Definitive treatment of Hirschsprung's disease in the newborn with a one-stage procedure

BACKGROUND: The purpose of this study was to review our experience and early follow-up with 15 one-stage pull-through procedures performed at the time of diagnosis in neonates and infants with Hirschsprung's disease. METHODS: Historic chart review of all patients with the new diagnosis of Hirschsprung's disease seen at the C.S. Mott Children's Hospital at the University of Michigan, Ann Arbor, between June 1989 and June 1992 was performed. Progress notes, operative and anesthetic records, pathology reports, and outpatient follow-up notes were used for data collection. RESULTS: Operative technique included a modified endorectal pull-through after determining the presence of ganglion cells by frozen section. No colostomies were performed before or after operation. Three patients had affected family members. All infants were born at term. Operation was performed within 24 hours of diagnosis and as early as 48 hours of age. Twelve patients had standard rectosigmoid disease, two had total colonic disease, and another had long-segment disease. Bowel function returned within 4 days of operation, and feeding was instituted by postoperative day 6 in all patients. All of the patients with rectosigmoid disease are doing well. Patients with long-segment or total colonic disease had more problems but are currently at home and doing well. Morbidity included two postoperative bowel obstructions and three patients with postoperative enterocolitis. CONCLUSIONS: A single definitive operation may be used to treat Hirschsprung's disease diagnosed in the newborn. Long-term follow-up in these patients is required.     

One-stage versus two-stage Soave pull-through for Hirschsprung's disease in the first year of life

Several investigators have reported good results after a one-stage Soave procedure without a stoma for infants with Hirschsprung's disease. The authors reviewed their concurrent experience with the one- and two-stage approaches, comparing the two groups with respect to rate of complications and clinical outcome. Over a 3-year period, 36 infants with colonic Hirschsprung's disease presenting in the first year of life were treated with a Soave pull-through. Thirteen had a one-stage pull-through, and 23 had a two-stage procedure using an initial stoma. There was no difference with respect to median age at time of diagnosis, median follow-up period, length of aganglionosis, or male:female ratio between the groups. The incidences of major complications such as small bowel obstruction, segmental or acquired aganglionosis, anastomotic leak, and malabsorption were equal between the two groups. However, 13% of the two-stage patients required revision of the stoma. All major complications in the one-stage group were in those who weighed less than 4 kg at the time of surgery. Minor complications such as wound infection, perianal excoriation, and need for repeated dilatation were similar between the groups, but minor stoma-related complications (prolapse or retraction) occurred in 26% of the two-stage infants. When complications were stratified using a more sophisticated scale of severity, no significant difference was found between the groups. The overall complication rate was 1.5 events per patient in the one-stage group and 2.0 events per patient in the two-stage group. This small difference was related to the presence of a stoma in the two-stage group. Overall, 10 of 12 survivors in the one-stage group and 22 of 23 in the two-stage group were doing well, with normal bowel function noted on long-term follow-up (mean period, of 14 and 19 months, respectively). Both one- and two-stage approaches were associated with a significant complication rate, although long-term outcome was excellent in both groups. The higher complication rate in the two-stage group was attributable to the presence of a stoma. For small infants, it may be beneficial to delay the one-stage pull-through until weight exceeds 4 kg.     

Laparoscopic Swenson pull-through: a comparison with the open procedure

This study was performed to compare the standard open Swenson pull-through (OSP) with the laparoscopic Swenson pull-through (LSP) for Hirschsprung's disease. The Swenson pull-through was performed on eight patients with a rectosigmoid transition zone, during a 14-month period, using one camera port and three working ports. The results were compared with those of 10 patients with a similar lesion treated by the open procedure during an overlapping 19-month period. One laparoscopic procedure was converted to the open version because of technical difficulties. Both methods had a hand-sewn anastomosis approximately 1 cm above the pectinate line. The preoperative variables of age, weight, incidence of colostomy, and incidence of Down's syndrome were similar for the two groups. The operating time for LSP was similar to that for OSP (4 hours 42 minutes v 4 hours 37 minutes, respectively: P = NS). Postoperatively, the laparoscopic group had a shorter hospital stay (5.25 v 8.8 days; P < .05) and had a shorter period until the start of oral intake (2.75 v 5 days; P < .05). The requirement for narcotic pain medication was similar (12.6 v 12.8 doses; P = NS). Early postoperative complications were more common in the open group (3 wound infections, 1 prolonged ileus, and 1 anastomotic leak). No complications occurred in the laparoscopic group. Late postoperative follow-up was too short to compare functional results. The authors conclude that the Swenson pull-through can be performed safely with the laparoscope, with reduced morbidity.     

