The outcome in newborns with congenital diaphragmatic hernia in a Norwegian region.

AIM: To evaluate the therapeutic strategies used in neonates with congenital diaphragmatic hernia (CDH) during the last 15 years in our department. METHOD: A retrospective study of 27 neonates with CDH treated at the Neonatal Intensive Care Unit at Ullevaal University Hospital between 1992 and 2006. Since 1992 we have used delayed operative repair and high-frequency ventilation (HFV). Because surfactant replacement and inhaled nitric oxide (iNO) therapy have been used since 1997, we divided the patients into two groups; group 1 from 1992 to 1996 (9 patients) and group 2 from 1997 to 2006 (18 patients). RESULTS: The overall survival was 70%. Group 1 had an exceptionally good outcome, 100% survival versus 56% in the last group. CONCLUSION: Pulmonary hypoplasia and pulmonary hypertension are still the most challenging factors in treatment of neonates with CDH, despite novel therapeutic modalities, such as HFV, surfactant and iNO. Delayed surgery in CDH allows pre-operative stabilization. Extracorporeal membrane oxygenation must be considered in the most severe cases.

[Endoscopic treatment of vesicoureteral reflux in children]. / Endoskopisk behandling av vesikoureteral refluks hos barn.

In the five-year period 1990-95, 102 patients, 78 girls and 24 boys, aged ten weeks to 14 years were treated for grade III-V vesicoureteral reflux by the same surgeon using subureteric teflon injection--the STING procedure. Both primary, secondary and complex reflux were included. The reflux had disappeared in 90 of 133 refluxing ureters, the grade of reflux had diminished in 17 and were unchanged in 26 at the control three months after treatment. After re-STING in 22 reflux ureters, reflux disappeared in 13, was reduced in six and unchanged in three. Reappearance of low grade reflux was seen in eight of 88 ureters between the three months and one year control, but only one needed re-STING. Open surgery was performed in 13 patients (18 reflux ureters) because of unchanged reflux after STING, most of them due to complex reflux: duplex ureters, ectopic ureters, ureteroceles and paraureteral diverticula. It is concluded that most patients with vesicoureteral reflux can be successfully treated by using subureteric teflon injection.

[Endoscopic treatment of vesicoureteral reflux in children]. / Endoskopisk behandling av vesikoureteral refluks hos barn.

In the five-year period 1990-95, 102 patients, 78 girls and 24 boys, aged ten weeks to 14 years were treated for grade III-V vesicoureteral reflux by the same surgeon using subureteric teflon injection--the STING procedure. Both primary, secondary and complex reflux were included. The reflux had disappeared in 90 of 133 refluxing ureters, the grade of reflux had diminished in 17 and were unchanged in 26 at the control three months after treatment. After re-STING in 22 reflux ureters, reflux disappeared in 13, was reduced in six and unchanged in three. Reappearance of low grade reflux was seen in eight of 88 ureters between the three months and one year control, but only one needed re-STING. Open surgery was performed in 13 patients (18 reflux ureters) because of unchanged reflux after STING, most of them due to complex reflux: duplex ureters, ectopic ureters, ureteroceles and paraureteral diverticula. It is concluded that most patients with vesicoureteral reflux can be successfully treated by using subureteric teflon injection.

[Lipoblastoma. A rare, benign tumor in children]. / Lipoblastom. En sjelden, benign tumor hos barn.

Lipoblastoma is a rare, benign tumour of embryonal fat seen almost exclusively in infancy and early childhood. It occurs mostly in the extremities, but it is also seen in other parts of the body. The tumour may grow rapidly, and the fact that lipoblastomas show immature fat cells could lead to the wrong diagnosis of liposarcoma. Complete surgical excision appears to be the treatment of choice. A correct, preoperative diagnosis is possible in most cases. Two cases of lipoblastoma of the upper limb and one case in the scapular region are reported.

[Balloon dilatation of postoperative esophageal stenoses in children]. / Ballongdilatasjon av postoperative oesophagusstenoser hos barn.

