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Biomedical subjects

Lewis Spitz

Publications and source records attributed to Lewis Spitz.

At least 19 recordsLinked to original sources
PubMed2007

Factors predicting failure of redo Nissen fundoplication in children.

Recurrence of gastro-oesophageal reflux (GOR) following redo Nissen fundoplication represents a significant clinical problem. The aim of this study was to identify factors predicting failure of redo Nissen fundoplication. The notes of children who underwent redo Nissen fundoplication for recurrent GOR in a single institution between June 1994 and May 2005 were reviewed. Data are reported as median (range), or as numbers of cases. Multiple logistic regression analysis, using type of first fundoplication, neurological status, presence of gastrostomy, age-weight, retching-gas bloat after first fundoplication, associated anomalies, oesophageal atresia and length of follow-up as factors, was used to generate a model to identify factors predicting recurrent vomiting (failure) after redo. Eighty-one children underwent redo Nissen fundoplication 15.9 months (0.2-176) after the initial Nissen fundoplication. In 29, the first Nissen was laparoscopic. Age at redo Nissen fundoplication was 3.3 years (0.3-15.9) and weight 12.8 kg (5-60). Thirty-four children (42%) presented with recurrent vomiting (failure). Overall, the model successfully predicted vomiting (failure) after redo fundoplication (P = 0.009). Open surgery at first fundoplication (P = 0.011) and neurological impairment (P = 0.046) were both significant predictors of redo failure in the model, whereas presence of gastrostomy (P = 0.035) and older-heavier age-weight (P = 0.028) were associated with significantly better results. Retching-gas bloat, associated anomalies and oesophageal atresia were not significant predictors of failure. Redo Nissen fundoplication has a high failure rate. Risk factors are open fundoplication at first operation and neurological impairment. Redo fundoplication after primary laparoscopic Nissen has a lower risk of failure.

Adolescent↗
PubMed2006

Imaging of conjoined twins.

The incidence of conjoined twins is estimated to be around 1 in 250,000 live births. There is a distinct female predominance. In this paper the imaging of conjoined twins both antenatally and postnatally is reviewed, in particular taking into consideration recent advances with multidetector CT. Accurate counselling of parents regarding the likely outcome of the pregnancy and the likelihood of successful separation is dependent on good prenatal imaging with ultrasound and MRI. Planning of postnatal surgical separation is aided by accurate preoperative imaging which, depending on the conjoined area, will encompass many imaging modalities, but often relies heavily on CT scanning.

Contrast Media↗
PubMed2006

Oesophageal atresia: improved outcome in high-risk groups?

PURPOSE: The Spitz classification of oesophageal atresia (OA) based on the birth weight and the presence of a major cardiac anomaly was proposed 1994. Advances in neonatal care have led us to question if these outcome figures are still valid. We tested the hypothesis that the outcome of neonates with OA has improved during the last decade. METHODS: The records of all neonates (n = 188) born with OA and treated in a single institution between 1993 and 2004 were reviewed and compared with data from the original Spitz study. Data were obtained on the birth weight, presence of a major cardiac anomaly, and survival. Differences in survival were compared using the Yates-corrected chi2 test. RESULTS: In the early period, 326 neonates survived (87.6%) compared with 174 (91.5%) in the most recent decade (P = .10). Based on Spitz classification, the outcome comparing both periods was the following: group I, 97% (283/293) and 98.5% (130/132) (P = .44); group II, 59% (41/70) and 82% (41/50) (P = .01); group III, 22% (2/9) and 50% (3/6) (P = .57), respectively. CONCLUSIONS: The Spitz classification remains valid. It may be of use when counselling parents and in comparing outcome among centres. In our centre, the overall survival of neonates with OA has not significantly changed in the recent decade. The improvement in survival of neonates in group II, however, demonstrated the recent advances in neonatal, paediatric surgical, and cardiac care.

Esophageal Atresia↗
PubMed2006

Esophageal atresia. Lessons I have learned in a 40-year experience.