Clinical outcome and long-term quality of life after surgical correction of Hirschsprung's disease

One hundred seventy-eight of 330 patients were recalled after undergoing surgery for histologically proven Hirschsprung's disease (HD). One hundred fifteen were older than 4 years at interview (Mean age, 10 years). This sample appeared to be representative of the whole in terms of demographic features such as ethnic group, sex, length of aganglionic segment, timing of presentation and surgery performed. Anthropomorphic indices for weight and height were comparable to norms, but many younger patients were below expected weight for age. In general, weight and height for age was regained with time. Nine patients had delayed developmental milestones, which were owing to specific causes in four. Nine patients had a poor functional outcome, of which two had neurological impairment. Satisfactory school performance was achieved in all but 19 (26%) of the remaining patients. Long-term functional results were comparable for the Soave and Duhamel procedures with less favorable results noted following the Swenson procedure. Assessment of complications demonstrated a significantly (P < .01) lower incidence of constipation, sexual dysfunction, and micturition disturbance following the Soave procedure when compared with the Duhamel and Swenson procedures. Neurological impairment and length of aganglionic segment beyond the rectosigmoid area appeared to influence functional outcome, as did persisting enterocolitis. Enterocolitis was observed in 16.6% of patients on presentation, but continued in only 6%. Constipation was particularly associated with the Duhamel procedure, and a higher incidence of micturition disturbance, abdominal distension, and cuff stricture was noted following the Swenson procedure. Functional assessment by three different scoring methods showed that 86 (74.7%) of the 115 patients over the age of 4 had excellent anorectal function and appeared to be well adjusted. Twenty-two patients (19.2%) had relatively minor long-term problems but seven (6.1%) had persistent fecal soiling with resulting psychosocial maladjustment.     

Zonal adult Hirschsprung's disease

BACKGROUND: Hirschsprung's disease is a congenital disorder which is rare in adulthood. In typical cases the aganglionosis involves mainly the rectum or rectosigmoid colon and the lesion starts from the anal valve. Zonal segmental aganglionosis is a very rare type even in children. PATIENT: A 54 year old women with zonal segmental aganglionosis had an aganglionic segment 18 cm in length located in the rectosigmoid colon with an 8 cm long normal appearing rectum and dilated proximal colon. Resection of the stenotic segment with end to end anastomosis was performed. CONCLUSION: The functional result was excellent five years after the operation.     

Posterior sagittal resection for rectal aganglionosis: preliminary results of a new approach

BACKGROUND: There is no general agreement about how patients who have short-segment Hirschsprung's disease should be treated. METHODS: Ten patients with Hirschsprung's disease, seven with rectal and three with rectosigmoidal aganglionosis, were operated on through a posterior sagittal incision. In nine patients, a primary rectal resection and coloanal anastomosis was performed. In one patient, a longitudinal posterior myectomy of the rectum was performed as a primary procedure, but the procedure was eventually converted to a rectal resection and coloanal anastomosis through the same incision. RESULTS: One early and one late anastomotic complication occurred. Both were successfully treated with a temporary fecal diversion (left-sided colostomy for 6 to 8 weeks). The functional results as evaluated with anorectal manometry were similar to a group of Hirschsprung's patients treated with transabdominal pull-through resection and coloanal anastomosis. CONCLUSION: This approach might prove to be a useful alternative both to the transabdominal resection and the posterior longitudinal rectal myectomy in Hirschsprung's disease with rectal aganglionosis.     

