11.4% among neonates operated under general anesthesia. Low birth weight was an independent risk factor for mortality on multivariate analysis (OR 1.002 g(-1), 95% CI [1.000-1.004], p = 0.029). CONCLUSIONS: Local anesthesia is an established option for the most fragile neonates with major surgical disease. Safe anesthesia ought to be accessible to all children of the world. The global pandemic of perioperative mortality needs to be addressed.

Transanal endorectal vs. Duhamel pull-through for Hirschsprung's disease.

INTRODUCTION: The aim of this study was to test the hypothesis that the early functional outcome for patients with rectosigmoid Hirschsprung's disease (HD) is comparable for the Duhamel pull-through procedure and the transanal endorectal pull-through (TERPT) procedure, with less discomfort for the patient postoperatively after the TERPT technique. MATERIAL AND METHODS: Eleven patients operated on with the TERPT technique (T Group) were prospectively registered and compared retrospectively with 18 patients operated on with the Duhamel pull-through (D Group). Data recorded included patient demographics, operative treatment, complications, hospital stay and bowel functions. The follow-up time was limited to 24 months. RESULTS: The T Group started oral feeding sooner, their bowel movements started sooner and they had less need for analgesia postoperatively and a significantly shorter hospital stay. 71% of the patients in the D Group needed re-intervention compared to only 18% of the T Group. Enterocolitis was seen in two patients in both groups. At the last clinical control ten patients had constipation (59%) and three had soiling (18%) in the D Group. Three patients in the T Group had constipation (27%) and one had soiling (9%). CONCLUSION: Our results support the use of the TERPT method rather than the Duhamel pull-through for rectosigmoid HD.

Congenital diaphragmatic hernia: improved surgical results should influence abortion decision making.

AIMS: To compare surgical results for congenital diaphragmatic hernia (CDH) in two Scandinavian university hospitals and to evaluate the effects of abortions on the clinical profile of CDH in Iceland. METHODS: A retrospective study including all CDH-cases in Iceland 1983-2002 and children referred to Lund University Hospital 1993-2002. Aborted fetuses with CDH from a nation-wide Icelandic abort-registry were also included. RESULTS: In Iceland, 19 out of 23 children with CDH were diagnosed < 24 hours from delivery, one with associated anomalies. Eight fetuses were diagnosed prenatally and seven of them aborted, three having isolated CDH at autopsy. In Iceland, 15 of 18 children operated on survived surgery (83% operative survival). In Lund 28 children were treated with surgery, 23 of them diagnosed early after birth or prenatally. Four children did not survive surgery (86% operative survival) and 9 (31%) had associated anomalies. All the discharged children treated in Iceland and Lund are alive, 3-22 years postoperatively. CONCLUSION: CDH is a serious anomaly where morbidity and mortality is directly related to other associated anomalies and pulmonary hypoplasia. However, majority of CDH patients do not have other associated anomalies. In spite of improved surgical results (operative mortality < 20%), a large proportion of pregnancies complicated with CDH are terminated. We conclude that the improved survival rate after corrective surgery must be emphasized when giving information to parents regarding abortion of fetuses with a prenatally diagnosed CDH.

48-hour wireless oesophageal pH-monitoring in children: are two days better than one?

BACKGROUND: Use of a catheter-free, radio telemetric, oesophageal pH-monitoring system in paediatric clinical practice allows patients to follow a more normal physiological pattern of activities and causes less discomfort. At our institution, placement of the capsule is done under general anaesthesia, which restricts the child's activity during the first day. The aim of this study was to determine whether oesophageal pH-measurements should be performed over 48 hours or whether 24-hour measurement provides sufficient and reliable results. CHILDREN AND METHODS: The study included 24 consecutive children with symptomatic gastro-oesophageal reflux problems who had undergone upper gastrointestinal endoscopies under general anaesthesia. The radio-transmitting Bravo capsule was introduced transorally and placed above the diaphragm at a width of two vertebral bodies. Oesophageal acid exposure was monitored via a portable receiver for 48 hours. The children's symptoms during measurements were registered. Wilcoxon signed rank test for paired samples was used after power analysis. RESULTS: The capsule was successfully attached to the oesophageal mucosa in all cases with minor technical problems in only one patient. The 48-hour pH-monitoring was completed in 23 patients. The median percentage time with an oesophageal pH of less than 4 was 5.4 +/- 6.8 for the first 24 hours and 5.8 +/- 7.4 for the 48-hour measurement. The DeMeester score was 20.5 +/- 23.7 and 22.2 +/- 25.7, respectively. CONCLUSIONS: Ambulatory pH-monitoring using the wireless system is feasible and safe. It was well-tolerated by the children. There was no statistical difference between the pH-measurements or DeMeester scores during the first 24 hours compared with the 48-hour measurements. Individual variations were noted but had no clinical significance except in two patients. Our results support the use of pH-measurement for a period of 24 hours only.