A brief resume of the highlights in the history of oesophageal atresia is presented. This is followed by research into the etiology, ontogeny and embryology, and microbiological studies. A revised classification of risk factors with consequent survival statistics is presented. Lessons learned in the management of the condition over a 40-year period are reported with particular emphasis on the management of the preterm infant with associated severe respiratory distress, right-side aortic arch, upper pouch fistula, 'long-gap' atresia, and the use of gastrostomy and intercostals drains. The incidence and treatment of early and late complications is discussed.

Digestive System Surgical Procedures↗
PubMed2005

Conjoined twins.

Conjoined twins have been a source of fascination for both the general public and the medical profession since time immemorial. Their birth was initially viewed as an ominous sign of impending disaster. This was followed by a prolonged period through the Middle Ages and into the nineteenth century when they were regarded as freaks or monstrosities and were exhibited with substantial financial reward at circuses and sideshows. Recently, conjoined twins have attracted intense media interest, which has coincided with increasing success in their separation. This article gives an overview of the role of prenatal ultrasound in assessing the prognosis and discusses the post-natal surgical management and outcome.

Female↗
PubMed2005

Staged repair of giant omphalocele in the neonatal period.

BACKGROUND/PURPOSE: The aim of this study was to analyze the outcome of giant omphalocele repaired in the neonatal period. METHODS: Twelve consecutive (1997-2004) neonates with giant omphalocele (defect >6 cm with liver herniation) were reviewed. A silo of Prolene mesh (Ethicon) was attached to the fascia and the defect was closed without opening the amniotic sac after sequential reduction. In 2 neonates with ruptured omphalocele a plastic sheet was inserted below the mesh. Data are reported as median and range. RESULTS: Gestational age was 38 weeks (range, 32-40 weeks) and birth weight was 2.9 kg (range, 1.0-3.1 kg). The final closure was achieved at 26 days (range, 16-62 days). Three neonates (25%) died before final closure (causes: ruptured omphalocele, lung hypoplasia, cardiac anomalies, and intestinal failure). In the 9 surviving neonates, mechanical ventilation was required for 8 days (range, 2-20 days), hospital stay was 42 days (range, 23-73 days), and full enteral feeding was achieved on day 12 (range, 4-53 days). Complications included wound infection in 5 neonates and midgut volvulus in 1. Prophylactic Ladd's procedure was performed laparoscopically at a later stage in 4 children. At laparoscopy, intraperitoneal adhesions were minimal and the central liver did not preclude the operation. The 9 survivors are all well after 46 months (range, 12-67 months). CONCLUSIONS: Giant omphalocele can be safely repaired in the neonatal period without opening the amniotic sac. Intestinal malrotation should be excluded and Ladd's procedure can be performed laparoscopically at a later stage.

Abnormalities, Multiple↗
PubMed2005

Effectiveness of alimemazine in controlling retching after Nissen fundoplication.

BACKGROUND: Retching, an early component of the emetic reflex, is a common and distressing symptom in children after Nissen fundoplication. Alimemazine (trimeprazine, Vallergan; Castlemead, Herts, UK) is a phenothiazine derivative histamine(1) antagonist, which anecdotally relieves the retching symptoms. MATERIAL AND METHODS: A prospective, double-blind, randomized, crossover, placebo-controlled study of 15 neurologically impaired children with retching after Nissen fundoplication over a period of 1 year (December 2002-December 2003). Patients were randomly allocated to receive 1 week each of alimemazine and placebo with crossover. A diary was maintained of retching episodes 1 week before, during, and 1 week after the trial. Dosage of alimemazine used was 0.25 mg/kg 3 times a day (maximum, 2.5 mg per dose). Statistical analysis was done using a paired Student's t test, where P value of less than .05 was considered significant. Results are presented as mean +/- SD. RESULTS: Twelve parents completed the diaries (9 open, 3 laparoscopic Nissen fundoplication). Median age of the child was 36 months (8-180 months), median duration of retching was 4.5 months (1-52 months), and mean number of retching episodes per week was 60 +/- 29.40. Mean number of retching episodes with alimemazine was 10.42 +/- 9.48 vs 47.67 +/- 27.79 with a placebo (P < .0001). No adverse effects were reported in those cases that completed the study. CONCLUSION: At low dose, alimemazine (Vallergan) is a safe and effective drug in the management of retching after Nissen fundoplication.