Repeat pull-through for Hirschsprung's disease

BACKGROUND: A repeat pull-through for Hirschsprung's disease is undertaken when the original procedure has failed. The reasons for failure include a retained aganglionic segment, stricture, fistula, or persisting incontinence. METHODS: All patients who underwent a redo pull-through from 1982 through 1996 were included. Twenty-two patients were underwent surgery; 20 notes were reviewed. The mean age at operation was 6 years (range, 1 to 13). Mean time between operations was 5.1 years (range, 0.5 to 13). RESULTS: Postoperative complications occurred in five patients. These included wound infection, recurrent rectal septum, division of a vas, compartment syndrome, and an anastomotic stricture. Follow-up was for 6.5 years (range, 0.2 to 12). The mean number of bowel movements was 2.2 per day (range, 1 to 6). Fourteen (of 19) patients were continent or soiling less than once per week. Soiling occurred more than once a week in four, but two of these were incontinent after the first operation. One has a colostomy. CONCLUSION: A repeat pull-through is a worthwhile procedure when dealing with an anatomic problem such as retained Hirschsprung's disease, stenosis, or fistula.     

Determination of codeine and its metabolites in microsomal incubates by high-performance liquid chromatography

One hundred seventy-eight of 326 patients had surgery for Hirschsprung's disease at Red Cross Children's Hospital (1957 to 1990) agreed to participate in a recall follow-up study. Assessment of the postoperative outcome of the Swenson, Duhamel, and Soave procedures included manometric evaluation in 43 patients by perfused-tube and balloon-series techniques. Rectal suction biopsies were performed for patients who had persistent problems with stool evaluation. One hundred fifteen of the 178 patients were more than 4 years of age, and long-term functional outcome could be assessed. Although good results were obtained in 94% overall, 16 had clinical evidence of a degree of persisting obstruction. Results of manometric assessment of anorectal function in these patients were not significantly different from those of 28 patients who had normal stool evacuation. A biopsy was performed in 14 of the 16 patients who had symptoms of obstruction postoperatively, and abnormal histological features were noted. There was aganglionosis in four, features of neuronal intestinal dysplasia in nine, ganglioneuromatosis of the colon in one. The results of two biopsies were entirely normal. Implications of postoperative dysfunction after surgery for Hirschsprung's disease are discussed, and a protocol for investigation and management is proposed.     

Surgical correction of Hirschprung's disease: 7 years' experience with the Rehbein technique

Twenty-seven children with Hirschsprung's disease underwent surgery using a modified Rehbein procedure. All the patients were admitted under one unit at the Jos University Teaching Hospital, Nigeria, over a 7-year period from April 1985 to March 1992. There was a male:female ratio of 3:1 with an average age at presentation of 21 months. Skin excoriation (19.0%) following initial colostomy was the commonest postoperative complication, while wound infection (18.5%) featured most often after definitIve surgery. There were no deaths following this procedure. The modified Rehbein technique is a safe and efficacious definitive method of surgical correction of Hirschsprung's disease.     

Secular changes in radical prostatectomy utilization rates in Olmsted County, Minnesota 1980 to 1995

PURPOSE: We estimated the changes in utilization of radical prostatectomy for treatment of prostate cancer and describe the clinical characteristics of men undergoing radical prostatectomy in a population based setting. MATERIALS AND METHODS: The Rochester Epidemiology Project was used to identify all Olmsted County residents who underwent radical prostatectomy from 1980 to 1995. The community medical records of these men were reviewed to determine the clinical and pathological stage and grade at biopsy and following surgery. RESULTS: From 1980 to 1995, 311 radical prostatectomies were performed on Olmsted County men. From 1980 to 1987 prostatectomy rates ranged from 6.3 to 31.0/100,000 men but rates increased dramatically to 53.6/100,000 in 1988 and 106.2/100,000 in 1992. The rate after 1992 decreased to 53.0/100,000 and then increased slightly to 80.4/100,000. There was a shift to younger age in more recent times (mean patient age 65.4 years in 1980 to 1986 and 62.4 in 1993 to 1995, p = 0.02), a nonsignificant (p = 0.10) trend toward lower pathological stage in recent years (42% stage pT2 in 1980 to 1986 versus 55% in 1993 to 1995) and a significant decrease in the proportion of cases of disease up staged following surgery (53% in 1980 to 1986 versus 37% in 1993 to 1995, p = 0.03). There was no significant trend in pathological grade with time (63% Mayo grade I or II in 1980 to 1986 versus 52% in 1993 to 1995, p = 0.30). CONCLUSIONS: These findings demonstrate an increase in radical prostatectomy rates that coincided with increases in prostate cancer incidence. There was a decrease in population prostatectomy rates in 1993 which was followed by modest increases to levels lower than the peak in 1992. However, the clinical characteristics of patients during this period did not change dramatically, suggesting that in a population based setting the selection factors for patients undergoing surgical treatment may not have changed.     

