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
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
