Biliary atresia,the next generation: a review of liver function,social activity,and sexual development in the late postoperative period

Purpose: The current study aimed to establish the management for biliary atresia (BA) patients in the late postoperative period. Methods: Of 165 BA patients operated on in the authors' department, 44 patients (16 boys, 28 girls) with a follow-up period of more than 15 years were reviewed retrospectively. Results: Forty-one of 44 patients (93.2%) currently are employed or highly educated, 7 are married, whereas 2 (4.5%) died, and 10 (22.7%) required liver transplantation after puberty. Four babies have been born from BA parents without congenital anomalies. Four girls conceived 5 times and delivered 3 newborns weighing 2,330 to 2,474 g including one delivered after transplantation. Maternal portal hypertension uniformly deteriorated during pregnancy, and one pregnancy was terminated. Menstrual disorder correlated significantly with the biochemical data related to liver function at puberty such as serum choline esterase (266 [plusmn] 70.4 in 19 normal patients v 159 [plusmn] 34.3 IU/L in 9 abnormal patients, P = .00057), asparate aminotransferase (42 [plusmn] 30.8 v 96.0 [plusmn] 63.6 IU/L; P = .0031), and serum albumin (4.6 [plusmn] 0.4 v 3.9 [plusmn] 0.6 g/dL; P = .013). Conclusions: The long-term survivors of Kasai's operation, with or without liver transplantation, have reached the next generation. Transgenerational follow-up and management including conception and perinatal care should be required for BA patients.     

Streamlining the care of patients with hypertrophic pyloric stenosis: application of a clinical pathway

Purpose: The purpose of this study was to evaluate the impact of a clinical pathway on infants admitted to a pediatric tertiary care center with the diagnosis of hypertrophic pyloric stenosis (HPS). Methods: The records of 132 HPS patients were evaluated before and after implementation of a clinical pathway. Infants were excluded for prematurity, admission to nonsurgical services, or multiple diagnoses requiring prolonged hospitalization, resulting in 83 patients for analysis. Group I (prepathway, n = 40) and group II (postpathway, n = 43) infants were analyzed for time from admission to operation, operation to first feeding, operation to discharge, total length of stay, hospital charges, metabolic status at time of admission, and postoperative complications. The Mann-Whitney test was performed (statistical significance at P [lt ] .05). Results: There was no significant difference between group I and group II patients in the length of preoperative hospitalization or metabolic status at the time of hospital admission. In comparison with group I patients, there was a significant reduction in time to resumption of oral feedings (4.6 [plusmn] 1.9 hours v 7.5 [plusmn] 3.2 hours; P [lt ] .001) for group II infants and a significantly earlier discharge (26.7 [plusmn] 6.8 hours v 38.0 [plusmn] 11.7 hours; P [lt ] .001). This resulted in a shortened length of stay (41.8 [plusmn] 9.7 hours v 57.8 [plusmn] 14.3 hours; P [lt ] .001) with an associated decrease in hospital charges ($4,555 [plusmn] $464 v $5,400 [plusmn] $1,017; P [lt ] .001). Conclusions: Elimination of practice variability by the use of a clinical pathway for HPS resulted in significant reduction of hospital stay and related charges. The impact of the pathway occurred in the postoperative period and is a consequence of a rapid and systematic return to oral feedings. J Pediatr Surg 37:1072-1075.     

Significance of [lsquo ]blush[rsquo ] on computed tomography scan in children with liver injury

Background/Purpose: The aim of this study was to determine if the presence of [ldquo ]blush[rdquo ] (an indication of active bleeding) on abdominal CT in children with blunt liver injury adversely affected their clinical outcome as has been reported in adults. Methods: The authors reviewed the records of 105 children ages 1 to 16 years with blunt liver injury seen on admission IV contrast CT seen over a 6-year period. Demographic characteristics measured were age, mechanism of injury, and injury severity score (ISS). Clinical outcomes included ICU stay, hospital length of stay (LOS), transfusion requirement (milliliters per kilogram), operations performed, and mortality rate. CT scans were evaluated retrospectively by a radiologist blinded to prior reports, for a [ldquo ]blush[rdquo ] and grade of liver injury. No patient underwent arterial embolization. The authors eliminated children with grade I-II injuries (30 patients), because only one had a blush, and analyzed the 75 patients with severe liver injuries (grades III-V). Those patients without a blush (n = 53) seen on CT were the control group, whereas patients with a blush (n = 22) were the study group. Data were analyzed using the Fisher's Exact and Mann-Whitney U test. The level of significance was set at .05. Results: Patients with a blush had a significantly larger transfusion requirement (17.3 [plusmn] 30.5 mL/kg v 5.0 [plusmn] 10.9 mL/kg; P = .02) and mortality rate (23% v 4%; P = .02), but the ISS also was significantly greater (25.8 [plusmn] 14.5 v 17.5 [plusmn] 12.2; P = .019). All other data were similar between the 2 groups. Conclusions: Children with a blush seen on abdominal CT after blunt liver injury have higher transfusion requirements and greater risk of mortality than those without blush. Mortality is primarily related to the severity of their other injuries. J Pediatr Surg 38:363-366.     