Antipruritics↗
PubMed2005

Moderate hypothermia protects against systemic oxidative stress in a rat model of intestinal ischemia and reperfusion injury.

Multisystem organ failure represents a major cause of mortality in intestinal ischemia and reperfusion (I/R), and oxidative stress plays a key role in its pathogenesis. Hypothermia is beneficial in I/R injury, but its effects on systemic oxidative stress have not been elucidated. The aim of this study was to evaluate the effects of moderate hypothermia on systemic oxidative stress after intestinal I/R injury. Anaesthetized adult rats (n = 10 per group) underwent 60 min of intestinal ischemia followed by 120 min of reperfusion or sham operation at normothermia (36 degrees C-38 degrees C) or moderate hypothermia (30 degrees C-32 degrees C). At sacrifice, ileum, liver, lungs, and kidneys were removed to determine the concentration of malondialdehyde (a marker of lipid peroxidation), reduced and oxidized glutathione (a major endogenous antioxidant), and glutathione redox state. Plasma malondialdehyde and nitrate plus nitrite (reflecting nitric oxide production) were also analyzed. A marked elevation of malondialdehyde was observed after I/R at normothermia in plasma, ileum, and lungs; however, hypothermia during I/R prevented this increase. I/R at normothermia caused a profound decrease in reduced glutathione and glutathione redox state in the ileum, but this was not observed in I/R at hypothermia. Interestingly, hypothermia increased glutathione content of control intestine. Nitric oxide production was increased only in normothermic I/R animals. Moderate hypothermia attenuates systemic oxidative stress associated with experimental intestinal I/R in an animal model by decreasing lipid peroxidation in plasma, ileum, lungs, and kidneys, by preventing the depletion of gut glutathione, and by reducing systemic nitric oxide production. However, whether these effects persist after rewarming is unknown.

Animals↗
PubMed2004

Management of pyopagus conjoined twins.

INTRODUCTION: Approximately 18% of conjoined twins (1 in 200,000 live births) are joined at the sacrum ("pyopagus"). As the joined structures are not life-threatening, there is generally a good prognosis, with time for investigation and planning of operative separation. CASE REPORT: This paper reports on the management of pyopagus twin girls, the first in the UK delivered at 36 weeks by Caesarean section. The diagnosis had been made by ultrasound at 12 weeks' and confirmed by MRI scan at 26 weeks' gestation. Each twin had wasting and weakness below one knee, but no deficit in the other leg. The perineum had two urethras but only one anus. One infant had a colostomy in the immediate neonatal period. With appropriate further imaging, surgery was planned in two stages. First, a balloon expander was inserted in the bridging area. At 3 months of age a team comprising Plastic, Paediatric and Neurosurgeons undertook the definitive separation. DISCUSSION: Details of the multidisciplinary planning, operative separation and follow-up of these two children will be discussed.

Female↗
PubMed2004

Tyrosine nitration of carnitine palmitoyl transferase I during endotoxaemia in suckling rats.

Heart carnitine palmitoyl transferase I (CPTI) is inhibited in vivo during endotoxaemia and in vitro by peroxynitrite but the biochemical basis of this inhibition is not known. The aim of this study was to determine which isoform of CPT I is inhibited during endotoxaemia and whether the inhibition is due to increased tyrosine nitration. Cardiac mitochondria were isolated from endotoxaemic suckling rats. To determine whether M- or L-CPTI was inhibited, we carried out titrations with DNP-etomoxir-CoA. Slopes of the titration curves with DNP-etomoxir-CoA were no different between control and endotoxaemia, suggesting that M-CPTI was specifically inhibited. Immunoprecipitation was carried out using an anti-nitrotyrosine antibody. Immunoprecipitated proteins were identified by Western blotting with L- and M-CPTI specific antibodies. L-CPTI was nitrated both in control and in 2- and 6-h endotoxaemia mitochondria but there was no significant difference in the level of nitration. M-CPTI was also nitrated in control mitochondria but nitration was significantly increased at both 2- and 6-h endotoxaemia. Either 10 mM 3-nitrotyrosine plus 40 microg nitrated-albumin or 0.5 M dithionite, during immunoprecipitation, greatly decreased immunopositivity for M- and L-CPTI on WB. M-CPTI appears to be a novel target for peroxynitrite during endotoxaemia, which would alter myocardial substrate selection.

