Ileal pedicle grafting for esophageal replacement in children

Reconstruction of the upper esophagus in small children remains a challenge. Free jejunal interposition as frequently used in adults is much less appropriate in children because of the limited vessel size. The use of a jejunal pedicle graft in children has been described, but gaining enough length may be a problem. A pedicle graft of terminal ileum may be a better option, but this technique has never been described. We report a child with esophageal atresia and distal fistula who had a very short upper esophageal pouch. Primary repair was impossible. The fistula was ligated and a gastrostomy created. A second attempt at anastomosis was not successful either, and a cervical esophagostomy was created. The child was fed by gastrostomy and received sham feeding orally. When the child was 10 months old, the upper esophagus was successfully reconstructed with a pedicle graft of terminal ileum. Postoperatively there was a limited leak of the proximal anastomosis, which healed spontaneously. The distal anastomosis had to be dilated on a few occasions. With a follow-up of 1 year, the child is eating well without gastrostomy supplementation. On imaging, the ileal pedicle graft looks somewhat tortuous but contracts nicely. We feel that ileal pedicle graft reconstruction of the esophagus should be part of the instrumentarium of pediatric surgeons dealing with esophageal reconstruction

Surgery for necrotising enterocolitis: primary anastomosis or enterostomy?

The ideal surgical management of neonates with necrotising enterocolitis (NEC) is still a matter of debate. The purpose of this study was to compare the results of bowel resection with primary anastomosis with the results of bowel resection with enterostomy. Sixty-three neonates with NEC had a bowel resection in the acute phase of the disease in the period between February 1990 and March 2001. Thirty-four of them (54%) underwent resection of the bowel with primary anastomosis (Group A), and 29 (46%) had resection with enterostomy (Group B). Group A had a lower gestational age and lower birth weight. Mortality, complication rate, and postoperative weight gain were not significantly different between the groups. However, Group B had a significantly longer primary hospital stay (80+/-49 days versus 58+/-31 days,

Risks and benefits of surgical management of gastroesophageal reflux in neurologically impaired children

BACKGROUND: The aim of this study was to investigate the feasibility and results of laparoscopic antireflux procedure in neurologically impaired children. METHODS: Over a 5-yr period, 259 children affected by gastroesophageal reflux disease underwent laparoscopic antireflux procedure. Eighty of them (30.8%) were neurologically impaired. In 58 children we performed an anterior fundoplication according to Thal and in 22 patients a 360 degrees fundoplication according to Nissen. Forty-eight children underwent an associated gastrostomy placement at the same time as the laparoscopic antireflux procedure. RESULTS: We recorded 4/80 intraoperative complications; in all cases the complication was managed laparoscopically and no conversion was needed. Follow-up ranged from 6 months to 6 yrs (median 3 yrs). We recorded 24/80 postoperative complications, 5 of which required a redo procedure. We have a mortality rate of 17.5% but in only one case was the event related to the antireflux procedure. CONCLUSIONS: Laparoscopic fundoplication can be performed safely and with acceptable results in neurologically impaired children. The indication to add a gastrostomy should be tailored to the needs of the individual patient. Mortality rate in neurologically impaired children patients with gastroesophageal reflux disease is high but in most cases unrelated to the antireflux procedure

Should an infected Nuss bar be removed?

Background: The Nuss procedure is a minimally invasive procedure for correction of pectus excavatum. It involves insertion of a substernal metal bar. A feared complication of any implanted device is infection, which often necessitates removal. The purpose of this report is to describe the authors' experience with infectious complications after the Nuss procedure. Methods: From February 2000 to July 2002, 102 patients underwent the Nuss procedure in 2 pediatric surgical centers. In a retrospective way, the files of those patients in whom a postoperative infection developed were studied. Results: Seven patients suffered postoperative infectious complications. Only one bar needed to be removed. Conclusion: The authors' experience indicates that there is no need for immediate removal of an infected Nuss bar. Most of these infections can be managed conservatively. However, early antibiotic treatment is warranted to ensure salvage of the bar. (c) 2005 Elsevier Inc. All rights reserved

Direct bypassing of extrahepatic portal venous obstruction in children: A new technique for combined hepatic portal revascularization and treatment of extrahepatic portal hypertension

Background: Decompression of extrahepatic portal hypertension by directly bypassing the thrombosed portal vein has never been reported in cases of children with idiopathic (or neonatal) portal vein obstruction and cavernoma. Methods: Seven children (15 years or younger) with portal vein obstruction requiring surgical decompression (urgently in two cases), and in whom preoperative Doppler had shown that the intrahepatic portal branches were hypoplastic but free of thrombus, were included in a pilot study. The cavernoma was bypassed by interposing a venous jugular autograft between the superior mesenteric vein and the distal portion of the left portal vein. Patients received follow-up using routine clinical parameters, upper gastrointestinal endoscopy, and Doppler ultrasound. Results: The mesenterico-portal bypass restored a direct (physiological) hepatopetal portal flow. The operation resulted in effective portal decompression as demonstrated by decrease of the pressure gradient, rapid regression of clinical signs of portal hypertension, and definitive control of bleeding. Conclusions: This study shows that direct bypassing of portal cavernoma is possible and results in effective portal decompression. Restoration of the hepatic portal flow is a major advantage compared with conventional surgical shunting procedures. This new technique is potentially applicable to two thirds of children with portal vein thrombosis and should be considered when shunting procedures are indicated. Copyright (C) 1998 by W.B. Saunders Company