CART-peptide immunoreactivity in enteric nerves in patients with Hirschsprung's disease.

AIMS: Cocaine- and amphetamine-regulated transcript (CART)-peptide is found in the brain and participates in the control of feeding behavior. It is also expressed in the peripheral nervous system and is suggested to have neuromodulatory and/or neurotrophic effects in rat intestine. The aims of this study were to investigate the presence of CART-peptide in the normal ganglionic as well as aganglionic intestine from patients with Hirschsprung's disease and the peptide's possible coexistence with other neurotransmitters. METHODS: Intestinal specimens from nine patients with Hirschsprung's disease were examined using immunohistochemistry. A double immunostaining technique was used in order to elucidate the presence of CART-peptide in NOS and VIP-containing enteric neurons. RESULTS: In ganglionic intestine, CART-peptide was found in numerous nerve fibers, predominantly within the smooth muscle layers and in myenteric nerve cell bodies. A high degree of co-localization of CART with NOS and VIP was seen. Only very few CART immunoreactive nerve fibers and no nerve cell bodies were found in the aganglionic intestine. CONCLUSIONS: This is the first report on the presence of CART-peptide in the human intestine. In the ganglionic intestine CART was detected mainly in myenteric neurons, while only very few CART-IR nerve fibers were found in the aganglionic intestine. This, together with the coexistence of CART with NOS and VIP, indicates an intrinsic origin of the CART-containing neurons and suggests that CART may influence NO and VIP-induced effects.

Etiology of portal hypertension may influence gastrointestinal transit.

BACKGROUND: Gastrointestinal transit studies have shown contradictory results in patients with portal hypertension. We have studied gastric emptying. small-bowel transit and colonic transit in patients with portal hypertension. The association between small-bowel bacterial overgrowth and gastrointestinal transit was assessed. METHODS: Sixteen patients (6 females) with portal hypertension and esophageal varices were included. A newly developed radiological procedure was used to measure gastrointestinal transit during one visit. Variceal pressure was measured and culture of small-bowel aspirate was used to diagnose small-bowel bacterial overgrowth. The results were compared to results obtained in 83 healthy subjects. RESULTS: Half gastric emptying time in male patients was 3.8 (0.9-5.8) h versus 2.5 (0.4-4.0) h in healthy males (median and percentile 10-90: P < 0.05). Small-bowel residence time in male patients was 5.9 (2.0-13.7) h versus 3.2 (1.5-6.0) h in healthy males (P < 0.05). Small-bowel residence time in patients with bacterial overgrowth was significantly longer than in patients without bacterial overgrowth. Small-bowel residence time was also significantly longer in male patients with alcoholic cirrhosis as compared to male patients with other causes of portal hypertension. Colonic transit in all patients and gastric emptying and small-bowel transit in female patients were not significantly different from healthy subjects. CONCLUSION: Etiology of liver disease and gender may influence transit in patients with portal hypertension. Small-bowel bacterial overgrowth was associated with delayed small-bowel transit.

[Home mechanical ventilation in Iceland.].

OBJECTIVE: To describe the users of home mechanical ventilation treatment in Iceland. MATERIAL AND METHODS: Records for all patients in Iceland using noninvasive ventilatory support at home on April 30th 1999 were analysed. RESULTS: A total of 54 patients were using ventilatory support at home. There were 33 males and 21 females. The mean age for the group was 61 years. The mean treatment time was 3.5 years. The majority were using pressure controlled ventilators that were connected to a nose mask or full face mask. The most common reason for treatment was decreased respiratory muscle function. In 11 patients this was secondary to muscle- or neurological diseases, in nine from TBC sequelae and in six post polio or from idiopathic kyphoscoliosis. In addition there were 21 patients that had a combination of chronic obstructive pulmonary disease and sleep-related breathing disorder. Cheyne-Stoke breathing secondary to congestive heart failure was the reason for home ventilatory treatment in five males and two females. These patients had relatively normal spirometric and bloodgas results, which is in contrast to the rest of the group, where spirometric values were on the average less than 50% of predicted. Arterial blood gases commonly showed hypoxia and 16 of the patients had long-term oxygen therapy (over 16 hrs/day). CONCLUSIONS: Home ventilatory treatment has become part of medical treatment in Iceland and benefits patients with decreased ventilatory function, especially during sleep.