During the period 1987-92, seven patients (two girls and five boys under one year of age) were dilated for strictures following oesophageal atresia operation. The total number of dilatations was 47. Six out of seven patients were treated successfully. No sedation/anaesthesia was used. There was one episode of cyanosis and brief respiratory arrest, and two incidents of intramural tears. None of these episodes required surgical intervention. Fluoroscopically guided balloon dilatation of oesophageal strictures is considered a safe and efficient treatment, also for outpatients.

[Gastroesophageal reflux associated with severe cerebral paresis]. / Gastroøsofageal refluks ved alvorlig cerebral parese.

Five patients, aged 9-16, living in a community-based home for the mentally retarded, have undergone Nissen fundoplication for gastroesophageal reflux. They were all severely physically handicapped by cerebral palsy. Their symptoms had persisted from 1-10 years, and included chronic retching and vomiting, intermittent obstruction of the upper airways, frequent bronchial and pulmonary infections, and episodic abdominal pain and failure to thrive. Three had hematemesis. Two patients lost a great deal of weight. One had chronic reflux associated with lower airway obstruction, which improved postoperatively. All patients had undergone conservative medical treatment of four to 12 months duration, with no lasting improvement. There were very few postoperative complications. One patient had to be reoperated. After surgical treatment their main symptoms had disappeared and their subsequent management was easier. We have reasons to believe that this condition is seriously underdiagnosed in our society, thereby causing unnecessary pain and distress in patients who are unable to convey their complaints to others.

Predictive ability of choledocholithiasis indicators. A prospective evaluation.

To assess the predictive ability of various indicators of common bile duct calculi, 457 patients undergoing cholecystectomy for gallstone disease were prospectively screened for the presence of 11 predefined criteria of possible choledocholithiasis. The predictive ability of the criteria, individually and in combinations, was determined. For all criteria, except a history of pancreatitis, a significantly increased incidence of choledocholithiasis was found. The number of positive criteria correlated positively with the frequency of common bile duct calculi. The negative predictive value and sensitivity of the total set of criteria were 98% and 89.5%, respectively. Following common duct exploration, the number of complications and the duration of postoperative hospitalization were significantly increased as compared with simple cholecystectomy. Peroperative cholangiography with cholecystectomy is recommended in all patients, with one or more criteria of possible choledocholithiasis. Routine peroperative cholangiography in patients with no positive criteria does not seem to be necessary.

Comparison of bypass and resection of the small intestine in germfree rats.

Germfree rats were subjected to: (1) 90% jejunoileal resection (15 rats) or (2) 90% end-to-side jejunoileal bypass (20 rats). The mortality rate was 67 and 75%, respectively, which is markedly higher than after the same types of operation in conventional rats. Late mortality occurred only in the bypass group. Possible reasons for the high mortality rate are discussed. 5 rats in each group survived and were followed up for 6-12 weeks. At autopsy, the liver was normal, and except for lower serum concentration of albumin in the operated rats, the other liver function tests were normal. There did not seem to be any difference in body weight between the two groups of surviving rats which may indicate that the intestinal microflora is an important factor in causing the difference in body weight after resection and bypass of the small intestine in conventional rats. The number of surviving rats was small, however, and further studies are therefore necessary to give a definite answer to this question.

Intestinal bypass. Bacteriological studies from different parts of the small intestine in rats.

Forty-five rats were divided into four groups according to type of operation: 1) end-to-side jejunoileal bypass (ES), 10 rats; 2) end-to-end jejunoileal bypass (EE), 10 rats; 3) jejunoileal resection (R), 10 rats; and 4) no operation, 15 rats. The luminal contents from the proximal jejunum and distal ileum, in groups 1 and 2 also from the proximal and distal part of the excluded small intestine, were examined bacteriologically 5-11 months after operation. The total number of aerobic and anaerobic microbes in the jejunum was equal in all groups. The number of aerobic bacteria in the ileum was significantly higher in the ES group than in the R and U groups. The number of bacteria capable of producing gas in glucose-supplemented media was increased both in the jejunum and ileum after ES bypass. Enterobacteriaceae and Bacteroides were commonly present in the ileum after both types of bypass but were not cultured in jejunal contents. The proximal part of the excluded intestinal segment in groups 1 and 2 contained very low numbers of microbes, whereas the flora of its distal part was similar to that of the ileum in continuity in group 1. Thus, the most marked changes of the intestinal flora occurred after ES bypass in the region of the anastomosis and distal to this.

