419
CORRESPONDENCE
7. Jolley SG, Tune11 WP, Hoelzer DJ, et al: Intraoperative esophageal manometry and early postoperative esophageal pH monitoring in children. J Pediarr Surg 24~336-340, 1989
8. Vos A, Boerema I: Surgical treatment of gastroesophageal reflux in infants and children. Long-term results in 28 cases. J Pediatr Surg6:101-111, 1971 9. Kim SH, Hendren WH, Donahoe PK: Gastroesophageal reflux and hiatus hernia in children. Experience with 70 cases. J Pediatr Surg 15:443-451, 1980 10. Bettex M, Kuffer F: Long-term results of fundoplication in
To the Editor:
We read with much interest the article by Millar et al on the emergency management of patients with bleeding gastric varices uncontrollable by endoscopic sclerotherapy and tamponade.’ We concur with the authors in believing that for this subset of patients, emergency surgery is life-saving and plication of the bleeding varices via a high gastrotomy is simple, expedient, efficacious, and safe in these hemodynamically unstable patients. This procedure may be the only one technically feasible in small children in an emergency setting. However, this procedure mandates oftrepeated postoperative endoscopic injection sclerotherapy, often under general anesthesia. Injection of fundal gastric varices can be technically demanding. In the past decade we performed essentially the same operation except for one important modification. After underrunning the bleeders, we plicated the visible varices with gut sutures at several sites, thereby isolating the varices into several short segments using 5-mL syringes laden with 5% ethanolamine oleate; blood was aspirated and evacuated from the segment of varices, followed immediately by the injection of 0.5 to 1 mL of the sclerosant. The injection site was compressed for a few minutes. In all 9 cases, including the youngest one less than 3 years of age, control of acute
To the Editor:
We were pleased to read the article by Dr Shah.’ We agree with the author that en block resection and forceful reduction of an advanced irreducible intussusception should be avoided and preservation of considerable length of colon is still feasible in such cases. However, we feel that it is important to make several comments particularly in regard to factors producing irreducibility, route and method of amputating apex, site and nature of colotomy, and concern about the ultimate outcome. It appears from experimental work and clinical evidence that irreducibility of an intussusception is determined by at least two factors: the proximal one acting at the neck by adhesions between the sheaths, and the distal one acting at the apex due to maximum degree of edema.* Both factors, one due to excessive compression at neck and other due to enormous expansion at apex, increase with time and become more effective in preventing reduction. The method described by the author takes into account only the latter factor. The majority of advanced cases either have obviously necrotic intussusception prolapsing transanally or could be assisted to bring out of the anus after laparotomy and advancement of the apex by pressing the sigmoid loop. An assistant then proceeds with transanal cautery amputation of apex and a separate colotomy in the left colon could be avoided altogether. Our policy is to continue reduction until it reduces easily and
hiatus hernia and cardioesophageal chalasia in infants and children. J Pediatr Surg 4:526-530, 1969 11. Ashcraft KW, Holder TM, Amoury RA: Treatment of gastroesophageal reflux in children by Thai fundoplication. J Thorac Cardiovasc Surg 82:706-712, 1981 12. Randolph J: Experience with the Nissen fundoplication for correction of gastroesophageal reflux in infants. Ann Surg 198:579584.1983 13. Caniano DA, Ginn-Pease ME, King DR: The failed antireflux procedure: Analysis of risk factors and morbidity. J Pediatr Surg 25:1022-1026, 1990
bleeding was uniformly successful. Follow-up injection of the gastric varices was not required because they were judged sclerosed both endoscopically and by the absence of rebleeding. Intraoperative intravascular injection under direct vision is simple, precise, efficient, and does not significantly add to the operating time. It is noteworthy that accurate intravenous injection of excessive amount of sclerosing agents into unoccluded veins can be hazardous.’ W.D. Ng Y T Chan
Surgical B Unit Hong Kong Government Princess Margaret Hospital Hong Kong
REFERENCES 1. Millar AJW, Brown RA, Hill ID; et al: The fundal pile: Bleedinggastricvarices. J Pediatr Surg 26:707-709, 1991 2. Ng WD, Chan YT: Digital gangrene complicating intraoperative injection sclerotherapy. Gastrointest Endoscopy 34:151-153. 1988
