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Biomedical subjects

K W Ashcraft

Publications and source records attributed to K W Ashcraft.

At least 37 records · Page 2Linked to original sources
PubMed1997

Efficacy of partial wrap fundoplication for gastroesophageal reflux after repair of esophageal atresia.

Gastroesophageal reflux (GER) often develops in children who have undergone prior repair of esophageal atresia/tracheoesophageal fistula (EA/TEF). Fundoplication is necessary in many of these children. The complete wrap (Nissen) fundoplication is often used in this setting. However, poor results have been noted, with a mean failure rate of 30% reported in four recent studies. A partial wrap fundoplication for GER associated with EA/TEF is theoretically attractive, because the poor esophageal motility and diminished acid clearance (already physiologically present) is exacerbated by a complete wrap fundoplication. The authors reviewed their extensive experience with partial wrap (Thal) fundoplication in EA/TEF to determine if the failure rate was better than that reported for the Nissen fundoplication. In the past 18 years, the authors performed 1,467 fundoplication procedures. During the same period, 143 children underwent repair of EA/TEF. Fifty-nine children underwent fundoplication after a previous EA/TEF repair. Most of the fundoplications (58 of 59, 98%) were Thal procedures. Defining failure strictly as a need for reoperation, the failure rate in our series was 15% (9 of 59 children). Compared with the failure rate in the 1,408 non-EA/TEF patients (61 of 1408, 4.3%), results were significantly worse for the EA/TEF group (P > .001). The failure rate of Thal fundoplication performed for GER in the EA/TEF population is substantially higher than the non-EA/TEF patients. The same factors responsible for the development of reflux in these children (poor acid clearance, altered motility, esophageal shortening) may contribute to the higher failure rate. Although partial wrap fundoplication frequently failed (15%), the results were still substantially better than those reported for Nissen fundoplication in these children (30% failure rate).

Adolescent↗
PubMed1997

Survival after necrotizing enterocolitis in infants weighing less than 1,000 g: 25 years' experience at a single institution.

Necrotizing enterocolitis (NEC) primarily affects premature newborns. Regional and national decreases in the mean birthweight and gestational age of neonatal intensive care unit (NICU) admissions prompted a review of NEC in VLBW (very low birth weight, defined as < 1,000 g) infants in our institution over a 25-year period. There were 266 patients treated for NEC during the study interval. We compared 71 VLBW with 195 non-VLBW infants and found that VLBW infants were: fed later (6.4 days v 4.1 days, P = .009), developed NEC later (20.8 days v 13.1 days, P = .002), had significantly lower 1- and 5-minute Apgar scores, were more likely to require surgery (51% v 34%, P = .016), more often had panintestinal (defined as > 75% of intestinal length) involvement (10% v 4%, P = .043), and had poorer survival (56% v 72%, P = .013). Overall survival after NEC has improved over the study interval, both in our series and in other reports. However, the increasing number of VLBW infants who have NEC represent a subgroup who appear to be generally more ill, develop NEC later, require surgery with greater frequency than their non-VLBW counterparts, and are less likely to survive.

Age of Onset↗
PubMed1996

Thal fundoplication in neurologically impaired children.

Children with neurological impairment (NI) frequently require feeding gastrostomy, and this often aggravates or produces gastroesophageal reflux (GER). From 1976 to 1994, 141 children with severe NI underwent Thal fundoplication and gastrostomy (GT). GER was evident in 80%; in the rest, fundoplication was an adjunct to GT. Ph results were positive in 38 cases, and 57 children had reflux according to the barium studies. There were no major intraoperative complications. Disruption of the repair and/or recurrent GER was noted in 14 cases (10%); 8 were redone as Thals, and 6 were converted to Nissen procedures. Pyloroplasty was done later in 9 children (6%). Bowel obstruction was seen in 4 patients (3%). Clinical follow-up (mean, 54 months) showed improvement in 96%; only 5 of the 141 (3.2%) have residual symptoms. Of the patients with an intact Thal, 67% could burp or vomit. The ability to vomit may protect the Thal fundoplication and avoid disruption of the repair.