Long-term morbidity in total colonic aganglionosis

BACKGROUND/PURPOSE: No surgical treatment for total colonic aganglionosis (TCA) clearly has been proven superior. To identify clinical criteria associated with long-term functional outcome, a 28-year retrospective institutional review of this entity from 1969 through 1996 inclusive was undertaken. METHODS: Total colonic aganglionosis (TCA), defined here as aganglionosis extending from the anus to at least the ileocecal valve but no further than 50 cm proximal to the ileocecal valve, was identified in 29 infants and children. Appropriate leveling ileostomy was performed in 28 of 29 patients, and definitive surgical reconstruction was performed in 26 of 29. Three groups were identified based on the definitive surgical repair performed: group 1, construction lacking or incorporating a short ganglionic-aganglionic common channel (modified Soave or modified Duhamel, n = 8); group II, construction of an extended common channel (Martin-Duhamel, Martin-Soave; n = 6); and group III, all others including an intermediate-length common channel (n = 13). RESULTS: Functional outcome at extended follow-up (mean, 6.6 +/- 5.6 years; range, 0.7 to 23) was determined based on survival, long-term ostomy requirements, growth, major complications, continence, and enterocolitis and bowel movement frequency. Although long-term functional outcome was deemed satisfactory in six of seven patients in group I, function was satisfactory in none of six group II patients. Group III results were intermediate (satisfactory in 6 of 13). CONCLUSIONS: Acceptable long-term outcome was most frequent in TCA patients whose definitive repair did not incorporate an extended ganglionic-aganglionic common channel. The use of extensive lengths of aganglionic bowel to maximize fluid absorption is frequently met with substantial morbidity.     

Swenson's operation for neonatal Hirschsprung's disease

OBJECTIVE: To describe our experience with Swenson's operation for Hirschsprung's disease done during the neonatal period. DESIGN: Retrospective study. SETTING: University department of paediatric surgery. SUBJECTS: 10 Neonates with Hirschsprung's disease. INTERVENTIONS: Rectosigmoidectomy and pull through (Swenson's operation), with covering transverse colostomy. MAIN OUTCOME MEASURES: Mortality, morbidity, and continence. RESULTS: The median age at definitive operation was 25 days (range 15-35). There was one late death three weeks after discharge from hospital of respiratory and cardiac failure. Two patients presented with caecal perforation and two with intestinal obstruction; in all four Hirschsprung's disease was diagnosed on frozen section, a transverse colostomy was done, and the Swenson's operation was done electively. The other six were diagnosed by barium enema examination and biopsy, and underwent total bowel irrigation followed by Swenson's operation and transverse colostomy. The colostomies were closed three to four weeks later. There were no postoperative complications. All nine surviving patients were continent (3-4 stools/day), at a mean (SD) follow up of 21 (5) months. CONCLUSION: With the current high standards of anaesthesia and neonatal intensive care, and an experienced surgeon, Swenson's operation for neonatal Hirschsprung's disease is safe and the procedure of choice for this condition.     