Hypothermia throughout intestinal ischaemia-reperfusion injury attenuates lung neutrophil infiltration

Background/Purpose: Secondary organ damage to the lungs is an important consequence of intestinal ischaemia reperfusion (IIR) injury. Moderate hypothermia ameliorates gut necrosis and liver energy failure after IIR but potential beneficial effects on lung neutrophil infiltration after reperfusion of ischaemic bowel have not been investigated. Methods: Adult Sprague-Dawley rats underwent 60 minutes intestinal ischaemia followed by 120 minutes of reperfusion. The animals were maintained at either normothermia (36[deg ] to 38[deg ]C) or moderate hypothermia (30[deg ] to 32[deg ]C). Four groups were studied: (A) sham normothermia; (B) IIR normothermia; (C) sham hypothermia; and (D) IIR hypothermia. Lungs and terminal ileum were removed for measurement of myeloperoxidase activity (a marker of neutrophil infiltration). Results are expressed as milliunits per milligrams protein, mean [plusmn] SEM, and one-way analysis of variance (ANOVA) with Tukey post-test was used for group comparisons. Results: Lungs: IIR at normothermia significantly increased lung neutrophil infiltration assessed by myeloperoxidase activity compared with sham-operated controls (normothermia sham 4.6 [plusmn] 1.0, n = 8; normothermia IIR 37.7 [plusmn] 13.8, n = 8; P = .011). Moderate hypothermia during IIR significantly attenuated lung neutrophil infiltration (7.2 [plusmn] 2.1, n = 9) compared with normothermia IIR (P = .016) such that myeloperoxidase activity was similar to that found in sham normothermia (4.6 [plusmn] 1.0, n = 8) and sham hypothermia (3.1 [plusmn] 1.3, n = 8). Intestine: Gut myeloperoxidase activity was 0.9 [plusmn] 0.5 in sham normothermia (n = 9) and 2.3 [plusmn] 0.6 after normothermic IIR (n = 8). After IIR at hypothermia gut myeloperoxidase activity (0.5 [plusmn] 0.2; n = 8) was significantly less than normothermic IIR (P = .035) and higher than sham hypothermia (0.2 [plusmn] 0.1, n = 9; P = .01). Conclusions: These results indicate that moderate hypothermia may prevent damage to another distant organ, ie the lungs, by preventing recruitment of neutrophils. This may be of benefit in decreasing distal organ damage in diseases in which intestinal ischaemia-reperfusion is implicated in the pathogenesis. J Pediatr Surg 38:88-91.     

Robotic-assisted esophagoesophagostomy

Background/Purpose: Minimally invasive repair of esophageal atresia has been described but remains technically challenging. Robotic surgical systems address many of these technical challenges. The purpose of this study was to develop the procedure for and evaluate the technical feasibility of performing a robotic-assisted esophagoesophagostomy using the Zeus Robotic Surgical System. Methods: Esophagoesophagostomy was performed in 10 piglets using thoracoscopic (control, n = 5) and robotic-assisted (Zeus, experimental, n = 5) approaches. An interrupted esophageal anastomosis using intracorporeal knot tying techniques was performed and evaluated for leak, narrowing, caliber, and mucosal approximation. Anesthesia, operative, anastomotic, and robotic set-up times were recorded as was the number of stitches used. Results: All 10 anastomoses were patent with no narrowing and with excellent mucosal approximation. One anastomosis in the control group had a small leak. There was no statistically significant difference between the groups for the parameters measured. Weight (kg): control (C), 6.4 [plusmn] 0.8; experimental (E), 6.3 [plusmn] 1.0, P = .08. Times (min): anesthesia, C-124 [plusmn] 25, E-151 [plusmn] 20, P = .09; operative, C-97 [plusmn] 21, E-131 [plusmn] 27, P = .06; anastomotic, C-89 [plusmn] 20, E-125 [plusmn] 34, P = .08; robotic set-up, C-6.4 [plusmn] 9.3, E-15.6 [plusmn] 20, P = 0.13. Stitches (No.): C-11.8 [plusmn] 0.8, E-12.0 [plusmn] 1.2, P = .7. Caliber (French):C-18F-5; E-18F-4, 14F-1. Conclusion: Robotic-assisted esophagoesophagostomy is technically feasible and offers an alternative approach to thoracoscopic repair of esophageal atresia. J Pediatr Surg 37:983-985.     