rapidly. Once the bowel stubbornly resists reduction, we do not use strenuous methods of reduction and proceed for a circular colotomy just distal to the neck with or without antimescolic slit to deliver irreducible intussusceptum and perform localized resection with iliocolic anastomosis. Our present policy described above is based on two important observations in the natural history of the disease: (I) spontaneous sloughing of the intussusceptum and spontaneous rupture of the intussuscipiens, and (2) the consistent good results of one intriguing old method proposed for dealing with gangrenous and nonreducible intussusception, which is based on the observation that the intussuscipiens rarely ever becomes gangrenous, so that a short circuiting anastomosis around the neck of intussusception relieves the intestinal obstruction and interrupts the further progression of the lesion.“’ However, such natural accidents of spontaneous sloughing with recovery are rare, require 2 to 3 weeks to develop, happen chiefly in older children rather than in infants, and may result in progressive cicatricial constriction, ultimately producing intestinal obstruction. Our method simply speeds up this natural machinery and is straight-forward, definitive, safe, effective, rapid, applicable to all age groups, and has been performed in several clinical cases successfully. In cases of rupture of intussuscipiens, the sites of rupture are either in the vicinity of neck or over the region of the apex.‘,’ In such a case. we were able to save colon by controlled
420
CORRESPONDENCE
proximal circular colotomy described above successfully? In the development of intussusceptum from the first moment, there is simultaneous interference with patency of the alimentary canal and with the vascular supply of the intussusceptum: the middle layer is isolated between two sharp U-shaped turns of the bowel and mesenteric vessels and understandably is the first to become gangrenous; the innermost layer becomes gangrenous much later; and the outermost layer of the intussuscipiens rarely, if ever, becomes gangrenous, remains viable to the end, has enormous capacity to expand, is of larger caliber, and bears pressure during reduction. If a short circuiting operation by a side-to-side anastomosis around the neck is effective in overcoming alimentary obstruction and vascular compromise described above, our method is more direct and definitive as bowel of questionable viability is safest resected and all viable colon is preserved. In a majority of cases, the neck of the intussusception would not proceed beyond midtransverse colon because of the obvious restraints posed by omentum and transverse mesocolon and,
therefore, left colon can always be preserved, which is sufficient to carry out colonic function. Our present concern is to save ileocecal valve and terminal ileum that form the apex. However, the loose stools and frequency observed at follow-up of these cases even after preservation of large amount of colon are related more to the amount of ileum resected than to the extent of colonic excision.” Although resection of the ileocecal region is well tolerated in children and does not affect growth, it does affect bowel habbit (due to bacterial overgrowth and increased bile salts as a result of reduced transit time and absorption following resection of valve and terminal ileum) and nutritional status (folate and vitamin B,? deficiency). R.V. Pate1 M.H. Mehta J.S. Gondalia
K.T. Children Government Hospital Rajkot, India
REFERENCES 1. Shah AJ: Colotomy with minimum resection for advanced irreducible intussusception. J Pediatr Surg 26:42-43,199l 2. Ravitch MM: Intussusception, in Ravitch MM, Welch KJ, Benson CD, et al (eds): Pediatric Surgery, vol2 (ed 3). Chicago, IL, Year Book, 1979, pp 988-1003 3. Yadav K, Pate1 RV, Mitra SK, et al: Intussusception infancy and childhood. Indian Pediatr 23:113-120,1986
in
To the Editor:
I read an article entitled “Intussusception: Barium or Air?” in the Journal of Pediatric Surgery.’ Failure of either modality to reduce an intussusception showed a correlation to the presence of either an ileoileal or ileoileocolic intussusception. I just wondered if they encountered, on those operated on, the “caput” forming the lead point for intussusception. The caput being the lead point of an intussusception-it is a depression that is concave toward the serosa and convex toward the lumen of the gut. When I was a resident in paediatric surgery, I failed to break the caput out of ignorance; 2 hours postoperatively the child had a
To the Editor:
We were very interested by the article by Tovar et al. in which the “area under pH curve” (AUC) was proposed as a single-figure parameter representative of esophageal acid exposure.’ This parameter was indeed already previously (in 1989) proposed by our group,? and was shown to have a higher specificity in the prediction of esophagitis than the “classic” parameters, such as the percentage time the pH was