Acyl Coenzyme A↗
PubMed2004

Melatonin protects from, but does not reverse, the effects of mediators of sepsis on liver bioenergetics.

BACKGROUND: Reactive oxygen species (ROS) have been reported to play a significant role in the pathogenesis of sepsis and liver dysfunction. In particular, neonates are at risk for sepsis and have less protection against oxidation. Melatonin has been reported to reduce the oxidative stress status in neonates with sepsis. Little is known about the effect of melatonin on liver bioenergetics. The aim of this study was to investigate the protective effect of melatonin on hepatocyte oxidative energy metabolism against hydrogen peroxide (H2O2), a free radical mediator of septic damage. METHODS: Hepatocytes were isolated from neonatal suckling rats (11-15 days old). The cells, respiring on palmitate, were exposed to H2O2 at the concentration of 2 mmol/l, melatonin alone at 1 micromol/l or 10 micromol/l, or H2O2 plus melatonin at each of the two concentrations. Oxygen consumption was measured polarographically. In subsequent experiments, melatonin was added after the hydrogen peroxide. RESULTS: Hydrogen peroxide significantly reduced hepatocyte oxygen consumption ( p<0.001), but melatonin added at the same time was able to prevent this effect ( p<0.001). However, melatonin at a low dose significantly inhibited hepatocyte oxygen consumption ( p<0.001), an effect which has not been previously described. When melatonin was added to cells after they had been exposed to hydrogen peroxide, a beneficial effect was not observed, indicating that melatonin is not able to reverse the effects of hydrogen peroxide. CONCLUSION: Melatonin has a protective effect on hepatocyte oxidative metabolism, improving mitochondrial function by counteracting oxidative stress.

Animals↗
PubMed2004

Neonatal severe hyperparathyroidism: genotype/phenotype correlation and the use of pamidronate as rescue therapy.

UNLABELLED: Familial hypocalciuric hypercalcaemia (FHH) is an autosomal dominant condition due to heterozygous loss of function calcium sensing receptor (CaSR) mutations. However, individuals who are homozygous for CaSR mutations have neonatal severe hyperparathyroidism (NSHPT), which unlike the relatively benign and asymptomatic FHH can be fatal without parathyroidectomy. We report three patients with NSHPT associated with marked hypercalcaemia and severe hyperparathyroidism with related skeletal demineralisation. We describe the novel use of intravenous pamidronate in NSHPT, to control severe hypercalcaemia in these patients prior to parathyroidectomy and in one individual as a rescue therapy to stabilise life-threatening demineralisation. Furthermore, a marked phenotypic heterogeneity was observed amongst four members from a large kindred with the same homozygous CaSR mutations: one patient would have died without parathyroidectomy in infancy; a second patient survived infancy but underwent parathyroidectomy in early childhood following severe symptomatic hypercalcaemic episodes; whilst the other two patients have survived to adolescence without parathyroidectomy. Additionally, in contrast to the literature these two individuals suffered minimal morbidity. CONCLUSION: We commend the short-term use of pamidronate in neonatal severe hyperparathyroidism to treat extreme hypercalcaemia and halt hyperparathyroid-driven skeletal demineralisation in preparation for parathyroidectomy. The remarkable degree of phenotypic variation demonstrated remains unexplained without functional studies; this variability highlights the challenge of treating this rare condition.

Antineoplastic Agents↗
PubMed2004

Gastric transposition in children--a 21-year experience.

