A comparison of the results of primary repair of esophageal atresia with tracheoesophageal fistulas using end-to-side and end-to-end anastomoses

Over the last $\text{2}\text{1}\text{2}$ yr at the Hospital for Sick Children, Toronto, two groups of unselected newborns with the common type of esophageal atresia and tracheo-esophageal fistula were repaired using either the end-to-side or end-to-end techniques. Bearing in mind that two-thirds of the end-to-side repairs were constructed under some tension (as opposed to one-third of the end-to-end anastomoses), there was a higher incidence of leaks, anastomotic strictures, and recurrent tracheoesophageal fistulas in the end-to-side repair. The overall mortality, however, was equal in both sets of patients.     

Malignant ovarian tumors in children

Malignant ovarian tumors in childhood, though uncommon, should be considered in any female child with an abdominal mass. The treatment is prompt, complete surgical removal if possible. These tumors vary greatly in their malignancy, but if removed before spread has taken place, the child's prognosis may be relatively good. Unfortunately, complete resection is frequently impossible. Radical surgery has no place in this disease, but radiotherapy and chemotherapy may give some palliation. Long-term favorable results are the exception as exemplified by a 73% mortality in the small series of 15 patients reviewed here.     

Simple method of elongating a colonic segment for esophageal replacement

Occasionally the surgeon is confronted with a major problem that can be solved easily if he has been alerted to an applicable and simple maneuver. Several years ago Najafi and Beattie¹ employed such a maneuver in elongating a piece of colon to bridge a gap in an adult with extensive stricture of the esophagus. Although their technique would not seem feasible with the colon of an infant, they did call attention to the fact that the teniae coli, rather than the blood supply, limited the stretching of the colonic segment. It is this point that deserves emphasis and justifies the following report.     

Peptic ulcer in children with gastric tube interposition.

An infrequent, but potentially serious, complication of gastric tube interposition is ulceration within the conduit. It is important, therefore, to recognize ulcer formation in its early stages by serial radiographs throughout the childhood years. While redundancy and partial obstruction with impaired drainage of the tube appear to be etiologic factors, distension of the transposed antrum may lead to hyperacidity and may play a role in ulcerogenesis. A course of dietary and antacid therapy may heal the ulcer, but surgical revision of the tube may prove necessary.     

Pneumopericardium and pneumomediastinum in infants and children

The increasing use of continuous positive airway pressure (CPAP), and positive end-expiratory pressure (PEEP) in the treatment of pulmonary insufficiency is associated with an increased frequency of pneumothorax, pneumomediastinum, and pneumopericardium in children. While the clinical implications and treatment of pneumothorax are well documented, the treatment of pneumomediastinum and pneumopericardium in the presence of continuing elevated airway pressures is not.In the presence of continuing positive-pressure ventilation in the newborn compression of the heart and great veins, sudden bradycardia, and loss of blood pressure lead to a fatal outcome unless the pericardium is decompressed.In older patients, routine palpation for subcutaneous emphysema aids in early diagnosis. When positive-pressure ventilation is needed to sustain life, early measures to decompress the trapped air are necessary.     

Significance of absent vas deferens at hernia repair in infants and children.

An absent vas deferens may be associated with unilateral renal agenesis or undiagnosed cystic fibrosis. Such patients should be further evaluated with a sweat chloride and intravenous pyelogram. The finding of absent vas deferens during exploration for an undescended testis does not provide absolute evidence for absence of the testis, since these structures have independent embryologic origins.     

Peritoneoscopy in infants and children

Peritoneoscopy is the visualization of the contents of the peritoneal cavity by means of a small telescope introduced through the anterior abdominal wall after establishment of a pneumoperitoneum. This procedure, also referred to as laparoscopy or celioscopy, is “rediscovered” with brief flurries of popularity every few years with the development of new instruments and new techniques. The greatest use and most lasting progress have been made by the gynecologists. The method has also had limited success in the hands of the internist and surgeon, particularly in evaluating liver disease. However, benefits to pediatrics have been few, if any, and it is rare to find mention of the procedure in the pediatric literature, or use of the method in the pediatric treatment centers of the world. No doubt this is due to the fact that when conventional telescopes are miniaturized for pediatric use, the view is so poor that it is relatively useless.In recent years technical advances have made possible significant improvements in telescopic endoscopy.¹ The most significant of these is the development by Hopkins of the rod lens optical system, which can be miniaturized for pediatric use, at the same time achieving a wide angle view and increased transmission of light. A high-intensity cold light is brought to the subject by fiber optic threads placed along the length of the glass rod lenses.Stimulated by these advances, it was decided to evaluate the method for infants and children, to explore its parameters, to recognize its limitations, and to establish a safe and satisfactory technique. Because of the lack of details in the literature and the absence of experience in other pediatric centers, a modification of the adult procedure was employed as a starting point for the development of the present method.     