CORRESPONDENCE
7. Jolley SG, Tune11 WP, Hoelzer DJ, et al: Intraoperative esophageal manometry and early postoperative esophageal pH monitoring in children. J Pediarr Surg 24~336-340, 1989
8. Vos A, Boerema I: Surgical treatment of gastroesophageal reflux in infants and children. Long-term results in 28 cases. J Pediatr Surg6:101-111, 1971 9. Kim SH, Hendren WH, Donahoe PK: Gastroesophageal reflux and hiatus hernia in children. Experience with 70 cases. J Pediatr Surg 15:443-451, 1980 10. Bettex M, Kuffer F: Long-term results of fundoplication in
To the Editor:
We read with much interest the article by Millar et al on the emergency management of patients with bleeding gastric varices uncontrollable by endoscopic sclerotherapy and tamponade.’ We concur with the authors in believing that for this subset of patients, emergency surgery is life-saving and plication of the bleeding varices via a high gastrotomy is simple, expedient, efficacious, and safe in these hemodynamically unstable patients. This procedure may be the only one technically feasible in small children in an emergency setting. However, this procedure mandates oftrepeated postoperative endoscopic injection sclerotherapy, often under general anesthesia. Injection of fundal gastric varices can be technically demanding. In the past decade we performed essentially the same operation except for one important modification. After underrunning the bleeders, we plicated the visible varices with gut sutures at several sites, thereby isolating the varices into several short segments using 5-mL syringes laden with 5% ethanolamine oleate; blood was aspirated and evacuated from the segment of varices, followed immediately by the injection of 0.5 to 1 mL of the sclerosant. The injection site was compressed for a few minutes. In all 9 cases, including the youngest one less than 3 years of age, control of acute
To the Editor:
We were pleased to read the article by Dr Shah.’ We agree with the author that en block resection and forceful reduction of an advanced irreducible intussusception should be avoided and preservation of considerable length of colon is still feasible in such cases. However, we feel that it is important to make several comments particularly in regard to factors producing irreducibility, route and method of amputating apex, site and nature of colotomy, and concern about the ultimate outcome. It appears from experimental work and clinical evidence that irreducibility of an intussusception is determined by at least two factors: the proximal one acting at the neck by adhesions between the sheaths, and the distal one acting at the apex due to maximum degree of edema.* Both factors, one due to excessive compression at neck and other due to enormous expansion at apex, increase with time and become more effective in preventing reduction. The method described by the author takes into account only the latter factor. The majority of advanced cases either have obviously necrotic intussusception prolapsing transanally or could be assisted to bring out of the anus after laparotomy and advancement of the apex by pressing the sigmoid loop. An assistant then proceeds with transanal cautery amputation of apex and a separate colotomy in the left colon could be avoided altogether. Our policy is to continue reduction until it reduces easily and
hiatus hernia and cardioesophageal chalasia in infants and children. J Pediatr Surg 4:526-530, 1969 11. Ashcraft KW, Holder TM, Amoury RA: Treatment of gastroesophageal reflux in children by Thai fundoplication. J Thorac Cardiovasc Surg 82:706-712, 1981 12. Randolph J: Experience with the Nissen fundoplication for correction of gastroesophageal reflux in infants. Ann Surg 198:579584.1983 13. Caniano DA, Ginn-Pease ME, King DR: The failed antireflux procedure: Analysis of risk factors and morbidity. J Pediatr Surg 25:1022-1026, 1990
bleeding was uniformly successful. Follow-up injection of the gastric varices was not required because they were judged sclerosed both endoscopically and by the absence of rebleeding. Intraoperative intravascular injection under direct vision is simple, precise, efficient, and does not significantly add to the operating time. It is noteworthy that accurate intravenous injection of excessive amount of sclerosing agents into unoccluded veins can be hazardous.’ W.D. Ng Y T Chan
Surgical B Unit Hong Kong Government Princess Margaret Hospital Hong Kong
REFERENCES 1. Millar AJW, Brown RA, Hill ID; et al: The fundal pile: Bleedinggastricvarices. J Pediatr Surg 26:707-709, 1991 2. Ng WD, Chan YT: Digital gangrene complicating intraoperative injection sclerotherapy. Gastrointest Endoscopy 34:151-153. 1988