Adolescent↗
PubMed1996

Esophageal duplication cyst with esophageal web and tracheoesophageal fistula.

The authors report the case of lower cervical/upper thoracic esophageal duplication associated with an obstructing esophageal web. This presented in the newborn period as an esophageal atresia. Initial resection of the web and closure of the fistula were performed. The duplication was excised electively at 2 months of age. Persistent symptomatic tracheomalacia required aortopexy, after which the child recovered uneventfully. There are only three other reports (four cases) in the literature of esophageal atresia (or variants) associated with esophageal duplication.

Aorta↗
PubMed1994

Gastroesophageal reflux.

GER is a major pediatric disease. The respiratory, nutritional, and inflammatory complications of this disease process, invisibly hidden in the gastroesophageal junction, have a profound effect on the quality and sometimes the very life of infants and children. The astute pediatrician and surgeon should always keep this disease process in mind when dealing with these problems of children. Having a high suspicion of GER is often necessary to find this hidden enemy. The Nissen fundoplication and the Thal fundoplication are equally successful in the treatment of GER in children. However, the complication rate with the Nissen fundoplication is higher than with the Thal. We feel that the Thal does an outstanding job of treating GER while maintaining normal gastroesophageal function in the developing child, and is therefore our operation of choice for GER.

Child↗
PubMed1993

Decreased incidence of intracranial hemorrhage using cephalic jugular venous drainage during neonatal extracorporeal membrane oxygenation.

Intracranial hemorrhage (ICH) remains one of the more common serious complications of extracorporeal membrane oxygenation (ECMO) in neonates. In 1990 this center began routine use of cephalic jugular venous drainage during neonatal ECMO to augment blood return to the ECMO pump and potentially decrease the incidence of ICH by decreasing cerebral venous pressure. Thirty-four ECMO cases utilizing cephalic jugular venous drainage were compared with the previous 34 ECMO cases. The incidence of ICH decreased from 35% (12/34) to 6% (2/34) when neonates without cephalic jugular venous drainage are compared with those being subject to this technique (P < .01). No differences were found between the two groups in gestational age, birth weight, duration of ECMO, survival, platelet counts, activated clotting times, or incidence of other bleeding complications. Cephalic jugular venous drainage during neonatal ECMO appears to be safe and may decrease the incidence of ICH.

Catheterization, Central Venous↗
PubMed1992

Congenital diaphragmatic hernia presenting due to gastrointestinal complications.

Congenital diaphragmatic hernia (CDH) presents beyond the first hours of life in 10% to 20% of cases. Presenting symptoms may be quite nonspecific, and are often gastrointestinal rather than respiratory in origin. We have recently had experience with five such cases, one in a newborn and four in older children. All presented with symptoms related to gastrointestinal complications of their diaphragmatic defect. In the newborn, gastric perforation had occurred, a complication of this anomaly not previously reported. The chest radiograph showed loops of bowel in the chest in all cases, allowing correct preoperative diagnoses. Urgent operative intervention was undertaken in each case with good results and no long-term morbidity. The risk of intestinal strangulation in the late-presenting CDH patient warrants emergent surgical management, which should be rewarded by uniform survival with few complications. Although preoperative stabilization may decrease the severity of pulmonary vasospasm in the newborn with respiratory failure, delay may increase the risk of bowel infarction in the older child presenting with gastrointestinal symptoms.

Child, Preschool↗
PubMed1992

Abbreviated esophageal pH monitoring as an indication for fundoplication in children.

Intraesophageal pH recordings from 40 patients with abnormal studies who underwent fundoplication during a 1-year period were evaluated. Scores were recalculated for the first 12, 16, and 20 hours, respectively. Five of the recordings were for less than 24 hours, but were grossly abnormal and mathematically could not have normalized at 24 hours. The percentage of studies which were normal at 12, 16, and 20 hours were 20%, 15%, and 0%, respectively. One fifth of the patients would have been denied a fundoplication based on 12-hour results. In addition, 75 consecutive pH recordings were evaluated prospectively. Total scores were determined for the first 12, 16, and 20 hours with accuracies of 85%, 93%, and 92%, respectively. The sensitivity of 12-hour monitoring was only 78%. All abbreviated studies had a low rate of false positives; however, any false positives may be significant when used to determine the need for an operation. Abbreviated studies were associated with high false-negative rates (up to 52% for the 12-hour studies) for the calculated mean duration of sleep reflux, a parameter that has been found to be useful in identifying patients with respiratory symptoms secondary to gastroesophageal reflux. The use of abbreviated pH monitoring is discouraged.