Recurrent intussusception in children.

Twenty-eight children with 35 recurrent intussusceptions were collected and analyzed from a series of 600 intussusceptions over 17 yr. The overall recurrence rate in the entire series was 5% with 11% recurring after hydrostatic barium enema reduction, and 3% after operative reduction. Twenty-three children had one recurrence each, four children had two recurrences, and one child had four recurrent intussusceptions. More than two-thirds of the patients had a recurrence within 6 mo of their first intussusception, and half of these presented earlier and with fewer signs and symptoms than the previous attack had manifested. Twenty-one of 30 recurrences were reduced with barium enema. Sixteen were operated on, reducing nine manually and resecting four others. Only two leading points were found, and in both instances resection was required. All but two of the intussusceptions were ileocolic. The previous mode of reduction of each intussusception did not set a trend for future treatment of recurrent intussusceptions in the same child. While operative reduction diminishes the chances of a recurrent intussusception and ileocolic resection eliminates it, there does not seem to be any indication for surgery as long as barium enema reduction is successful. We have never observed the hydrostatic reduction of an intussusception caused by a leading point.     

Experience with 55 silon pouches

The application of a Silon pouch usually indicates a desperate if not impossible situation in which the abdominal contents cannot be returned to the abdominal cavity and therefore require some type of covering. Since 1968, we have had experience with 55 Silon pouches in infants and children. Almost all of these pouches were applied to newborns. There were 22 deaths in this series (40%), although 12 of these deaths were in the diaphragmatic hernia group and were almost all due to respiratory failure unrelated to the pouch itself. There were nine deaths in the gastroschisis and omphalocele group (28%) and in all these instances infection (especially Candida) was the underlying cause. While much debate exists as to how the Silon pouch should be handled after its application our series demonstrated that the longer it stayed in place the greater the chance of infection. Furthermore if broad spectrum antibiotics were used for a prolonged period of time, Candida overgrowth of the pouch followed by Candida sepsis and death were almost inevitable.     

Peptic esophageal stenosis in children

Of 192 cases of hiatus hernia, 121 were operated upon and 28 (14.5%) had peptic esophageal stenosis. Unduly prolonged medical treatment is likely to increase the incidence of stricture. Using conservative surgical procedures, a success rate of 85.7% has been achieved in the treatment of peptic esophageal stenosis without mortality.     

Gastroesophageal fundoplication for reflux in infants and children

Fifteen infants and young children with symptomatic gastroesophageal reflux underwent fundoplication during a $\text{6}\text{1}\text{2}\text{-}\text{yr}$ period. Standard barium esophagrams clearly demonstrated reflux in only 10 of the 15 patients; however, cine esophagrams indicated reflux in the remaining patients. Esophagoscopy with mucosal biopsy demonstrated esophagitis in 9 of the 10 patients in whom it was performed, and it is a very helpful diagnostic procedure. Esophageal manometry showed low sphincter pressures in each of 7 patients.Fundoplication was performed when there was (1) persistent reflux after a 3-wk hospital course of vigorous medical management, (2) failure to gain weight, (3) malnutrition, (4) recurrent aspiration, (5) esophagitis, or (6) stricture. Concomitant gastrostomy prevented the gas bloat syndrome in all patients. All strictures were successfully relieved by postoperative dilatation (average four per patient). Esophageal replacement is rarely indicated for strictures due to reflux in children.No deaths or major complications occurred following operation. Each of the patients has been relieved of clinical reflux, and each has gained weight more rapidly than preoperatively. Follow-up esophagrams on each of the patients show absence of reflux, and manometry shows the low esophageal sphincter pressure to be increased an average of 10 mm Hg above preoperative values.Since the results of Nissen fundoplication to correct reflux in infants and young children are highly satisfactory, and since the consequences of persistent reflux may be severe, a fairly aggressive approach should be taken in the management of symptomatic reflux.     

Low molecular weight dextran in the treatment of necrotizing enterocolitis and midgut volvulus in infants

Because of its abilities to reduce thrombus formation, low molecular-weight dextran was administered to eight newborns with necrotizing enterocolitis and two infants with midgut volvulus. The enterocolitis group which received dextran when compared with an otherwise similarly treated group which did not receive dextran, revealed the following differences: half of the dextran-treated group did not require operation while all of the patients not receiving dextran did. Although repeated perforation and late intestinal strictures occurred commonly in the group which did not receive dextran, no dextran-treated infant demonstrated either of these complications. The patients with midgut volvulus receiving dextran demonstrated remarkable recovery of bowel at reexploration, despite the widespread ischemic appearance of bowel at initial operation. No complications from the use of dextran were encountered.