Surgical acquired aganglionosis: myth or reality?

Purpose

A number of patients operated on for Hirschsprung disease continue to have constipation and abdominal distension for years after surgery. Some authors have proposed that ischemia during surgery may induce secondary aganglionosis. The aim of the present study was to study the effects of ischemia on the enteric nervous system of sigmoid colon in an animal model.

Methods

A surgical model of colonic ischemia was created. 34 adult Sprague–Dawley rats underwent a laparotomy where the marginal arterioles of the sigmoid colon were ligated. After that, a section in the middle segment of the sigmoid colon was performed followed by an anastomosis. The presence of ischemia was assessed by measurement of visible light spectroscopy tissue oximetry and histological examination. Colonic function was assessed by evaluation of stool weight. Rats were killed at 1, 8 and 12 weeks after the operation. 12 rats were sham-operated. Enteric nervous system was evaluated by means of immunohistochemistry with NGFR p75. Quantitative analysis of the number of ganglia and ganglion cells in the myenteric plexus was performed.

Results

The surgical model of colonic ischemia significantly decreased tissue oxygenation (pre-surgical = 54.69 ± 7.32 %; post-surgical = 27.37 ± 9.2 %; p < 0.001). There was no disturbance in body-weight gaining in experimental groups and daily stool output did not vary after surgery (pre-surgical = 4.24 ± 0.94 g; post-surgical = 3.82 ± 1 g; p = 0.09). All experimental groups showed persistent ganglia. However, there was a significant decrease in the number of ganglia in all the experimental groups compared to control (1w: 45.91 ± 7.66; 8w: 44.17 ± 10.56; 12w: 36.17 ± 15.06 vs control: 56.88 ± 8.66; p < 0.01). The number of total ganglion cells was significantly reduced only in the experimental group killed at week 12 compared to control (1w: 539 ± 167.58; 8w: 488.58 ± 154.41; 12w: 343.94 ± 161.91 vs control: 513.96 ± 126.97; p < 0.01). The rate of ganglion cells per ganglia was significantly higher in the groups killed at week 1 and 8 versus control group (1w: 11.63 ± 2.53; 8w: 11.11 ± 2.56; 12w: 9.34 ± 1.16 vs control: 9.02 ± 1.81; p < 0.05).

Conclusion

Long-term follow-up after surgically induced colonic ischemia in the rat showed a decreased number of ganglion cells and ganglia. Nevertheless, it did not produce aganglionosis.     

Neonatal gastric pull up: reality or myth?

Between 1991 and 1998, 28 out of 356 neonates with esophageal atresia and tracheoesophageal fistula (EATEF) required esophageal substitution. As only 8 returned (28%) for the esophageal replacement after initial esophagostomy and gastrostomy at our center, we were prompted to offer single-stage esophageal replacement when the primary repair had either failed or was not found feasible. Twelve full-term neonates (mean birth weight 2.32 kg) with EATEF who underwent esophageal replacement by gastric pull-up between 1998 and 2000 were reviewed. The indications were: major leak after primary repair (n=9); pure EA (n=2); and EATEF with a very wide gap (n=1). The average ages at presentation and gastric pull-up were 6.0 and 8.5 days, respectively. The patients were evaluated for gastric transit by a colloid radiopharmaceutical, for duodenogastric reflux (DGR) by hepatic immunodiacetic acid (HIDA) scan, and for gastric clearance and transit by contrast studies. Three patients had minimal leaks from the neck site, all of which healed well. Follow-up with nuclear scans and contrast studies to evaluate gastric emptying revealed obstruction in 1 case and DGR in 25% of cases. There were 2 deaths (16%), 1 due to complex congenital cardiac disease and the other due to septicemia. In view of the acceptable morbidity, mortality, and functional outcome following gastric pull-up, we recommend this procedure if it becomes inevitable in the neonatal period.     

Growing pains in children: myth or reality?

"Growing pains" are a frequent problem in paediatric practice. Over the last years, their diagnostic and therapeutic approaches have changed. Other syndromes than those well-known by paediatricians are to be taken in consideration. Current treatment consists in reassurance of children and their family reactivation of patients (which means to take up a normal physical activity) and treatment of painful crisis as well as complementary therapies.     

Risk-compensation behavior in children: myth or reality?

OBJECTIVE: To assess risk compensation and risk homeostasis theory in children. DESIGN: We used a case-control study design in children aged 8 to 18 years who had an injury while participating in an activity that did or could entail the use of protective equipment (PE). SETTING: Montreal Children's Hospital emergency department from December 1, 2001, to November 30, 2002. PARTICIPANTS: We interviewed consenting children and compared the reports of risk-taking behaviors in those who did and those who did not report using PE. MAIN OUTCOME MEASURES: Indicators of risk-taking behavior and injury severity. RESULTS: A total of 674 children presented with injuries during the study, and 394 were interviewed (235 PE users and 159 nonusers). There was no evidence of an association between indicators of risk-taking behavior and PE use after adjusting for age, sex, personality, and type of activity and no relationship between injury severity and PE use. CONCLUSIONS: Results of this study provide no support for hypotheses about risk homeostasis theory among children using PE. The validity of the theory appears highly doubtful for children in this age range.     

Medical or surgical management for children with vesico-ureteric reflux?

A critical survey of the literature on treatment of children with vesico-ureteric reflux was carried out in order to create a basis for the new Swedish management policy. There are few studies that meet modern standards of scientific methodology and provide adequate patient numbers. The only large investigations that randomized patients to operative or non-operative treatment were the Birmingham Reflux Study and the International Reflux Study in Children. In these studies, long-term outcome of renal status and renal function, as well as the number of recurrent infections, were independent of treatment modality. Although pyelonephritic recurrences were less common in the surgically managed group, this did not influence appearance of renal damage. There is no evidence to indicate clear superiority of either medical or surgical management. Further studies are needed to address such questions as the optimal duration of antibacterial prophylaxis and the effect of a dilating reflux that persists into adulthood.     