rapidly. Once the bowel stubbornly resists reduction, we do not use strenuous methods of reduction and proceed for a circular colotomy just distal to the neck with or without antimescolic slit to deliver irreducible intussusceptum and perform localized resection with iliocolic anastomosis. Our present policy described above is based on two important observations in the natural history of the disease: (I) spontaneous sloughing of the intussusceptum and spontaneous rupture of the intussuscipiens, and (2) the consistent good results of one intriguing old method proposed for dealing with gangrenous and nonreducible intussusception, which is based on the observation that the intussuscipiens rarely ever becomes gangrenous, so that a short circuiting anastomosis around the neck of intussusception relieves the intestinal obstruction and interrupts the further progression of the lesion.“’ However, such natural accidents of spontaneous sloughing with recovery are rare, require 2 to 3 weeks to develop, happen chiefly in older children rather than in infants, and may result in progressive cicatricial constriction, ultimately producing intestinal obstruction. Our method simply speeds up this natural machinery and is straight-forward, definitive, safe, effective, rapid, applicable to all age groups, and has been performed in several clinical cases successfully. In cases of rupture of intussuscipiens, the sites of rupture are either in the vicinity of neck or over the region of the apex.‘,’ In such a case. we were able to save colon by controlled
420
CORRESPONDENCE
proximal circular colotomy described above successfully? In the development of intussusceptum from the first moment, there is simultaneous interference with patency of the alimentary canal and with the vascular supply of the intussusceptum: the middle layer is isolated between two sharp U-shaped turns of the bowel and mesenteric vessels and understandably is the first to become gangrenous; the innermost layer becomes gangrenous much later; and the outermost layer of the intussuscipiens rarely, if ever, becomes gangrenous, remains viable to the end, has enormous capacity to expand, is of larger caliber, and bears pressure during reduction. If a short circuiting operation by a side-to-side anastomosis around the neck is effective in overcoming alimentary obstruction and vascular compromise described above, our method is more direct and definitive as bowel of questionable viability is safest resected and all viable colon is preserved. In a majority of cases, the neck of the intussusception would not proceed beyond midtransverse colon because of the obvious restraints posed by omentum and transverse mesocolon and,
therefore, left colon can always be preserved, which is sufficient to carry out colonic function. Our present concern is to save ileocecal valve and terminal ileum that form the apex. However, the loose stools and frequency observed at follow-up of these cases even after preservation of large amount of colon are related more to the amount of ileum resected than to the extent of colonic excision.” Although resection of the ileocecal region is well tolerated in children and does not affect growth, it does affect bowel habbit (due to bacterial overgrowth and increased bile salts as a result of reduced transit time and absorption following resection of valve and terminal ileum) and nutritional status (folate and vitamin B,? deficiency). R.V. Pate1 M.H. Mehta J.S. Gondalia
K.T. Children Government Hospital Rajkot, India
REFERENCES 1. Shah AJ: Colotomy with minimum resection for advanced irreducible intussusception. J Pediatr Surg 26:42-43,199l 2. Ravitch MM: Intussusception, in Ravitch MM, Welch KJ, Benson CD, et al (eds): Pediatric Surgery, vol2 (ed 3). Chicago, IL, Year Book, 1979, pp 988-1003 3. Yadav K, Pate1 RV, Mitra SK, et al: Intussusception infancy and childhood. Indian Pediatr 23:113-120,1986
in
To the Editor:
I read an article entitled “Intussusception: Barium or Air?” in the Journal of Pediatric Surgery.’ Failure of either modality to reduce an intussusception showed a correlation to the presence of either an ileoileal or ileoileocolic intussusception. I just wondered if they encountered, on those operated on, the “caput” forming the lead point for intussusception. The caput being the lead point of an intussusception-it is a depression that is concave toward the serosa and convex toward the lumen of the gut. When I was a resident in paediatric surgery, I failed to break the caput out of ignorance; 2 hours postoperatively the child had a
To the Editor:
We were very interested by the article by Tovar et al. in which the “area under pH curve” (AUC) was proposed as a single-figure parameter representative of esophageal acid exposure.’ This parameter was indeed already previously (in 1989) proposed by our group,? and was shown to have a higher specificity in the prediction of esophagitis than the “classic” parameters, such as the percentage time the pH was
