Pedsurg-L Online JPS Journal Club


May 99

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May 99 Journal Club Discussion Thread

While we await a decision from Saunders about whether or not we can reproduce an abstract from the Journal of Pediatric Surgery on Pedsurg-L each month, I believe it is entirely acceptable if we get the ball rolling by paraphrasing an article's abstract and engendering discussion online. Hereafter I will ask that Tito Lugo pick an article from each month's Journal and attempt to post the lead discussion in the first few days of the ensuing month (e.g., the May issue in the first week of June, the June in the first days of July, etc.)  I look forward to this new aspect of Pedsurg-L, and I thank all those who emailed me personal notes about the value of this concept.

The members of Pedsurg-L are invited to review the actual article in J Ped Surg for details.  I realize that many international members may not have yet received the Journal, and for that I apologize.  If I can get a better concept of the number of list members who receive the journal late, then we can perhaps gauge our discussions to this (perhaps discuss the May issue in
August, for example).

So for this first Journal Club I would like to suggest that we discuss the lead April article:

"Antireflux surgery in children under 3 months of age" by Fonkalsrud EW, Bustorff-Silva J, Perez CA,
J Pediatr Surg 34:527-531, 1999.
This was a retrospective review  of 110 patients undergoing fundoplication while under three moths of age between January of 1980 and December of 1997. There were 59 boys and 51 girls.  Indications for operation were recurrent emesis (62), respiratory symptoms (85) or both (54).  One third of the patients had some degree of neurological impairment, a third had associated anomalies, and one fifth were premature. The most common confirmatory test was an UGI, followed closely by esophageal pH monitoring.  While six patients had a Thal procedure, all others underwent a Nissen procedure, and thirty one underwent concurrent gastric emptying procedures.  Complications were seen in 6.4%.

Allow me to start the discussion with the following questions or observations:

* It has been my impression that over the last twenty years we are doing less antireflux surgery in infants, in part prompted by a rather large complication rate of the operation when done in infants.  The authors have a rather modest 6.4% complication rate.  Do others have a similar experience?

* The average age at time of surgery in this article was 1.8 months.  Do others adhere to operative intervention this young?

* Is an UGI an appropriate test to be used to decide upon performing a Nissen operation?  The authors do not discuss milk scans, yet performed gastric emptying procedures in nearly a third of patients.  What do others do to assess gastric emptying, especially in the neurologically impaired child?  By whatever means used, if gastric emptying is significantly delayed do you perform just a gastric emptying procedure or a concurrent fundoplication?

Please do not be constrained by the questions above but feel free to bring up your concerns and inquiries.  I look forward to your collective thoughts on this paper.

Thomas V. Whalen, M.D.
Associate Professor of Surgery & Pediatrics
Head of the Division of Pediatric Surgery
Robert Wood Johnson Medical School at Camden
3 Cooper Plaza, Suite 411              Camden, New Jersey  08103
Voice: 609-342-3018          Fax: 609-541-2634

We do a lot of fundoplications in infants less than 3 mo of age as well.  Many of these have swallowing dysfunction  or apnea/bradycardia associated with their reflux.  I usually get a gastric emptying scan and, if abnormal, add a pyloroplasty to the procedure.  We do a mixture of Thals and Nissens.  Complications are rare.  In my experience, the number of fundos done in this age group has increased over the last several years.
Tim Black, Ft. Worth, TX

Have not received the issue yet. Commenting on the abstract-

Indications - too many pts with emesis as sole indication. Does this means FTT was associated or not?  This young group of children is generally operated due to respiratory (aspiration) or life-threatening event (apnea, choking spells, etc). The number of infants operated for reflux has also increased in my experience. More reluctance to keep the child in-hospital under strict medical care for six wks before deciding on surgical tx? Maybe...

Diagnosis - as the authors suggest we use UGIS and gastric emptying scans in this age group. Some people have challenged the utility of scintigrams in selecting DGE pts. (JPS 33(4):573-9, 1998) arguing a difference when using solid or liquid phase label. I still don't understand very well what an abnormal pH study in this age group means and would not dare operate an infant using this test alone. How is that, that clinical symptoms alone may be unreliable ? (33(11):1623-7, 1998). Well if you operate by pH study, you will need to f-u by pH study. Something of a mystery...

