C. Keith Hayden

Successful management of congenital tracheal stenosis in infancy

Seven infants with congenital tracheal stenosis were evaluated and treated to assess the efficacy of current techniques of management. All had multiple congenital anomalies in addition to tracheal stenosis. Notably, three infants had imperforate anus and three had vascular rings. Each infant presented early with respiratory distress. While bronchoscopy and/or bronchography were performed in some, the diagnosis could be made from high contrast x-rays of the chest in each instance. The complexity of the tracheal lesion(s) determined the operative approach. Complicating factors included tracheomalacia, multiple stenoses, pulmonary hypoplasia, and carinal involvement. The trachea was approached through an anterolateral thoracotomy in five cases and through the neck in one. Cardiopulmonary bypass was never required. Simple resection was possible only once. Four patients received costal cartilage grafts, and one graft was created from dura. Grafts varied from 2 1/2 to 6 cm in length and extended onto the bronchi in two cases. All patients with grafts were treated with postoperative endotracheal stents and ventilatory assistance and all were extubated successfully. One patient had trisomy 16p+ detected after successful extubation and died later. One patient was treated expectantly and died. While each case must be individualized, repair of complex tracheal stenosis often results in dramatic immediate improvement and long-term success.

A prospective evaluation of intestinal stenosis following necrotizing enterocolitis

In a retrospective study, we noted a 25% incidence of colonic stenosis following medical management of necrotizing enterocolitis (NEC). From March, 1980 to March, 1982, we performed routine contrast enemas to prospectively identify the incidence of colonic stenosis following medical management for NEC. Three to four weeks following recovery from the acute phase of NEC 28 infants were prospectively evaluated by contrast enema for post-NEC stenosis. Ten of the 28 infants had one or more sites of colonic stenosis (36%). Four infants were symptomatic when the contrast enema was performed and underwent colonic resection. Three of the six asymptomatic infants developed symptoms requiring surgery within 33 days following hospital discharge. Therefore, seven of the ten infants with post-NEC stenosis required segmental colectomy. Three patients with colonic stenosis have remained asymptomatic and are being followed on an outpatient basis. The weight gain in these three infants has been steady and has paralleled a normal growth curve. The data from this study demonstrate that: (1) the incidence of post-NEC colonic stenosis is 36%; (2) patients with colonic stenosis initially may not have symptoms but may become symptomatic after hospital discharge; (3) the sites of stenosis frequently are located in the left colon; and (4) normal weight gain can occur despite the presence of colonic stenosis. Because of the above findings, we recommend routine contrast enemas in all patients with NEC who have had successful medical management.

Intestinal stenosis following successful medical management of necrotizing enterocolitis

In the past decade, increased clinical awareness and better medical and surgical management of necrotizing enterocolitis (NEC) has resulted in improved survival. With an increase in the number of infants surviving the acute stages of NEC the sequelae, including intestinal stenosis, have become more apparent. In the past 5.5 yr, 62 patients with NEC have been treated at our institution. Of the 28 survivors of medical management for NEC seven patients developed intestinal stenosis. An average of 23 days elapsed between the recovery from NEC and the diagnosis of colonic stenosis. Only three patients manifested symptoms of intestinal obstruction. Two patients had blood in their stools and two patients were asymptomatic. Five infants were managed by primary or staged resection of the intestinal stenosis. The remaining two patients were treated nonoperatively. Our data suggests a high incidence of intestinal stenosis (25%) following medical management of NEC. There is a marked preference for the stenosis to occur on the left side of the colon. Colon stenoses can exist without symptoms and radiographically proven areas of stenosis can resolve. We recommend that all infants following medical management of NEC have a barium enema prior to hospital discharge. In selected cases asymptomatic patients with colonic stenosis may not require operative intervention.

Mycotic thromboaneurysmal disease of the abdominal aorta in preterm infants: Its natural history and its management

Five infants with mycotic complications of umbilical artery catheterization were evaluated with abdominal ultrasound and followed serially to document their natural history. Methicillin-resistant Staphylococcus aureus was always the infecting organism. There were one female and four male infants and they weighed between 900 and 1,200 g at birth. While two of the catheters were positioned in the abdominal aorta, three were located above the diaphragm. The predominate signs and symptoms included: thrombocytopenia, unexplained anemia, renal failure, hypertension, and embolic phenomena to the toes. Real-time ultrasound always proved sufficient for diagnosis. Serial studies detected the initial aortic thrombosis in three patients and accurately documented its progression to aneurysmal disease over 10 days in one patient and 17 days in another. Three of the infants were diagnosed with aneurysms at their initial examination. Of the five patients, three were treated nonoperatively and died of complications of their aortic disease. One patient was discovered at operation to have necrotic ischemic intestine. Aortic repair was postponed and he died of septic complications. The remaining patient underwent a PTFE interposition graft and survived for 6 months, dying of pulmonary failure with autopsy confirmed graft patency.

Abdominal Masses in Children

The authors examine the effects of ultrasound on the diagnosis and treatment of abdominal masses in children. Some of the newer imaging modalities may also be required on a selective basis. All in all, these modalities have led to a completely new approach to abdominal masses in children.

SUBEPENDYMAL GERMINAL MATRIX HEMORRHAGE (SEH) IN TERM NEONATES

Cerebral ultrasonography was done within 72 hours of birth on 505 newborns of ≥ 37 weeks gestation admitted during an 8 week period to the normal newborn nursery. Abnormalities were detected in 23 babies (4.6%). Bilateral SEH occurred in 14 (2.8%) and unilateral SEH in 6 (1.2%). Agenesis of the corpus callosum was detected in 2 (0.4%) and mild ventricular dilatation in 1 (0.2%). None of the 20 babies with SEH had intraventricular hemorrhage. When compared to babies with no SEH, those with SEH were of significantly lower gestational age and birth weight. The difference in weight was attributable to lower birth weights in females with SEH compared to females without SEH. Significantly more babies with SEH were small for gestational age, were delivered vaginally, and were black. No differences existed between babies with and without SEH in regard to gender, obstetrical presentation, use of forceps, birth trauma, Apgar scores, asphyxia, maternal age and parity, and clinical problems. Although SEH is primarily a problem of the premature baby, this study indicates that SEH is relatively common (4.0%) in the term newborn and may be clinically silent. In this study babies at greatest risk for SEH were black, small for gestational age, and vaginally delivered.