Epidermal growth factor improves nutritional outcome in a rat model of short bowel syndrome

Background/Purpose: This study investigates the effect of epidermal growth factor (EGF) on nutrient absorption in a rat model of short bowel syndrome (SBS). Methods: Male juvenile rats underwent either transection (Sham) or ileocecal resection leaving a 20-cm jejunal remnant. Animals underwent follow-up for 10 days, and resected animals were treated with placebo or recombinant human EGF (1-53). Animals were pair fed; in vivo nutrient absorption, intestinal permeability, morphology, and total intestinal DNA and protein content were measured. Results: Resected EGF-treated animals lost significantly less weight than those in the placebo group ([minus ]4.2 [plusmn] 3 v [minus ]13.7 [plusmn] 6.9%), absorbed significantly more 3-0 methylglucose (76.8 [plusmn] 6.6 v 64.9 [plusmn] 10.1%), and had reduced permeability (lactulose/mannitol ratio, 0.35 [plusmn] 0.19 v 0.60 [plusmn] 0.20; P [lt ] .05 for all comparisons). Conclusions: These findings show that treatment of short bowel syndrome animals with EGF reduced weight loss and improved carbohydrate absorption and intestinal permeability. These findings suggest that enteral EGF may be a useful therapy for short bowel syndrome; further studies are indicated.     

Ad libitum feeding decreases hospital stay for neonates after pyloromyotomy

Purpose: The optimal feeding regimen for neonates after pyloromyotomy for hypertrophic pyloric stenosis (HPS) remains controversial. This study sought to compare ad libitum feeding to a Conventional feeding regimen with regard to time to full diet, length of hospital stay, and readmission rates. Methods: A 6-month review of 36 consecutive patients who underwent pyloromyotomy for HPS was undertaken. Patients were fed in 1 of 2 ways according to specific surgeon preference. Conventional Regimen patients (n = 19) were kept nothing by mouth (NPO) for 6 hours after surgery and incrementally advanced to full feedings. ad libitum (n = 17) patients were kept NPO until fully reversed from anesthesia and then given full strength formula or breast milk. Discharge was considered when 2 feedings of 60 mL were tolerated. Results: Twenty-eight males and 8 females with a mean age of 5.0 [plusmn] 1.7 (SD) weeks, gestational age of 39 [plusmn] 2.1 weeks, weight of 4.0 [plusmn] 0.9 kg, and operating time of 56 [plusmn] 12 minutes were studied. The interval from operating room to full diet was significantly less with ad libitum feeding than on the conventional regimen (20.3 [plusmn] 5.0 v. 25.4 [plusmn] 8.3 hours, P [lt ] .05). The Ad Libitum group also had a significantly decreased length of hospital stay (28.5 [plusmn] 8.9 hours v. 35.8 [plusmn] 11 hours; P [lt ] .05). There were no readmissions in either group. Conclusions: Ad libitum feedings decrease time to full diet and discharge without an increase in readmission rates. The estimated potential savings per patient using ad libitum feedings were $392.00. Thus, the use of ad libitum feedings after pyloromyotomy for HPS appears indicated.     

