E. Thomas Boles

SACROCOCCYGEAL TERATOMA: THE EXPERIENCE OF FOUR DECADES

To determine the extent of progress in the treatment of sacrococcygeal teratomas (SCTs), we evaluated the experience with 73 patients over 40 years. The medical records of the children were reviewed for demographics, histology, clinical course, and outcome. Therapy differed depending on the type of SCT, histology, and decade of diagnosis. The female:male ratio was 4.2:1 and did not vary significantly with the histology of the tumor. Fifty-seven patients presented with benign disease. There were five recurrences in this group, only one of which did not have an initial coccygectomy. One tumor, originally thought to be benign with immature elements, had a local recurrence at 7 months, 10 months, and 16 months after the original operation and was discovered to have embryonal carcinoma with nodal involvement. This child was treated with chemotherapy and is disease-free at 7 years. Morbidity in the benign group included 3 postoperative wound infections. Three infants died, one before operation with beta-hemolytic Streptococcus sepsis. Two neonates died in the early postoperative period, one on day 1 with a ruptured subcapsular hematoma of the liver, and the second on day 2 with disseminated intravascular coagulation/sepsis. Benign SCT occurs at a younger age than malignant tumors. The average age of presentation of benign tumors is 20 days versus 468 days in children with malignant disease. The technique of wide resection of benign lesions with coccygectomy is helpful in preventing recurrence and has changed little over the last four decades. Malignant SCT occurred in 16 children (22%).(ABSTRACT TRUNCATED AT 250 WORDS)

Atresia of the colon

Eleven infants with colon atresia have been managed by staged procedure with survival and good health in ten. Complications have been relatively few. At the initial operation the proximal atretic segment is exteriorized as an end colostomy. Such a procedure is simple and safe, results in rapid relief of the obstruction, and permits normal feeding by mouth within a few days. At a second procedure several weeks or months later, intestinal continuity is established by an end-to-end or end-to-side anastomosis. Gastroschisis has been an associated anomaly in four of these cases. This association gives additional support to the concept that intrauterine interference to the blood supply to a segment of intestines is the etiologic factor responsible for such atresias.

Evaluation of colonic replacement of the esophagus in children.

Abstract Replacement of the thoracic esophagus with an interposed segment of colon was done in 29 children with esophageal atresia, stricture, or varices. There were no deaths. One failed because of vascular insufficiency of the transplant. The incidence of early postoperative complications was high. Long-term clinical and radiological evaluations were generally quite satisfactory in terms of normal growth, absence of pulmonary and intestinal symptoms, and rapid emptying of the transplant.

The management of gastroschisis

Summary A striking improvement in the results of infants with gastroschisis has occurred in recent years. The overall survival of 47 patients in a 25-yr period was 53%. In the first 20 years of this experience, only six of 20 lived (30%). In the past 5 yr, 19 of 27 have survived (70%). Two methods have given very satisfactory results. The skin-closure technique involves a major postoperative problem of respiratory support and a lesser problem of impaired wound healing. Furthermore, later hospitalizations for staged repairs of the ventral hernias are required. Despite these problems, there have been only two deaths in the 13 patients handled in this fashion in the last 5 yr. The silo technique is much simpler from the standpoint of the initial procedure and has the great advantage of avoiding significant postoperative respiratory embarrassment. Early technical problems with the material used. separation or tearing of the silo, and infection have largely been solved and the recent results have been very satisfactory. Although the recent experience with both techniques has been comparable in terms of mortality, the much reduced morbidity with the silo technique recommends it as the preferred method.

An ultrastructural study of the intimal injury induced by an indwelling umbilical artery catheter

In an experimental study, catheterization of the abdominal aorta with small umbilical artery catheters consistently produced significant intimal injury. The duration of catheterization varied from 1 hr to 7 days, and recovery periods following catheter removal varied from 1-150 days. Endothelial disruption was observed in all animals sacrificed within 24 hr of catheter removal. Healing progressed rapidly when the duration of catheterization was short, but was protracted with longer periods of catheterization. Thrombi were frequently found adhering to the exposed subendothelial surface. Routine light, scanning, and transmission electron microscopy demonstrated consistent cellular changes, which depended upon the duration of catheterization and the length of recovery periods. A consistent relationship between the degree of intimal injury and the duration of catheterization was observed.

Partial Splenectomy in Staging Laparotomy for Hodgkin's Disease: An Alternative Approach

Partial splenectomy, with resection of the lower one-fourth to one-third spleen, was performed in 10 children with Hodgkins disease as part of an otherwise standard staging laparotomy. The technique proved to be safe and practical, with no postoperative complications. No evidence to date indicates that splenic involvement was missed, and all the children have thus far continued to do well, with no deaths from either underlying disease or postsplenectomy sepsis. The procedure is undergoing a prospective clinical trial in an effort to determine whether or not it is comparable from a diagnostic point of view to total splenectomy. Available data indicate that the risk of missing intraabdominal disease in a staging laparotomy with a partial splenectomy is quite low. Such a procedure should eliminate the substantial risk of postsplenectomy sepsis in such children.

Extrahepatic portal hypertension in children: Long-term evaluation

A long-term evaluation of 43 children with extrahepatic portal hypertension indicates a high success rate and excellent subsequent health when a splenorenal or mesocaval shunt can be performed. On the other hand, makeshift shunts inevitably fail. Direct operations are considerably less successful than standard shunts. Esophagogastric resections with interpositions result in long-term freedom from bleeding in only about half the cases, and portoazygous disconnection procedures have been uniformly disappointing. Sclerotherapy in a relatively recent experience has been quite successful, but long-term results are presently unavailable. The condition carries a significant mortality rate. Complications from failed operations, division of the vena cava, and multiple transfusions are numerous. The general health of long-term survivors is excellent in those with successful operations, and is surprisingly good for patients whose operations have been unsuccessful and for those who have had no operations.

Surgical treatment of meconium ileus

Abstract Meconium ileus is a form of congenital intestinal obstruction associated with cystic fibrosis which may present as a straightforward obturation blockage. In about half the cases, however, the pathologic condition is complicated by problems such as volvulus, gangrene, perforation with meconium peritonitis, and atresia. Relief of the obstruction in the simple form is almost invariably accomplished with a variety of operative procedures. A recently described nonoperative technic using Gastrografin enemas gives promise of consistent success and may supplant the surgical methods. The complicated cases require operations designed to correct the pathology found, and this usually involves resection and some form of temporary exteriorization. An intensive prophylactic and therapeutic program directed toward the pulmonary complications of the disease has significantly increased the proportion of surgical survivors in recent years and has similarly improved the long-term results in terms of both good health and survival.

Duplication of pylorus in the newborn: A rare cause of gastric outlet obstruction

Abstract Complete pyloric obstruction caused by a duplication was relieved by excision without resection of the contiguous pylorus. Histologically all of the normal layers of the pylorus were present. In addition a few foci of pancreatic tissue showing acute inflammation were found.

An improved method of wound management for pediatric patients

Polyurethane moisture-vapor permeable film (MVPF), a new product for the management of superficial wounds, was studied in an uncontrolled clinical trial in 50 pediatric patients. MVPF was used in the management of skin graft donor sites, partial thickness burns, traumatic abrasions, decubitus ulcers, intravenous skin sloughs, and a variety of other wounds. Advantages of this material over standard dressing techniques include: more comfort, freedom of motion of the injured part, fewer dressing changes, and apparently faster epithelialization in many cases. Folliculitis, noted in one patient, was the only complication. MVPF is easily adaptable to outpatient wound management, and has gained rapid acceptance by nurses, patients and parents.