Child↗
PubMed1991

Relief of subglottic stenosis by anterior cricoid resection: an operation for the difficult case.

Anterior cricoid resection is an effective procedure to relieve subglottic stenosis. This is well documented in adults, although reports of the procedure in growing airways are limited. Over an 11-year period, seven pediatric patients underwent anterior cricoid resection for recalcitrant subglottic stenosis. In four patients, the stricture was secondary to prolonged intubation, one developed subglottic stenosis following a high placement of tracheostomy for epiglottitis and another had congenital subglottic stenosis. One child had subglottic stenosis combined with laryngotracheoesophageal cleft and more distally located tracheoesophageal fistula. All patients had failed to respond to previous treatment: dilatations (3 to 20), steroid injection (3 patients), and Evan's tracheoplasty (2 patients). All patients had an excellent result from anterior cricoid resection. The median age of children undergoing anterior cricoid resection was 3 years. There was no mortality. Tracheostomy decannulation was accomplished within 12 weeks following operation in all patients. It was necessary to remove a tracheal granuloma in one patient. Anterior cricoid wedge resection leaving the posterior portion of the cricoid in place is done to avoid recurrent nerve injury. It is a relatively simple and effective procedure. There has been minimal morbidity and no mortality. Follow-up from 1 to 11 years shows no recurrence of stenosis. There has been normal laryngeal and airway growth.

Child, Preschool↗
PubMed1990

Rectal prolapse: 17-year experience with the posterior repair and suspension.

Using a posterior repair and rectal suspension procedure for those patients who need surgical treatment of rectal prolapse, we have treated 46 patients over a period of 17 years at Children's Mercy Hospital in Kansas City, MO. One patient with caudal dysgenesis died of multiple congenital anomalies following two unsuccessful attempts at posterior repair and suspension. Four patients developed a recurrence afterwards, which was found to be due to sigmoid intussusception and, presumably, had played a major part in their original prolapse. Two of these required resection, one from the transanal approach and one from the transabdominal approach. One resolved spontaneously and another is as yet unresolved. Three patients had minor mucosal prolapse that was transient and two patients had extrusion of silk sutures but continued to have a very satisfactory result. Overall, 42 patients had satisfactory resolution of their rectal prolapse. Three of the four patients who had unsatisfactory results had associated anomalies that contributed to their poor outcome.

Child↗
PubMed1988

Hepatic hemangioma: resection using hypothermic circulatory arrest in the newborn.

Hepatic hemangioma (hemangioendothelioma) is a benign vascular tumor with significant morbidity and mortality. Two newborn infants underwent partial hepatectomy for treatment of massive hepatic hemangioma, one with atrial septal defect and secondary congestive heart failure, and the other with symptomatic marked hepatomegaly. Cardiopulmonary bypass with induced deep hypothermic circulatory arrest was used in both patients in order to facilitate resection and prevent sudden massive blood loss. One infant also had closure of an atrial septal defect in addition to the partial hepatectomy. Both infants survived without complication and showed complete resolution of preoperative symptoms. This technique coupled with the use of fibrin glue is of value in infants with large hepatic hemangiomata and cardiac decompensation in the neonatal period.

Cardiopulmonary Bypass↗
PubMed1988

Histology of the intestine in human gastroschisis--relationship to intestinal malfunction: dissolution of the "peel" and its ultrastructural characteristics.