Medical or surgical management for children with vesico-ureteric reflux?

A critical survey of the literature on treatment of children with vesico-ureteric reflux was carried out in order to create a basis for the new Swedish management policy. There are few studies that meet modern standards of scientific methodology and provide adequate patient numbers. The only large investigations that randomized patients to operative or non-operative treatment were the Birmingham Reflux Study and the International Reflux Study in Children. In these studies, long-term outcome of renal status and renal function, as well as the number of recurrent infections, were independent of treatment modality. Although pyelonephritic recurrences were less common in the surgically managed group, this did not influence appearance of renal damage. There is no evidence to indicate clear superiority of either medical or surgical management. Further studies are needed to address such questions as the optimal duration of antibacterial prophylaxis and the effect of a dilating reflux that persists into adulthood.     

Acute scrotum in Henoch-Schönlein purpura: fact or fiction?

Henoch-Sch?nlein purpura (HSP) is the most common systemic vasculitis of childhood. It is usually seen following upper respiratory tract infections. It rarely involves the genital system or causes scrotal edema. With this report, we wanted to bring a different perspective to this clinic of acute scrotum. Herein, we present two HSP patients admitted to our clinic with scrotal involvement, with a review of the literature.     

Phenylketonuria: diet for life or not?

In order to evaluate the argument whether or not a restricted phenylalanine diet should be maintained for life in patients with phenylketonuria (PKU), 16 patients with early treated PKU but off diet since their 11th birthday were investigated. The evaluation included a detailed neurological examination, IQ, neurophysiological testing and MRI of the brain. Even if IQ and electrophysiological studies were normal or unchanged if compared to results before diet discontinuation, all patients revealed abnormal neurological signs. We conclude that the diet should be continued during adult life, but somewhat higher phenylalanine levels (<10mg/dl;<600 micromol/l) than at younger ages should be allowed.     

Transient hyperglycemia in acute childhood illnesses: To attend or ignore?

Transient hyperglycemia occurs as a part of stress response in acute illnesses and is brought about by elevated levels of counter regulatory hormones. It is frequently encountered but the exact prevalence and implications, especially in childhood have not been studied in detail. 758 children (1 month to 6 years) with acute illness were screened for hyperglycemia; of these 36 children were found to have a glucose level of ≥150 mg/dl at admission and were designated hyperglycemics. The overall prevalence of hyperglycemia was 4.7 per cent. The disease-wise prevalence in neurological disorders, septicemia, respiratory illnesses and diarrhoea was 7.9, 7.6, 4.2 and 3.0 per cent respectively. Family history of diabetes did not predispose towards developing transient hyperglycemia. The demographic profile (age, sex, nutrition status and disease pattern) and severity of illness (as assessed by temperature, heart rate, respiratory rate, duration of illness and hospitalization, treatment modalities required, hypoxia and acidosis) did not affect the prevalence, extent and the rate of normalization of hyperglycemia. The mortality in hyperglycemics was double (13.9%) as compared to 6.9% in non-hyperglycemics, although the difference was insignificant, statistically (O.R=2.17, CI=0.81–5.82, p>0.05). It was, therefore, concluded that transient hyperglycemia occurs in 4–5% of patients with acute pediatric illnesses. However, it does not significantly correlate with the clinical profile and severity of the illness, and has no immediate prognostic significance.     

Roux-en-Y hepaticojejunostomy or hepaticoduodenostomy for biliary reconstruction during the surgical treatment of choledochal cyst: which is better?

We reviewed our experience of Roux-en-Y hepaticojejunostomy (RYHJ) and hepaticoduodenostomy (HD) performed for the surgical repair of choledochal cyst (CC), with special emphasis on postoperative complications related to the type of biliary reconstruction performed. Eighty-six patients underwent primary cyst excision for CC from 1986 to 2002 at our institution. Forty-six cases with concurrent intrahepatic bile duct dilatation (IHBD) were excluded because HD was not used for biliary reconstruction if IHBD was present. Thus, 28 cases had RYHJ, and 12 had HD. Differences between the RYHJ and HD groups with respect to type of CC, age at cyst excision, and length of follow-up were not statistically significant. However, the incidences of postoperative complications related to biliary reconstruction, such as endoscopy-proven bilious gastritis due to duodenogastric bile reflux [4/12 (33.3%) of the HD group], and adhesive bowel obstruction/cholangitis [2/28 (7.1%) of the RYHJ group] were significantly different (p<.05). Our experience suggests that HD is not ideal for biliary reconstruction in CC because of a high incidence (33.3%) of complications due to duodenogastric bile reflux. Currently, RYHJ is our exclusive technique of choice for biliary reconstruction during the surgical repair of CC.     

Organic foods for children: Health or hype?

Organic foods are promoted as superior and safer options for today’s health-conscious consumer. Manufacturers of organic food claim it to be pesticide-free and better in terms of micronutrients. Consumers have to pay heavily for these products - and they are willing to - provided they are assured of the claimed advantages. Scientific data proving the health benefits of organic foods, especially in children, are lacking. Indian Government has developed strict guidelines and certification procedures to keep a check on manufacturers in this financially attractive market. American Academy of Pediatrics, in its recently issued guidelines, did not recommend organic foods over conventional food for children. Indian Academy of Pediatrics has not opined on this issue till date. In this perspective, we present a critical review of production and marketing of organic foods, and scientific evidence pertaining to their merits and demerits, with special reference to pediatric population.