Management- the never-ending story whether a partial or total fundoplication is needed. With no evidence of esophageal dysmotility I favor a Nissen procedure. With delayed gastric emptying would favor a pyloromyotomy (after all we are experts in this procedure) to avoid entry to the GI tract (pyloroplasty). This same group of investigators has rallied us the need of adding a gastric drainage procedure to reduce the risk of recurrent reflux (JPS 34(1):79-82, 1999). Also, in my experience partial wraps have a shorter half-life than Nissen in NI children.

Overall - When analyzing many of these series the patients should be divided in neurologically impaired (NI) and non-NI, since GERD has different results (failure rate), outcome and complications. Complications and recurrence is higher in NI and children with associated conditions. DGE take more importance in this group of children (Surgery 122(4):690-7, 1997). The Feb 99 JPS issue has an article (34(2):295) describing how fundoplication in early infancy (< 4 mo) is unsuccessful in a high proportion of patients. The highest incidence of failure and redo occurred in infants with associated anomalies and the best results were achieved in infants with emesis and respiratory symptoms.

--tito lugo

Historic note - Rudolph Nissen (a German surgeon) flew Hitler catastrophic times and took care of Albert Einstein abdominal aneurysm while working in a Jewish Hospital in NY...

Humberto Lugo-Vicente, MD FACS FAAP
Pediatric Surgeon
San Juan, Puerto Rico

Years ago in 1972 when I made a motion picture dealing with the technique of  the Nissen fundoplication, I wrote Rudolph Nissen and inquired how much trouble his patients experienced with difficulty and/or inability to vomit. He answered my letter and stated that he didn't know what I was talking about  and that I should contact Dr. Bettex. I have that letter somewhere. It  would be a collectors item.

I know this is anecdotal but I became involved with one patient who had a Nissen at UCLA and one who came for a second opinion. The first patient had a Nissen at age of about one month for what I believed to be questionable reflux. The parents were incredibly nervous about their baby spitting up which I think was partially responsible for the Nissen.Post-op the infant couldn't eat because the Nissen was too tight. I reoperated on this patient and was sorely tempted to take down the NIssen and do nothing else but I didn't have the courage so I did a Toupet fundoplication which I consider a superior operation over the Nissen fundoplication. The patient did fine despite her parents and is now five years old and normal.  The second patient was seen for a second opinion mandated by the insurance company. He was a healthy 6 month boy who was constantly spitting up causing the house to smell.  His weight gain was normal, he had no couging, had no recurrent pneumonia, no evidence of esophagitis,etc. I told the mother to wait until her child gets older and buy new furniture.  She left my office very angry. Having done the first Nissen fundoplication in Los Angeles in 1965 I think I can speak with some authority about the subject.  I believe far too many Nissen fundoplications are done. Maybe in a severely brain damaged child it doen't matter but in a mentally normal child there must be clear evidence that this child in the long run will not do well unless he or she has a Nissen.There was a time when antireflux surgery didn't exist and it was a rare child who was normal mentally that eventually didn't get well with no sequelae.

Jordan Weitzman, MD

Right on, Jordy. It has long been a source of irritation to me that almost the only angry parents in my office are the ones that I deny what I think is
unneccessary surgery to, or from. This coupled with the allegations we see in the lay press that we are doing too much surgery.
In a lighter vein, therefore, I suggest that those who wish to submit examples of conditions they see that don't need an operation. Here are some
of my favorites:
1. The breast-fed  baby with infrequent stools. These unfortunate infants get a thermometer twiddled in their anus on a daily basis to make them go, and come in with a request for at least a rectal biopsy.
2. The child with a slightly asymmetric subcutaneous fat conture below and to one side (usually right) of the umbilicus, who want a "spigelian hernia" repaired.
3. The baby with an unusually prominent internal anal sphincter muscle, that protrudes a little, and looks like a lump, requesting a biopsy.

Dave Collins,
San Diego

I dont,t have the april issue, but a comment; we do nissen in impaired patiens younger than 3 months,if scan shows not a good grastric empty we do piloroplasty after eppisodes of bronchoaspirations,apneas. But I also have 2 patients that presents an ileo-ileon invaginations some days after Nissen funduplicature; any comments??

Mauricio Duarte V.   M.D.
Cirujano Pedíatra
Bucaramanga - Colombia

I think I know the reason for Prof. Nissens' strange answer. He was treating adult patients in Basel. He wanted you to contact Prof. Bettex, who was the head of department of pediatric surgery in Berne at that time. He may have thought that Prof. Bettex had more experience  in children.

Dr. med. R. Leuthardt
Chirurgische Universitäts-
Kinderklinik und Poliklinik
Inselspital Bern

A question somewhat related to the journal club discussion:

Does anyone keep older kids who do not have a gastrostomy on a liquid diet after an open or laparoscopic Nissen to address post-op dysphagia?