Determinants of successful balloon valvotomy in infants with critical pulmonary stenosis or membranous pulmonary atresia with intact ventricular septum

OBJECTIVES: This study reviewed our experience with percutaneous balloon valvotomy in infants with critical pulmonary stenosis or membranous pulmonary atresia with intact ventricular septum and defined the anatomic and hemodynamic characteristics of infants in whom this procedure is successful and provides definitive therapy. BACKGROUND: Unlike children with valvular pulmonary stenosis, the follow-up of infants with critical pulmonary stenosis undergoing percutaneous balloon valvotomy is limited. METHODS: Between December 1987 and August 1992, percutaneous balloon valvotomy was attempted in 12 infants with critical pulmonary stenosis (n = 10) or pulmonary atresia with intact ventricular septum (n = 2). Two outcome groups were identified: Group A patients are acyanotic, have mild residual pulmonary stenosis and have not required operation; Group B patients have required operation. RESULTS: Of the 12 infants, 11 had a successful balloon valvotomy procedure. Group A patients (n = 7) have a residual gradient of 22 +/- 18.7 mm Hg (mean +/- SD) at follow-up of 3.2 years (range 1.2 to 5.0). In Group B (n = 5), operation was required for inability to cross the pulmonary valve (n = 1) or persistent severe hypoxemia for > or = 2 weeks after valvotomy (n = 4). Significant differences (p < or = 0.01) between the two groups (Group A vs. Group B) were identified in pulmonary valve annulus (Z value) 8.1 mm (-1.1) versus 5.5 mm (-3.4); tricuspid valve annulus (Z value) 14.0 mm (0.8) versus 8.8 mm (-1.8); right ventricular volume 65 versus 29 ml/m2; and Lewis index 10.9 versus 8.9. CONCLUSIONS: Percutaneous balloon valvotomy is effective and likely to provide definitive therapy in infants with critical pulmonary stenosis or membranous pulmonary atresia with intact ventricular septum who have a tricuspid valve annulus > 11 mm, pulmonary valve annulus > or = 7 mm and right ventricular volume > 30 ml/m2.     

Single-stage repair of Hirschsprung's disease: a comparison of 109 patients over 5 years

Current management of Hirschsprung's disease (HD) typically involves staged therapy, which necessitates multiple hospital admissions and associated costs. The authors therefore investigated the course and outcome of treating such children using a single-staged (SS) approach, and compared them with those treated via multiple-staged (MS) therapy. The cases of one hundred nine consecutive patients who presented with HD from 1991 to 1996 were reviewed. Four patients were excluded (two unrelated deaths, two with small intestinal aganglionosis). Twenty-one of the remaining 105 patients underwent SS repair. Both groups were similar in gender, age at diagnosis, and frequency of comorbidities. Repair was possible in 100% of the SS patients. Complications, including enterocolitis, occurred in 63% of patients, and did not significantly differ between groups. The outcome in SS patients was unaffected by whether the repair was performed before or after 30 days of life. The outcome was unaffected by operative weight in either group. By contrast, the number of hospital admissions and total length of stay was significantly higher in the MS group, which resulted in a twofold increase in total costs associated with MS repair compared with SS repair. These data indicate that primary repair of HD is efficacious (even in the newborn), with morbidity equal to MS repair, and requires fewer hospital admissions. The significant savings to the patient and the health care system suggest that SS repair may be an improved strategy for treating HD.     