Intestinal bypass. A randomized, prospective clinical study of end-to-side and end-to-end jejunoileal bypass.

Of 21 patients with morbid obesity 10 were randomly allocated to ES (end-to-side) and 11 to EE (end-to-end) jejunoileal bypass. Ten patients in each group were followed up for more than 3 years. Average weight loss 18 months after operation was 37 kg or 33% of preoperative body weight in the ES group and 40 kg or 37% in the EE group (p = 0.26). One year after operation the mean serum concentration of magnesium was 0.84 mmol/l in the ES group and 0.66 in the EE group (p = 0.02), and the serum concentration of folic acid was 11.5 nmol/l in the ES group and 6.0 in the EE group (p = 0.01). The liver biopsies showed significant (p = 0.01) increased steatosis 1 year after operation in the EE group compared with peroperative biopsies, and the difference between the two groups at the 12-month follow-up almost reached statistical significance in favour of the ES group (p = 0.07). In the EE group, interposition of an intestinal segment was performed in 4 patients 17-27 months after the primary operation because of electrolyte deficiency and/or ulcer in the ileocolic anastomosis. The results in this series indicate that the ES shunt is a better operation than the EE shunt.

A single dose tinidazole and doxycycline prophylaxis in elective surgery of colon and rectum. A prospective controlled clinical multicenter study.

Antimicrobial prophylaxis with agents active against aerobic and anaerobic micro-organisms leads to a significant reduction of infectious complications following colorectal surgery. A single dose (1600 mg) of tinidazole (a nitroimidazole derivate) and doxycycline (400 mg) will provide serum and tissue values well above minimum inhibitory concentration (MIC) values for more than 24 hours. To reduce the unwanted side effects and cost of prolonged antimicrobial prophylaxis, a prospective controlled clinical multicenter study comparing the effect of a single dose before operation of tinidazole and doxycycline to five days of prophylaxis before operation in 234 patients undergoing elective colorectal surgery was undertaken. Six patients given a single dose of prophylaxis before operation (n = 118) developed infectious complication (5.1%). Prolongation of prophylaxis before operation for four days after operation (n = 116) did not lead to any further reduction of infectious complications. A single dose of tinidazole and doxycycline before operation is a simple and effective prophylaxis against infectious complications following elective colorectal surgery.

Intestinal and gastric bypass. Changes in intestinal microecology after surgical treatment of morbid obesity in man.

Jejunal bacterial flora, bile acid deconjugation, and breath hydrogen and methane excretion were studied in nine patients with end-to-side and nine patients with end-to-end jejunoileostomy and in eight patients with gastric bypass. Bacterial numbers did not differ significantly between healthy controls and any of the patient groups. Production of fermentation gases in anaerobic cultures supplemented with carbohydrates did not occur with jejunal secretions from healthy controls but was found in all intestinal bypass patients and half the gastric bypass patients. Bacterial bile acid deconjugation activity was significantly higher in end-to-side compared with end-to-end jejunoileostomy patients. In gastric bypass patients bile acid deconjugation was not significantly affected. Breath hydrogen after glucose ingestion was abnormal in six patients with end-to-side and three with end-to-end jejunoileostomy and in six of the patients subjected to gastric bypass. The highest values were found in the later group. Breath methane, which is found in one third of a healthy population, was absent in all 18 patients with intestinal bypass, and this may indicate that a change occurs even in the colonic microflora after this operation. Both intestinal and gastric bypass may change the small-bowel microflora, with the greatest changes occurring after end-to-side jejunoileostomy and the least changes after gastric bypass.