A prospective,randomized pilot trial of perfluorocarbon-induced lung growth in newborns with congenital diaphragmatic hernia

Background/Purpose: Initial laboratory and clinical data suggest that partial liquid ventilation (PLV) can enhance pulmonary function and that lung growth can be induced via distension of the newborn lung using perfluorocarbon in patients with congenital diaphragmatic hernia (CDH). The authors, therefore, performed a prospective, randomized pilot study evaluating PLV and perfluorocarbon-induced lung growth (PILG) in newborns with CDH on extracorporeal life support (ECLS) at 6 medical centers. Methods: Patients were selected randomly using a permuted block design to PLV/PILG (n = 8) or conventional mechanical ventilation (CMV/control, n = 5). Patients in the PILG group received daily doses which filled the lungs with perflubron for up to 7 days and were placed on continuous positive airway pressure of 5 to 8 cm H₂O. CMV patients were treated with standard mechanical ventilation while on extracorporeal membrane oxygenation (ECMO). Results: A total of 13 patients were evaluated in this study. All 3 patients enrolled without being on ECLS rapidly transitioned to ECLS. The study, therefore, effectively evaluated PILG (n = 8) versus standard ventilation (control, n = 5) on ECLS. Mean ([plusmn] SE) gestational age was 37 [plusmn] 1 weeks and weight was 3.1 [plusmn] 0.1 kg. Time on ECMO was 9.8 [plusmn] 2.3 days in the PILG and 14.5 [plusmn] 3.5 days (P = .58) in the control group. Survival rate in the PILG group was 6 of 8 (75%), whereas survival rate was 2 of 5 (40%) in the control group (P = .50). The number of days free from the ventilator in the first 28 days (VFD) was 6.3 [plusmn] 3.3 days with PILG and 4.6 [plusmn] 4.6 days with control (P = .9). Causes of death in the PILG group included sepsis and renal failure in one patient and pulmonary hypertension in the other. There were no safety issues, and the deaths in the PILG group did not appear to be related to the administration of perflubron. Conclusions: These data show that PILG can be performed safely. The survival rate, VFD, and time on ECMO data, although not conclusive, are encouraging and indicate the need for a definitive trial of this novel intervention in these neonates with high mortality. J Pediatr Surg 38:283-289.     

Delayed institution of extracorporeal membrane oxygenation is associated with increased mortality rate and prolonged hospital stay

Background/Purpose: Severe meconium aspiration syndrome (MAS) is a frequent indication for extracorporeal membrane oxygenation (ECMO). Trials of less invasive cardiopulmonary support may result in fewer infants treated with ECMO but could delay institution of ECMO. The authors hypothesized that those infants with severe MAS who are treated with ECMO early will have a lower mortality rate and a shorter hospital course than those who receive delayed ECMO. Methods: A retrospective review of all patients with MAS in the national extracorporeal life support (ELSO) registry for the decade 1989 through 1998 was performed. Data from the ELSO registry were examined for demographics, clinical parameters, and treatment course. Patients were divided into 3 groups based on the time from birth to institution of ECMO: group 1, 0 to 23 hours; group 2, 24 to 96 hours; and group 3, greater than 96 hours. These groups were compared for survival, duration of extracorporeal support, and duration of ventilatory support after ECMO. Statistical relevance was determined by analysis of variance (ANOVA) and Tukey's post-hoc test. Results: A total of 3,235 of 4,002 patients with MAS had complete information on duration of mechanical ventilation. Overall mortality rate was 5.8%. The mortality rate in group 1 (n = 1,266) was 4.8%, group 2 (n = 1,568) 6.0%, and group 3 (n = 401) 7.7%. An increased time to ECMO was associated with a significant increase in mortality rate (P [lt ] .05). This also was associated with significant increases in the length of the ECMO run (157 [plusmn] 4 v 130 [plusmn] 2 hours, P = .02) and duration of post-ECMO ventilation (157 [plusmn] 17 v 118 [plusmn] 3 hours; P [lt ] .001). Those patients in groups 1 and 2 who did not respond to a trial of high-frequency oscillatory ventilation had significantly longer ECMO runs (129 [plusmn] 2 v 113 [plusmn] 1 hours; P = .001) and longer post-ECMO ventilator courses (137 [plusmn] 2 v 114 [plusmn] 1 hours; P = .002) than those who did not. Conclusions: Delay in institution of ECMO for MAS results in prolonged ECMO and need for post-ECMO ventilation. Consideration should be given to instituting ECMO earlier in patients with severe MAS.     