Perioperative complications of anterior procedures on the spine

We reviewed the operative and hospital records of 447 patients in order to determine the rates of perioperative complications associated with an anterior procedure on the thoracic, thoracolumbar, or lumbar spine. The anterior procedures were performed to treat spinal deformity or for débridement or decompression of the spinal canal. The diagnostic groups that we studied included idiopathic scoliosis in adolescents or young adults (100 patients), scoliosis in mature adults (sixty-three patients), kyphosis (sixty-one patients), neuromuscular scoliosis (sixty patients), fracture (forty-seven patients), a revision procedure (thirty-nine patients), congenital scoliosis (thirty-six patients), tumor (nineteen patients), vertebral osteomyelitis or discitis (eight patients), and miscellaneous (fourteen patients). Complications occurred in 140 (31 per cent) of the 447 patients and were classified as major or minor. Forty-seven patients (11 per cent) had at least one major complication and 109 (24 per cent) had at least one minor complication. Two patients died, both from pulmonary complications after the operation. The most common type of major complication was pulmonary; the most common type of minor complication was genito-urinary. The adolescent or young adult patients who had idiopathic scoliosis had the lowest rate of complications, and the patients who had neuromuscular scoliosis had the highest. An age of more than sixty years at the time of the operation was associated with a higher risk of complications. The duration of the procedures involving a thoracic approach was shorter than that of those involving a thoracolumbar or lumbar approach; however, the rate of complications was not significantly different among the three approaches. Vertebrectomies took longer to perform and were associated with a greater estimated blood loss than discectomies; however, there was no significant difference in the rate of complications between the two types of procedures. The patients who had a fracture or a tumor lost more blood than those from the other diagnostic groups. Blood loss increased as the duration of the operation increased for all procedures. Combined anterior and posterior procedures performed during the same anesthesia session were associated with a higher rate of major complications than were procedures that were staged. A logistical regression analysis showed that the variables that increased the risk of a major complication were an estimated blood loss of more than 520 milliliters and an anterior and posterior procedure performed sequentially under the same anesthesia session. This analysis also demonstrated that the diagnosis of idiopathic scoliosis in adolescents or young adults was associated with a reduced risk of major complications. Compared with other major operations, an anterior procedure on the thoracic, thoracolumbar, or lumbar spine performed for the indications mentioned in this study is relatively safe.     

Extra-anal mucosectomy: laparascopic-assisted endorectal pull-through using a prolapsing technique

BACKGROUND/PURPOSE: The mucosectomy of the aganglionic rectal mucosa has been performed transabdominally in the Soave procedure. Recently, mucosectomy with transanal approach was reported both in the laparoscopic and the open surgical procedure. However, the operative view and working field are restricted because the dissection has to be done in the anal canal. The authors report an innovative approach, an extra-anal mucosectomy, to perform mucosectomy in the Soave procedure for Hirschspung's disease in combination with the laparoscopic-assisted prolapsing technique. METHODS: Four patients underwent laparoscopic surgery for Hirschsprung's disease with extra-anal mucosectomy between 1995 and 1997. One 10-mm and 5-mm ports were used throughout the operation. The rectum was pulled out through the anal canal to create a rectal prolapse and was divided outside the anal canal. The mucosectomy was performed in the everted rectal mucosa outside the anal canal to the level of dentate line. The colon was sutured to the anal mucosa 2 mm above the dentate line. Mean operative time was 3 hours. RESULTS: The present technique made the whole mucosectomy possible under direct observation. CONCLUSION: The extra-anal mucosectomy in conjunction with a laparoscopic-assisted prolapsing technique seems to be a safe and reliable modality in the surgical treatment of Hirschsprung's disease.     

The neurobiological bases of aggression: the pharmacotherapeutic implications

The pathophysiology and aetiology of Hirschsprung's disease are still uncertain. The presentation varies with age. Various methods are used to make the diagnosis. Differing views of management are held both for emergency and definitive surgery, e.g. emergency colostomy or not, a covering colostomy or not for the definitive surgery, the type of operation used. The problems of diagnosis and treating diseases which mimic Hirschsprung's disease are highlighted.     

Changing practice patterns in the management of acute myocardial infarction complicated by cardiogenic shock: elderly compared with younger patients