There are conflicting views on the pathogenesis of the intestinal malfunction seen in infants with gastroschisis. It has been variously ascribed to abnormalities of ganglion cells and smooth muscle elements, intestinal ischemia, and the "peel" which invests the serosa of the intestine. Review of the clinical and experimental literature showed only limited information on the histology of the eviscerated human intestine. In order to add to this data base, and to further investigate the pathogenesis of the intestinal malfunction from a histologic standpoint, we reviewed surgical and autopsy material from our experience with 105 neonates with gastroschisis. Ten specimens were satisfactory for evaluation from a standpoint of tissue integrity. The specific mural components of mucosa, submucosa, muscularis, and ganglion cells were examined and found to be either normal, or to show nonspecific abnormalities that varied from case to case, and were related mostly to intestinal infarction due to compromise of the gut at the site of the gastroschisis defect. In six patients, this progressed to atresia formation. The most consistent abnormalities were found in the serosal layer with its peel. Using special stains, the peel was found to be composed largely of fibrin and collagen. Based on this study, we feel that edema and ischemic changes, though often present, are much less prominent than the peel, as the leading histologic abnormality of the intestine of gastroschisis. Squamous epithelial cells were seen in the peel in four cases, suggesting that the peel had been "appliqued" onto the serosa of the herniated fetal gut.

Abdominal Muscles↗
PubMed1987

Transannular GORE-TEX patch with pericardial unicusp for total correction of tetralogy of fallot.

When corrective surgery for tetralogy of Fallot was accomplished through the use of a transannular GORE-TEX patch with a pericardial unicusp, the right-ventricular end-diastolic volumes of all patients studied within a year of the surgery were within the normal ranges because of decreased pulmonary valve regurgitation. The right-ventricular ejection fraction was also only slightly depressed, indicating preservation of right-ventricular function. All patients were noted to maintain normal stroke volumes and normal systolic indices. In contrast, the patients who had transannular patches placed without unicusps showed significantly elevated right-ventricular end-diastolic volumes and lower right-ventricular ejection fractions. These resulted from markedly dilated right-ventricular outflow regions in conjunction with enlarged right-ventricular chambers, which manifested as large dyskinetic areas in the anterior right-ventricular walls.

Journal Article↗
PubMed1987

Care of infants with esophageal atresia, tracheoesophageal fistula, and associated anomalies.

One hundred consecutive patients with esophageal atresia or tracheoesophageal fistula, or both, were treated at The Children's Mercy Hospital during the past 14 years. Each patient was evaluated and a plan for therapy was formulated depending on the type and urgency of concomitant disease. Healthy patients were treated by primary repair. Those with respiratory disease were treated before repair by gastrostomy, upper pouch suction, and antibiotics. In the small premature infant and the patient with major associated anomalies, repair of the esophageal atresia and tracheoesophageal fistula was postponed by gastrostomy, upper pouch suction, and parenteral nutrition while the concomitant disease was treated. Fifteen patients with life-threatening associated anomalies required operation before esophageal repair and 13 of them survived. During the initial hospitalization two deaths related to esophageal atresia occurred, whereas three prerepair and two late (2 1/2 and 3 months) postrepair deaths related to associated anomalies occurred. Thus, 93 of the 100 patients left the hospital alive. The increased survival is due not only to improved care of esophageal atresia and tracheoesophageal fistula, but also to a more aggressive approach to the treatment of the serious associated anomalies.

Abnormalities, Multiple↗
PubMed1986

The reimplanted ureter as a catheterizing stoma.

Some current trends in the management of neurogenic bladder have been toward utilization of the urinary bladder as a storage device with a continent catheterizing stoma. This study presents a procedure using the now standard Cohen ureteral reimplantation, followed some 6 weeks later by transureteroureterostomy and distal ureteral stomal formation, after the method of Mitrofanoff. This staged procedure appears to have allowed the recently reimplanted ureter to be divided and brought to the skin as a viable catheterizing stoma. We believe that this experimental study has demonstrated that the Cohen technique of ureteral reimplantation is a reasonable antecedent to the use of transureteroureterostomy and distal ureteral stoma creation for continent catheterization. Monfort has demonstrated this clinically in one patient, and we feel that this technique deserves more extensive clinical trials.

Animals↗