Body temperature and heat production in suckling rat endotoxaemia: beneficial effects of glutamine

Background/Purpose: Sepsis is an important cause of neonatal mortality. The aim of the study was to investigate the metabolism of endotoxic neonatal rats and the potential beneficial effect of glutamine. Methods: Suckling rats received intraperitoneal saline (control; C), endotoxin (300 [mu ]g/g LPS; E), saline+glutamine (2 mmol/g; CG), endotoxin+glutamine (EG), saline+leucine (2 mmol/g; CL) or endotoxin+leucine (EL). Sepsis score (0-8) and rectal temperature were monitored. Hypothermia was defined as rectal temperature less than 32[deg ]C. Oxygen consumption (VO₂, mL/kg/h), a determinant of heat production, was measured by indirect calorimetry. Data (mean [plusmn] SEM) were compared by analysis of variance (ANOVA), paired t test or Fisher's Exact test. Results: Endotoxic (E) rats had significantly lower VO₂ than C rats from 90 minutes postinjection to the end of the experiment, 210 minutes (VO₂ from 150 to 210 minutes: C 671 [plusmn] 45; E 429 [plusmn] 36, P [lt ] .0004; n = 8; paired t test). VO₂ of CL or CG rats was elevated between 90 and 210 minutes compared with control, but significantly (P [lt ] .01) only in the L group (C 706 [plusmn] 31; CG 871 [plusmn] 63; CL 984 [plusmn] 31; n = 7-9, ANOVA). VO₂ was significantly higher (P [lt ] .05) in EG rats than E rats (E 460 [plusmn] 29; EG 654 [plusmn] 68; n = 9-10). In the EL group, VO₂ was raised but was not significantly different from E (E 460 [plusmn] 29; EL 637 [plusmn] 52; n = 8-10). EG rats were significantly less hypothermic between 90 and 210 minutes (58 of 132 measurements) compared with E (95 of 147; P = .0007, Fisher's Exact test), whereas the EL group were similarly hypothermic (74 of 120) to E (P = .7). Sepsis score was significantly lower in the EG group than both E and EL groups (E 4.9 [plusmn] 0.3; EG 3.6 [plusmn] 0.3; EL 5.0 [plusmn] 0.3; n = 40; P [lt ] .01; ANOVA). Conclusions: Neonatal endotoxaemia lowers VO₂, heat production, and body temperature. Glutamine and leucine both cause nutrient-induced thermogenesis in control animals and restore VO₂ of endotoxic animals. Glutamine additionally increases rectal temperature, reduces incidence of hypothermia, and improves clinical signs of endotoxic rats. This suggests that glutamine may be beneficial for nutrition in neonatal sepsis. J Pediatr Surg 38:37-44.     

Murine nitrofen-induced pulmonary hypoplasia does not involve induction of TGF-beta signaling

Background/Purpose: In the murine nitrofen-induced model of congenital diaphragmatic hernia (CDH), the lungs are primarily hypoplastic and immature even before diaphragmatic closure. Because excess transforming growth factor-[beta ] (TGF-[beta ]) signaling induces pulmonary hypoplasia, the authors hypothesized that primary hypoplasia after nitrofen exposure may be caused by abberant signaling by the TGF-[beta ] pathway. Therefore, abrogation of TGF-[beta ] signaling might rescue the hypoplasia. Methods: The authors performed intratracheal microinjections of a recombinant adenoviral vector encoding a dominant-negative TGF-[beta ] type II receptor (AdIIR-DN) in nitrofen-exposed and control E12 mouse lungs, which then were cultured for 4 days in serumless chemically defined media. The mRNA expression of Smad2, 3, 4, and 7 in nitrofen-exposed and control E12 lungs after 4 days in culture were compared. Results: ADIIR-DN increased terminal branching in control lungs by 28% compared with lungs injected with control virus (61.8 [plusmn] 4.6 v. 48.4 [plusmn] 4.7, P = .004). However, there was no difference between nitrofen-exposed lungs injected with ADIIR-DN and those injected with control virus. Compared with control lungs, Smad mRNA expression was decreased markedly in nitrofen-exposed lungs: Smad2 (40%, P = .16), Smad3 (29%, P = .02), Smad4 (25%, P = .07), and Smad7 (36%, P = .04). Conclusions: Because abrogation of TGF-[beta ] signaling does not rescue the hypoplasia seen in the nitrofen model, and Smad expression is decreased in nitrofen-exposed lungs, the TGF-[beta ] pathway does not appear to play a role in nitrofen-induced pulmonary hypoplasia. J Pediatr Surg 37:1123-1127.     

