Donald R. Cooney

The relative merits of various methods of indirect measurement of intraabdominal pressure as a guide to closure of abdominal wall defects

Visceral ischemia secondary to increased intraabdominal pressure (IAP) following closure of abdominal wall defects presents a serious postoperative problem. Currently, the method of closure and postoperative management are determined by clinical impressions rather than measurement of IAP. In this study various methods of indirectly measuring IAP were compared in 17 rabbits in which IAP was sequentially increased with an intraabdominal balloon. Vesical and inferior vena caval (IVC) pressures were found to have good statistical correlation with IAP. Other methods tested were gastric, rectal, superior vena caval, femoral and brachial artery, and rectus compartment pressures. All were found to be poor indicators of actual IAP. In nine of the rabbits, radiolabeled microspheres were used to assess cardiac output and visceral blood flow. Renal blood flow was very sensitive to increased IAP with dramatic impairment at IAP above 10 to 15 mmHg. Small intestinal flow was less sensitive and did not become significantly diminished until IAP exceeded 25 to 30 mmHg. Our studies suggest that vesical and IVC pressure monitoring should be used to evaluate IAP in the clinical setting. If IAP is in excess of 10 to 15 mmHg surgical intervention is indicated to prevent the development of renal ischemia.

Advances in the management of infected urachal cysts

Persistent urachal remnants are uncommon congenital anomalies. Unless an umbilical fistula exists, infection may be the first indication of this abnormality. Five children received initial treatment for this problem at the Childrens Hospital of Buffalo during a 20-year period, 1964 to 1984, and a sixth was seen secondarily. There were four boys and two girls; their ages ranged from 8 months to 9 years. Lower abdominal mass with fever and local tenderness were the most common presenting signs. Ultrasound was the most accurate study, correctly diagnosing the cyst in both patients so examined. Incision and drainage alone was performed in one patient. The other five were managed with antibiotic therapy and complete excision as the primary procedure. Cultures were obtained in five patients and were positive in four, growing Staphylococcus aureus in three and Escherichia coli in one. Significant genitourinary abnormalities were discovered in four of the five patients evaluated. It is concluded that the previously recommended therapy of incision and drainage followed by delayed resection was developed in the preantibiotic era to minimize the mortality from sepsis and the morbidity from recurrence. Our experience indicates that the use of appropriate antibiotics followed promptly by complete cyst excision as a primary procedure is both possible and safe in most cases. Furthermore, the large number of associated genitourinary abnormalities suggests that a complete work-up for these conditions should be performed.

Nonoperative management of major blunt renal trauma in children : in-hospital morbidity and long-term followup

The management of 26 children with major renal injury secondary to blunt trauma was reviewed. Emergency computerized tomography (CT) was performed in all instances. Injury ranged from parenchymal laceration to vascular avulsion. Early surgical exploration was done in 5 children due to hemodynamic instability, renal pedicle injury or suspected malignancy. The remaining 21 children were observed. Of these children 5 had associated intra-abdominal organ injuries. The average length of hospitalization was 13.4 days and the average intensive care unit stay was 6.9 days. A third of the children were transfused with an average 10.8 cc/kg. of packed red cells. Ten patients (47.6%) had febrile episodes that lasted an average of 3 days. No foci of infection other than bladder urine were identified and there were no infected perirenal collections. In 2 children ureteral stents were placed cystoscopically. Exploration was performed in 1 child for delayed hemorrhage 2 months after hospital discharge. Followup CT was available in 15 patients and all kidneys functioned, including 3 with residual focal scarring, 2 with parenchymal calcifications and 1 with a cyst. Eleven patients were evaluated clinically at least 1 year after injury and all were asymptomatic, while 1 child had mild diastolic hypertension. In conclusion, nonoperative management results in an excellent long-term outcome in the majority of cases. In-hospital morbidity is minimal and early surgical exploration should be reserved for those with hemodynamic instability or renal pedicle injury. Immediate CT is an invaluable aid in categorizing and managing these patients.

Use of Fresh Amnion as a Burn Dressing

Thirty-seven children with second and third degree burns dressed with amnion were compared to seventy-three children treated with Furacin (Eaton Labs, Norwich, N.Y.) dressing. Amnion was found to be as easy to use as Furacin. Fewer split thickness skin grafts were needed in amnion treated children and these patients required fewer days of hospitalization. Bacterial culture data suggests that amnion is as good as and possibly superior to nitrofurazone in decreasing the number of organisms on the burn wound. No adverse reactions to amnion were noted. The use of amnion is supported by this preliminary study and is deserving of further investigation and clinical use.

The relationship of class I MHC antigen expression to stage IV-S disease and survival in neuroblastoma

Cultured human neuroblastoma cells express low levels of class I (MHC) surface antigen. In order to determine if this low expression is representative of the clinical tumor, this study investigates class I expression in archival human neuroblastoma. Whereas stages I to IV neuroblastoma expressed low levels of class I antigen, stage IV-S tumor cells expressed normal levels, similar to control tissues. Expression of class I antigen in tumors from survivors of stage III neuroblastoma was significantly greater than in tumors from nonsurvivors. Tumors comprised predominantly of ganglion cells expressed significantly more class I antigen than neuroblasts. These data suggest that class I MHC expression may play a role in the natural history of human neuroblastoma.