PURPOSE: The purpose of this study was to analyze the outcome in 173 children (104 M, 69 F) undergoing transposition since 1981. METHODS: The most common indications for esophageal replacement included failed repair of different varieties of esophageal atresia (127), caustic injury (23), and peptic strictures (8). A total of 81% of the patients were referred from other hospitals (50% from other countries). Age at operation ranged from 7 days to 17 years. The gastric transposition was performed using blunt mediastinal dissection only in 90 patients with an additional 81 patients undergoing lateral thoracotomy. The retrosternal position was used in 2 patients. RESULTS: There were no graft failures including those who had previously failed gastric tube or Scharlilike operations. Anastomotic leakage occurred in 12% (all but 1 resolved spontaneously). Anastomotic stricture requiring dilatation occurred in 19.6%. Half of these patients had previous caustic esophageal injury. There were 9 deaths in the group (5.2%). One death occurred intraoperatively, 5 in the early postoperative period, and there were 3 late deaths. In more than 90% of our patients, the outcome was considered good to excellent in terms of absence of swallowing difficulties or other gastrointestinal symptoms. Many, however, preferred to eat small frequent meals. Poor outcome was particularly associated with multiple previous attempts at esophageal salvage. There was no deterioration in the function of the gastric transposition in those patients followed up for more than 10 years. CONCLUSIONS: Gastric transposition for esophageal substitution is an acceptable procedure. It is attended by 5% mortality and a 12% leak rate. A total of 19.6% of the patients needed anastomotic dilatation for stricture. In the long term, good function has been maintained. Gastric transposition compares favorably with alternative methods of esophageal replacement.

Adolescent↗
PubMed2004

Gastroenteric fistula complicating percutaneous endoscopic gastrostomy.

BACKGROUND: Gastroenteric fistula occurs in 2% to 3% of patients undergoing percutaneous endoscopic gastrostomy (PEG). The authors identified 12 children with this major complication. METHODS: A retrospective case note review was performed. RESULTS: Over a 5-year period, the complication rate for gastroenteric fistula was 3.5% (12 of 343 procedures). Presentation ranged from 1 day to 25 months post-PEG insertion. Eight patients presented with acute intestinal obstruction. The gastroenteric fistulous tract involved the posterior wall of the stomach in all cases. The plain abdominal x-ray was useful in establishing the diagnosis of the gastroenteric fistula. CONCLUSIONS: Patients with gastroenteric fistula as a complication of PEG insertion can remain asymptomatic for prolonged periods. It often is difficult to make the diagnosis. A plain abdominal x-ray is a useful diagnostic modality.

Cerebral Palsy↗
PubMed2004

Cloacal exstrophy: morbidity associated with abnormalities of the gastrointestinal tract and spine.

BACKGROUND/PURPOSE: The aim of this study was to review the management of the gastrointestinal tract in cloacal exstrophy and to assess the effect of spinal dysraphism on nutritional outcome. METHODS: Twenty-two patients with cloacal exstrophy were reviewed retrospectively. Gastrointestinal and spinal anomalies were documented. The need for nutritional supplementation was recorded. Weights at 1 and 5 years of age were used to assess growth in childhood. RESULTS: Ten patients were treated initially with ileostomy, 7 with colostomy, and 3 without stoma. Two patients died before surgical reconstruction. Total parenteral nutrition (TPN) was utilized in 8 infants for a median of 10 days (range, 5 to 200). Three patients had complications with colostomies requiring conversion to ileostomy. Patients with an ileostomy required more nutritional supplementation compared with patients with a colostomy (50% v 28%). High-output stoma losses were more common in patients with an ileostomy (40% v 14%). Fourteen patients (67%) with spinal dysraphism had a higher incidence of failure to thrive in the first year of life (69% v 26%) and multiple episodes of enteritis (40% v 25%). Two neonates with duodenal atresia and small bowel deletion died within the first month of life. One patient with short bowel syndrome died of TPN-associated liver disease at 6 months of age. There were no other deaths. CONCLUSIONS: The gastrointestinal tract contributes significantly to the morbidity and mortality in cloacal exstrophy. Nutritional supplementation is more frequently required in patients with an ileostomy. Stoma complications were higher in those with a colostomy. Morbidity is high in patients with spinal dysraphism.

Abnormalities, Multiple↗