Surgical management of open versus laparoscopic adrenalectomy: outcome analysis

Purpose: The authors sought to compare the outcome of children undergoing open versus laparoscopic adrenalectomy for an adrenal tumor. Methods: Medical records of children that underwent an adrenalectomy from 1990 through 1999 were reviewed. Sixty-four adrenalectomies were performed: 27 pheochromocytomas, 36 neuroblastomas, and 1 virilizing tumor. Sixty adrenalectomies were performed open and 4 laparoscopically. The patient's age, surgical length of stay, operative charge, hospital cost, operating time, blood loss, and outcome were examined. Results: Mean age for an open procedure was 8.9 [plusmn] 0.9 years and 14 [plusmn] 1.1 for laparoscopic (P = .019). Surgical length of stay for open was 5.4 [plusmn] .38 days and 2.7 [plusmn] .62 days for laparoscopic (P = .006). Patient operative charges were $12,941 [plusmn] 676 for laparoscopic and $4,714 [plusmn] 411 for open (P [lt ] .001). When total estimated patient cost, including hospital stay, were compared between groups there was no significant difference. Similar mean operating times and blood loss were noted. There were no deaths or complications in children with a pheochromocytoma. The mortality rate in children with neuroblastoma was 28%. Conclusions: Adrenalectomy for benign tumors can be performed safely. In selected children a laparoscopic procedure can be expected to decrease the surgical length of stay without increasing operating time or complications. J Pediatr Surg 37:1027-1029.     

Serial transverse enteroplasty (STEP): a novel bowel lengthening procedure

Background/Purpose: Bowel lengthening may be beneficial for children with short bowel syndrome. However, current techniques require at least one intestinal anastomosis and place the mesenteric blood supply at risk. This study seeks to establish the technical principles of a new, simple, and potentially safer bowel lengthening procedure. Methods: Young pigs (n = 6) underwent interposition of a reversed intestinal segment to produce proximal small bowel dilation. Five weeks later the reversed segment was resected. Lengthening of the dilated bowel then was performed by serial transverse applications of a GIA stapler, from opposite directions, to create a zig zag channel. A distal segment of equal length served as an in situ morphometric control. Contrast radiologic studies were performed 6 weeks later, and the animals were killed. Statistical comparisons were made by paired t test with P less than .05 considered significant. Results: After bowel lengthening, all animals gained weight (66.7 [plusmn] 3.0 [SD] kg v 42.5 [plusmn] 3.5 kg; P [lt ] .001) and showed no clinical or radiologic evidence of intestinal obstruction. Intraoperatively, immediately after serial transverse enteroplasty, the intestine was substantially elongated (82.8 [plusmn] 6.7 cm v 49.2 [plusmn] 2 cm; P [lt ] .01). Six weeks after surgery, the lengthened intestinal segment became practically straight and, compared with the in situ control, remained significantly longer (80.7 [plusmn] 13.1 cm v 57.2 [plusmn] 10.4 cm; P [lt ] .01). There was no difference in diameter between these segments (4.3 [plusmn] 0.7 cm v 3.8 [plusmn] 0.4 cm; P value, not significant). Conclusions: Serial transverse enteroplasty (STEP) significantly increases intestinal length without any evidence of obstruction. This procedure may be a safe and facile alternative for intestinal lengthening in children with short bowel syndrome. J Pediatr Surg 38:425-429.     

Neonatal endotoxemia affects heart but not kidney bioenergetics

Purpose: The aim was to determine the effects of early and late endotoxemia on neonatal cardiac and renal mitochondrial energetics. Methods: Suckling rats received intraperitoneal 300 [mu ]g/kg lipopolysaccharide; controls received saline. Heart and kidney mitochondria were isolated after 2 hours (early) or 6 hours (late sepsis). State 3 (maximum mitochondrial flux) and 4 O₂ consumption and complex I activity were measured. Results, expressed as mean [plusmn] SEM normalized to citrate synthase (CS), were compared using paired t tests. Results: Mortality rate was zero within 2 hours, 2.7% between 2 and 6 hours of endotoxemia, and 100% 6 to 8 hours; therefore, we consider that 2 hours and 6 hours represent early and late endotoxemia, respectively. Endotoxic heart mitochondria had unaltered O₂ consumption at 2 hours but significantly decreased state 3 after 6 hours, resulting in significantly decreased respiratory control ratio. Complex I activity, which could affect O₂ consumption, was decreased significantly at 6 hours (9.8 [plusmn] 0.6 mU/U CS; n [equals] 15) versus controls (11.3 [plusmn] 0.8, n [equals] 15; P [equals] .04), but not at 2 hours. There were no differences in these measurements at either 2 hours or 6 hours in kidney mitochondria. Conclusions: The respiratory chain is affected late in endotoxemia. Neither early nor late endotoxemia affects oxidative function of kidney mitochondria. J Pediatr Surg 38:690-693. [copy ] 2003 Elsevier Inc. All rights reserved.     