Most of the patients I do a Nissen on are on a liquid (formula) diet, are too young to talk, are neurologically impaired or are completely tube fed. I am unsure of the incidence of dysphagia in this group. I have had only two other kids (a 1 year old and a 17 year old) who had symptomptomatic dysphagia and got by on a liquid diet for the first few weeks post-op.

If the Nissen is too tight and symptomatic in a child who eats by mouth, how is it best managed?

When would you re-do a Nissen for being too tight?

Lesli Taylor, M.D.
Department of Surgery
University of North Carolina, Chapel Hill
Chapel Hill, N.C. 27599-7210

I have done > 750 Nissens and now believe that the indications to deal with too tight a Nissen is pretty clear. If from day 1 the patient sits with a bowl and spits therein the  wrap is too tight. I have seen this 3 times in the last 2-3 years and made the terribly humbling decision to reoperate WITHIN 1-4 DAYS OF THE INITIAL PROCEDURE. On all 3 occasions the children were immediately better...and the parents..far from being annoyed were overwhelmingly grateful. Why did these cases occur?...partly I think it amounted to becoming blase...I have always employed a largish naso or orogastric tube but more important I think is the need to take the babcock off the potential wrap after taking it around the  esophagus AND...if it flys back from whence it is too tight and you must mobilise it further if necessary dividing a succession of short gastric vessels. There is certainly (in my view) no place for do you dilate healthy muscle?...the critical decision is to swallow one's pride and reoperate....YOU and the patient feel great afterwards!

John Freeman

In Response to the discussion on Fundoplications in infants:

1.    It is interesting that a paper in the Feb issue (JPS, 34, p295), an article by Spitz's group came to the opposite conclusion, i.e. Not effective in Kids < 4 months old.

2.    It is difficult to draw conclusions regarding diagnostic practices from a series spread over 18 years (the paper under discussion), and in which the type of test is not indexed to the reason for the test. For example, in a 1 month old with multiple ALTE (life threatening apneic episodes) temporally related to clinical reflux an UGI study may be enough to document reflux, anatomy and gastric emptying. In contradistinction, a neurologically normal baby who just spits up and has failure to thrive may need a course of medical treatment, UGI, followed by a 24 hr pH probe, and technetium gastric emptying study, prior to a fundoplication.

3.    The age at which surgery was performed to some degree will reflect the practice environment, ie children's hospital Vs. community private practice. In addition, it is my impression that the number of neurologically impaired children with feeding, swallowing and reflux problems is increasing in larger centers with high risk NBICU's, because of increasing salvage of PTNB micropreemies.
    For example, I looked at some data from Arkansas Children's Hospital, in Little Rock, where I did my training. The operative database from 1993 to 1997, showed 427 Fundoplications, of which 32% (137) were in kids < 6 months old and 20% (87) were < 3months old. Although I have not analyzed the follow-up and complication rates by age, it did not appear that there was a significantly higher morbidity or mortality.

4.    Based on my review of the institutional experience in Little Rock, as well as the literature, a 5% to 10% complication rate appears to be realistic if there is enough volume of surgery.

Harsh Grewal, MD

Thank you for your humbling message. One of the pediatric surgeons best  tools is their ears to listen to what is really being said by parents and
children. In this day of increased pt load and less contact time with one primary care provider complaints often are not truly heard. i.e. I have seen three pts whose mothers had been to their pediatricians many times because of constipation and were told various bits of info as you shared without examining the baby's backside. One mother was told to give the baby a suppository and when she said that she couldn't get it in she was
scolded by a nurse practitioner as being a first time Mom and "anyone could do this if they wanted to." These three pt. had severe anal stenosis and could not have a suppository inserted.

#2 The teenager who is having reflux and needs the operation yesterday but has only soft objective data may be crying out for help in other areas.
(parents were both having affairs and pt was involved with a cocaine dealer)

These are just small anecdotes but as a pediatric surgeons we have the blessing of being able to listen and respond by helping to correct the
problem often with operative skill but also at times with wise counsel when operation is not required.