BACKGROUND: Cardiogenic shock continues to be an ominous complication of acute myocardial infarction (AMI). Evidence from retrospective analyses, registries and observational studies suggests that aggressive management using emergent revascularization strategies can bring about significant improvement in survival in this setting. Several studies have identified age as an independent predictor of survival. OBJECTIVE: To study retrospectively the possible changes in practice patterns in the management of patients with AMI complicated by cardiogenic shock in a tertiary care referral centre, and to determine what effect these changes may have had on survival of the patients, stratified by age. METHODS: From 1989 to 1995, 115 patients fulfilled the study criteria of cardiogenic shock based on pump failure and of presenting within 48 h of onset of shock. Prespecified data were extracted from medical records. All available coronary angiograms (n = 72) were analyzed by two experienced angiographers and consensus of findings was obtained. RESULTS: The study revealed a significant increase in the use of cardiac catheterization, interventional procedures and intra-aortic balloon pump (IABP) support in patients in the age groups 65 years or less, 66 to 75 years, and older than 75 years in 1989 to 1990, through 1991 to 1992, to 1993 to 1995. Significantly fewer patients aged older than 75 years received cardiac catheterization, coronary intervention and IABP support throughout the study period and even in the final period analyzed. In-hospital survival improved from 4% in 1989-90 to 33% in 1991-92, and 44% in 1993-95 (P = 0.001). Patients aged 65 years or less improved from 10% in 1989-90 to 59% in 1993-95 (P = 0.032). Only 20% of patients aged older than 75 years survived in the 1993-95 period. By univariate analysis, use of coronary angiography (catheterization 46% versus no catheterization 5%; P < 0.0001), coronary intervention procedures (percutaneous transluminal coronary angioplasty or coronary artery bypass grafting) (intervention 48% versus no intervention 9%; P < 0.0001) and IABP support (IABP 41% versus no IABP 18%; P = 0.0096) were all associated with improved in-hospital survival. Use of thrombolytic therapy showed possible survival benefit only in patients aged older than 75 years (thrombolysis 33% versus no thrombolysis 5%; P = 0.10). Patients who underwent coronary intervention were younger (P = 0.002), had a lower incidence of previous myocardial infarction (P = 0.0002), lower heart rate (P = 0.04), higher peak creatine phosphokinase (P = 0.04) and fewer vessels with at least 70% stenosis (P < 0.0001). On multivariate analysis only lower age, lower heart rate and presence of coronary intervention procedures were found to have an independent effect on survival. CONCLUSIONS: Use of invasive treatment strategies has increased significantly since 1989-90 in the management of patients with AMI complicated by cardiogenic shock. This increase has been associated with improved in-hospital survival in all age groups except possibly the very elderly. Patients undergoing coronary interventional procedures are significantly different in baseline clinical characteristics from patients not undergoing these procedures. These observations underscore the need for randomized trials to define the optimal treatment strategies in these patients. Efficacy of invasive treatment strategies in elderly patients aged older than 75 years-deserves special attention.     

Seven abdominal assessment signs every emergency nurse should know

BACKGROUND: Open or laparoscopic surgery for gastroesophageal reflux disease gives longterm freedom from symptoms in 83-100% of cases but has a certain percentage of complications. This study was undertaken to evaluate the early and late complication rates after primary or repeat antireflux operations. STUDY DESIGN: The records of all patients who underwent surgery for gastroesophageal reflux disease during a 32-year period at a university teaching hospital were reviewed retrospectively. Records for 793 adults (448 men and 345 women) aged 16-85 years (mean, 51) were retrieved for calculation of complication rates and statistical analysis. RESULTS: A total of 827 operations were performed: 793 primary and 41 for recurrent disease (2 patients were each reoperated on twice). There were 49 laparoscopic operations. Only two patients died (mortality, 0.3%), both after open operation. Morbidity was 24% after open surgery and 14% after laparoscopic operation. The total (early and late) complication rate was higher after reoperations than that after open or laparoscopic procedures. The overall complication rate in the open operations was similar in the first and the third decade of the study, namely, 24.6% and 26.1%, respectively. CONCLUSIONS: Surgical treatment of gastroesophageal reflux disease carries very low mortality when performed in a specialized unit. The main causes of morbidity after open operation are infectious complications. The incidence of complications is substantially lower after laparoscopic surgery than after open operation. Reoperation is seldom required, but it carries higher morbidity than the primary operations.     

A simplified approach to diagnostic rectal biopsy in infants and children

Ninety-four patients underwent rectal biopsy with a suction capsule during a two year period. This painless procedure was performed in seventy-one patients for diagnosis of aganglionosis (Hirschsprung's disease). In nine patients, no ganglion cells were encountered, and subsequent surgery confirmed the diagnosis of Hirschsprung's disease in each of these patients. In twenty-three patients, biopsies were taken to search for neuronal storage disease. Six specimens contained abnormal material in the cytoplasm of the ganglion cells.