Role of plasma thrombopoietin level in thrombocytopenia of postoperative biliary atresia patients

Background/Purpose: To evaluate if thrombocytopenia may be related to plasma thrombopoietin level (P-TPO) in postoperative biliary atresia (BA). Methods: Forty-three postoperative BA patients aged 1 to 20 years were included. P-TPO was measured by enzyme immunoassay. P-TPO was compared with platelet counts (Plt), Child's classification, presence of splenomegaly, and liver function tests. Results: P-TPO significantly correlated with Plt, child's classification, serum albumin, and cholinesterase level, respectively. In 4 patients undergoing portal decompression procedure, preoperative and postoperative Plt and P-TPO were 87.5 [plusmn] 69.1 [times ] 10³ and 50.3 [plusmn] 28.0, 118.8 [plusmn] 62.3 [times ] 10³/mm³, and 53.0 [plusmn] 55.0 pg/mL, respectively, without significant difference. In 6 patients undergoing liver transplantation (LTx), Plt and P-TPO after LTx was 157.5 [plusmn] 83.5 [times ] 10³ and 143.5 [plusmn] 75.2, respectively, which were significantly higher than those before LTx (55.0 [plusmn] 15.6 [times ] 10³/mm³ and 53.2 [plusmn] 32.9 pg/mL). Conclusion: Thrombocytopenia in postoperative BA may be caused by decreased plasma TPO level in accordance with the severity of liver dysfunction rather than hypersplenism. J Pediatr Surg 37:1195-1199.     

Energy expenditure in ill premature neonates

Background/Purpose: The energy needs of critically ill premature neonates undergoing surgery remain to be defined. Results of studies in adults would suggest that these neonates should have markedly increased energy expenditures. To test this hypothesis, a recently validated stable isotopic technique was used to measure accurately the resting energy expenditure (REE) of critically ill premature neonates before and after patent ductus arteriosus (PDA) ligation. Methods: Six ventilated, fully total parenteral nutrition (TPN)-fed, premature neonates (24.5 [plusmn] 0.5 weeks' gestational age) were studied at day of life 7.5 [plusmn] 0.7, immediately before and 16 [plusmn] 3.7 hours after standard PDA ligation. REE was measured with a primed continuous infusion of NaH¹³CO₃, and breath samples were analyzed by isotope ratio mass spectroscopy. Serum CRP and cortisol concentrations also were obtained. Statistical analyses were made by paired sample t tests and linear regression. Results: The resting energy expenditures pre- and post-PDA ligation were 37.2 [plusmn] 9.6 and 34.8 [plusmn] 10.1 kcal/kg/d (not significant, P = .61). Only preoperative energy expenditure significantly (P [lt ] .01) predicted postoperative energy expenditure (R² = 88.0%). Pre- and postoperative determinations of CRP were 2.1 [plusmn] 1.5 and 7.1 [plusmn] 4.2 mg/dL (not significant, P = .34), and cortisol levels were 14.1 [plusmn] 2.3 and 14.9 [plusmn] 2.1 [mu ]g/dL (not significant, P = .52). Conclusions: Thus, critically ill premature neonates do not have elevated REE, and, further, there is no increase in REE evident the first day after surgery. This suggests that routine allotments of excess calories are not necessary either pre-or postoperatively in critically ill premature neonates. Given the high interindividual variability in REE, actual measurement is prudent if protracted nutritional support is required.     