Daniel P. Croitoru, M.D.
Children's Surgical Associates
Children's Hospital of the King's Daughters
601 Children's Lane 5B
Norfolk, VA 23507
(757)668-7703  fax (757)668-8860

June 99 Journal Club Discussion Thread

Albanese CT, Jennings RW, Smith B @, Bratton B, Harrison MR:
Perineal One-Stage Pull-Through for Hirschsprung's Disease. J Pediatr Surg 34(3): 377-380, 1999

In this paper of the March issue the authors describes ten consecutive neonates with biopsy proven HD managed with what they call the POOP (perineal one-stage operative pull-through) procedure. They described their technique, which is no different from what a few of us are doing (transanal endorectal pull-through=TEP) thus far. Have a mean of 105 minutes of  operating time, no post-op complication, a mean stay of two days, while late functional results are pending.

In the discussion of the paper the authors bring some interesting points-
1- Preop colonic irrigation and decompression can blunt a transitional zone during laparoscopic visualization. Many of us have suffered from this blunting.
2- Adequacy of resection is solely dependent on accurate identification of the TZ pathologically using frozen section. The contrast study TZ is very important.
3- You must be very aware that with suspicion of TCA you must establish the diagnosis and TZ with open or lap biopsy before touching the perineum. It could become detrimental to discover TCA after performing the perineal dissection.

The POOP (or TEP) procedure, as you wish, is becoming an excellent alternative for children with -
1- well delineated (by contrast study) classic HD since you do not want surprises of finding out the child really has a long-segment or TCA.
2- no enterocolitis, as this could easily cause technical dissection problems with complications (i.e., vagina, bladder, nerves).
3- good weight gain > the 4 kgs, after all you might need to change to open and find that his postop recovery is problematic.
4- adequate rectal decompression at home while you wait for that weight to be achieved.
5- adequate pathological support, since findings of no ganglions cell in permanent sections 36 hours later is equivalent to leaving aganglionic bowel.

Let hear some comments/controversy/experience from people using the technique.

--tito lugo

PS - notice that I gave our actual PS net-member and one of the author of this paper (Smith Baird) his @ degree...

There is no question that the transition zone in HD can be oblique, long, etc.  It is important that at the time of the pull-through 2 biopsies 180 degrees apart is done to be sure the bowel to be pulled through is 100%  normal in terms of numbers of ganglion cells and absence of nerve trunks.  I am not against progress and actually refer patients who need laparoscopic surgery to my younger colleagues for gallbladder disease, appendectomies in obese children, etc. Until some time passes I will stick to the open procedure which has worked fine for me and a deceased colleague, Pat Brennan, in about 200 cases.  It is silly to talk about 105 minutes and 2 days in the hospital when the newly constructed rectum has to last at least 80 or more years.  Talking about speed of operation and length of stay in the hospital gives the operation a flavor of being a stunt-I can go to the circus and see a man shot out of a cannon if I want to see a stunt.
  Jordan J. Weitzman, M.D.
  Los Angeles, California

      The original series of infant pull throughs by Dr. Carcassone in France and in general the European experience showed many years ago that many kids could be managed with rectal irrigations without colostomies before the final procedure. If you remember 15 yrs ago when you were our fellow I managed some of my cases by this method when parents could be trained. If the baby decompresses well and his obstruction or enterocolitis resolves he is agood candidate for the POOP procedure if you can colonic dilatation or transition zones in the colon. I always start perineally and if I can not reach the ganglionic zone you may the convert to an open  procedure where you can movilize the necessary bowel to pull through the remaining segment  through the previous dissected SOAVE. The data about weight limits is still not clear but is logical to stay away from this patients until more information is accumulated. About 75% of our cases will do well this way.

August 1999 Journal Club Discussion Thread

Bouchard S, Lallier M, Yazbeck S, Bensoussan A: The Otolaryngologic Manifestations of Gastroesophageal Reflux: When is a pH study indicated ? JPS 34 (7): 1053-1056, 1999

The authors main objective was to evaluate the need of pH studies for persistent ENT symptoms and its relationship with GER. Retrospective study. From 3000 pH studies in 16 years! only 105 with ENT sx were referred to r/o GER. Pts with laryngomalacia, stridor and laryngitis were found to have a greater than 50% incidence of reflux. Sinusitis (40%). Resolution of sx occurred in 83% of medically reflux managed cases with stridor, laryngitis (86%) and laryngomalacia (80%). Four cases were operated for reflux. They conclude by recommending a pH study in children with stridor, laryngomalacia and sinusitis when faced with medical-ENT tx failure.

Comments: They did no established a cause/effect relationship in the study. No mention of other simpler and cost-effective study (esophagogram) was done to compare diagnostic yield, structural defects, etc. A pH study is costly and needs at least 20 hours hospitalization to be recommended to a wide variety of ENT manifestations, specially sinusitis which is endemic in some parts of the world.