Stooling and manometric findings after primary pull-throughs in Hirschsprung's disease: Perineal versus abdominal approaches

Background/Purpose: Primary pull-through via a perineal approach (PA) has recently been reported for Hirschsprung's disease. One criticism of this approach is that it requires a large amount of retraction on the anal sphincters. Additionally, because the procedure is new, most patients undergoing a PA are too young to assess long-term continence rates. This study examined early stooling patterns, anal sphincteric pressures, and number of enterocolitic episodes in infants who underwent a PA. Results were compared with a conventional combined transabdominal and perineal approach (TA). Methods: Over 2 years, 26 pull-through procedures were performed. Nine of those were PA, and 17 were TA. Twelve of the 26 patients had formal manometric studies postoperatively. Results are expressed as mean [plusmn] SD; unpaired t test and [Chi ]² were used for statistical analysis. Results: Mean follow-up post[ndash ]pull-through was 23 [plusmn] 2.3 months for the TA and 14 [plusmn] 1.9 months for the PA. Manometric resting sphincter pressure in the TA group averaged 79 [plusmn] 17 mm Hg compared with 76 [plusmn] 21 mm Hg in the PA group (P = .78). Number of stools per day was 3.3 [plusmn] 0.6 in the TA group compared with 2.2 [plusmn] 0.3 in the PA group (P = .17). Post[ndash ]pull-through enterocolitis was experienced by 53% of the TA group (mean, 1.5 [plusmn] 0.6 episodes) and 56% of the PA group (mean 0.9 [plusmn] 0.4 episodes) for a P = .08 by [Chi ]² analysis. Conclusions: Manometric sphincter pressure and enterocolitic episodes after a PA for Hirschsprung's disease appear to be similar to results obtained with a conventional TA. Evaluation of early stooling frequency shows a comparable frequency after a PA. This suggests that both methods are safe, and the PA does not appear to compromise sphincter integrity. J Pediatr Surg 37:1321-1325.     

Differences in outcome with subspecialty care: pyloromyotomy in North Carolina

Background/Purpose: Proponents of subspecialization in surgery claim that fellowship training improves the quality of care. Others claim that general training is adequate for most routine surgical procedures. The authors questioned whether there were differences in outcomes when general surgeons (GEN) operate on children and infants with common surgical conditions compared with the care of their pediatric surgical (PED) colleagues. Methods: The authors retrospectively reviewed the Healthcare Investment Analysts North Carolina Information Network database to identify patients who underwent pyloromyotomy for congenital hypertrophic pyloric stenosis in North Carolina during the period from October 1995 through September 1998 (n = 780). Information obtained included demographics, insurance type, hospital, length of stay, total hospital charges, occurrence of mucosal perforation, and type of surgeon (general v pediatric). Results: Of the 780 pyloromyotomies performed, 363 (48%) were performed by pediatric surgeons. Pediatric surgeons cared for more Medicaid patients than general surgeons (PED, 52% v GEN, 40%; P = .001). Infants treated by pediatric surgeons had a lower incidence of mucosal perforation (PED, 0.5% v GEN, 2.9%; P = .0015), which was associated with decreased overall total hospital charges (no perforation, $4,806 [plusmn] 79 v perforation, $6,592 [plusmn] 492; P = .002). When patients with uncomplicated pyloric stenosis were evaluated (96% of cases), those cared for by pediatric surgeons had lower total hospital charges (PED, $4,496 [plusmn] 95 v GEN, $5,121 [plusmn] 121; P = .0001) and shorter length of stay (PED, 2.7 [plusmn] 0.1 days v GEN, 3.1 [plusmn] 0.1 days; P = .01). Conclusions: In North Carolina, general surgeons treat more than half the patients who have pyloric stenosis, though fewer with Medicaid. The cost and incidence of mucosal perforation were increased in infants with pyloric stenosis when care was provided by general rather than pediatric surgeons.     

Initial management of the polytrauma patient

Trauma is the leading cause of death among those aged less than 40 years in the UK. This article highlights the management principles for treating the multiply injured patient, based on the algorithm devised by the American College of Surgeons Committee on Trauma called the Advanced Trauma and Life Support^® guidelines. These guidelines focus on the ABCDE approach, which stands for Airway and cervical spine control, Breathing, Circulation, Disability/neurological status and Exposure. The algorithm was devised to create a common structured approach to managing any patient involved in trauma. It also ensures that life-threatening injuries are identified and treated first, before moving on to treat limb-threatening injuries. The final aim is to identify all the injuries. The principles of treating the multiply injured can be divided into four phases: primary survey (ABCDE) and resuscitation, re-evaluation, secondary survey (full head-to-toe examination) and transfer to definitive care. Using these principles, problems are identified and addressed in a stepwise manner in a sequence that allows all injuries to be identified. Should the patient's condition deteriorate at any stage, the attending team must restart the primary survey at A (airway) once again.