Jugenburg M, Haddock G, Freedman MH, Ford-Jones L, Ein SH: The Morbidity and Mortality of pediatric Splenectomy: Does Prophylaxis Make a Difference? JPS 34(7): 1064-1067, 1999

While analyzing the incidence of post-splenectomy sepsis between two time periods they found that the number of splenectomies have not decreased (per year) but the incidence of infection and mortality has decreased. They attribute this to the immunization routine.

Comments: the red book recommendation for asplenic individuals are immunization with pneumococcal, Hemophilus and meningitis vaccine. The use of prophylactic antibiotics is questionable as an increase in resistance bacterias is possible. Otherwise URI should be managed with antibiotics. What do others think?

Sandler A, Winkler G, Kimura K, Soper R: The Role of prophylactic Cholecystectomy During Splenectomy in Children with Hereditary Spherocytosis. JPS 34(7): 1077-1078, 1999

In this retrospective study the authors follow for 15 years (even using Internet access!) 33 children who underwent splenectomy without cholecystectomy to evaluate the frequency of symptomatic gallstone development. None developed gallstones or biliary related symptoms. None needed cholecystectomy. They conclude there is no need for prophylactic cholecystectomy at the time of splenectomy in biliary asymptomatic children.

Comments: I bet the use of 'switchboard' to get hold of the patients was a Ken Kimuras'idea. Gallstones I remove the GB, but some of the children have asymptomatic sludge which I generally leave alone at the time of splenectomy. Still other people just do a cholecystostomy and remove the stones. This article seems a reason to do so. Do any of you remove the GB at the time of splenectomy for sludge? Other comments?

Koivusalo A, Rintala R, Lindhal H: Gastroesophageal Reflux in Children with a Congenital Abdominal Wall Defect. JPS 34(7): 1127-1129, 1999

Retrospective study to find incidence and frequency of GER in children with AWD. Endoscopy with biopsy and pH studies done in all patients. GER detected in 13 of 42 cases (Omphalocele 10/23= 43%, gastroschisis 3/19=16%). Primary closure was associated with a lower incidence of GER. Most cases had a benign course with a tendency for spontaneous resolution after medical tx. Only 1 pt needed a fundoplication.

Comment: this has also been our experience: the greater the defect, the smaller the abd cavity, the higher the incidence of GER. Most resolved by the age of two. But again, why not use simpler studies routines as esophagogram, instead of endoscopy and pH study?
Now lets hear reactions from the rest of the list members...
--tito lugo

I am curious to hear from those who perform cholecystectomy in patients undergoing splenectomy for hemolytic illness?  Is there any data to support the removal of a gallbladder, stones or no, in the absence of biliary tract symptomatology?  Do you make a different incision or change your laparoscopic approach?  Has anyone had a biliary/pancreatic complication due to the cholecystectomy in this context?
David Bliss


We have had a large number of pediatric patients with hemolytic syndromes that require laparoscopic splenectomy. We only perform combined laparoscopic cholecystectomy if we can document on pre-operative ultrasound that they have cholelithiasis (symptomatic or not). We typically start with the laparoscopic cholecystectomy (supine position) and then change to a lateral decubitus position (left side up) and use the umbilical port and the midline (or left upper quadrant port) for the laparoscopic splenectomy. Three additional ports are typically needed. The average operative time for the combined operations was 240 minutes.

Andre Hebra
Charleston, SC

In our part of the world (India) 24 hour pH monitoring is simply not available so we have no choice in the matter. We evaluate all suspected GERs with an esophagogram and a milk scan. However we have not been investigating
patients with ENT symptoms and this paper certainly makes a case for this and we shall certainly do a GER study as a routine in this group of patients.
We routinely use prophylaxis as described but do not put children on prophylactic antibiotics. However, we aggressively treat any URIs as and when they develop.

Dr. Rajesh Nathani

I am a ped. surgeon practising at Mumbai, India and at our centre,we have been consciously looking for ger in pts presenting with all kinds of respiratory symptoms including near miss SIDS, stridor,severe pharyngitis etc. As mentioned by Dr. Nathani, we do not have pH monitoring and do a Ba study under IITV (as we do not have cineradiography) One or more of our dept members are always present for the study where we ourselves give the right qty of Ba of appropriate consistency. Milk scan in my experience has yielded poor corelation and with a -ve Ba and strong suspicion, I do an endoscopy with biopsy if necessary. In combinations this gives us good dignostic

jyotsna kirtane

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