Farhat Moazam

Thoracoscopy in children.

In the past four and one-half years we have used thoracoscopy as the primary technique for pulmonary biopsy in children. During that interval, over 80 thoracoscopic procedures have been performed with no mortality and minimal morbidity. The ages of the patients have ranged between 2 weeks and 20 years. The procedure is carried out in the general operating room under regional and intravenous anesthesia, avoiding the need for endotracheal intubation. Fourty-two of the procedures have been performed in immunosuppressed patients, attempting to determine the presence of Pneumocystis carinii pneumonia. Twenty-four of the procedures have been performed for the diagnosis of intrathoracic tumors while 15 procedures have been performed for the diagnosis of localized pulmonary infiltrates. The diagnostic accuracy in immunosuppressed patients has been 100 persons and in the tumor patients has been 92 percent. The complications of this technique have been minimal. Four patients developed pneumothoraces which responded to manipulation of the chest tube and 3 patients have had sufficient postoperatoire bleeding to require transfusion, while none have required re-exploration. The technique of thoracoscopy has provided a safe and rapid method of pulmonary diagnosis in this aged patient.

Thoracoscopy for Intrathoracic Tumors

The technique of thoracoscopy has been performed on 49 occasions in 45 patients for the diagnosis or staging of intrathoracic tumors. The patients ranged from 8 months to 68 years old. Eight procedures were performed for pleural disease, 16 for mediastinal masses, 22 for parenchymal lesions, and 3 for intrathoracic staging. Seventeen patients had had previous invasive procedures performed without a pathological diagnosis being established. In 28 thoracoscopy procedures, a positive diagnosis for malignancy was obtained; in 6 instances, areas of unsuspected tumor involvement were identified. A correct diagnosis was obtained by thoracoscopy in 45 procedures for a 92% overall accuracy rate. There was no clinically significant morbidity in this series and no procedure-related mortality. Thoracoscopy, performed under stellate ganglion block and regional anesthesia, has proved to be a very attractive method of diagnosing intrathoracic neoplasia with very low morbidity.

Functional and metabolic evaluation of colon replacement of the esophagus in children

Thirteen children with esophageal replacement with colon interposition have been followed at the University of Florida Medical Center between 1962 and 1976. Eight of these patients were evaluated with a detailed functional and metabolic protocol, four requiring colon interposition for esophageal atresia and four for esophageal strictures. Growth was noted to be somewhat delayed in the patients with esophageal atresia, especially those with associated congenital anomalies. Otherwise, excellent functional results were obtained. Significant anemia with depressed serum iron concentrations was noted in four patients, and three patients had abnormal vitamin B12 absorption. This abnormality correlated with length of terminal ileum employed with the interposed segment. Serum parameters of intestinal absorption were normal in each patient. Manometric evaluation revealed absence of peristalsis within the colonic segment, but progressive peristalsis within interposed ileal segments. Radiologic evaluation demonstrated delay in passage of thick material from mouth to stomach and wide variability in overall intestinal transit time.

Fasting and postprandial serum gastrin levels in infants with congenital hypertrophic pyloric stenosis.

Recently attempts have been made to demonstrate the possible role of hypergastrincmia in the production of congenital hypertrophic pyloric stenosis in infants. Eleven infants with congenital hypertrophic pyloric stenosis, ranging in age from three to 11 weeks, were evaluated for fasting and postprandial serum gastrin levels. Two to ten weeks following successful pyloromyotomy, a similar evaluation was undertaken to demonstrate the possible role of elevated serum gastrin levels in the etiology of congenital hypertrophic pyloric stenosis. The average fasting and postprandial serum gastrin levels in infants with congenital hypertrophic pyloric stenosis did not differ significantly from levels noted in control infants. Similarly, no statistically significant difference was noted between the pre-and postoperative levels of serum gastrin in the affected infants. Several experimental studies have been reported within the past few years describing the production of hypertrophic pyloric stenosis in the offspring of dogs injected with pentagastrin during pregnancy. The results of our study minimize the direct importance of serum gastrin in the production of congenital hypertrophic pyloric stenosis. The role of the hormone secretin in the etiology of this condition is hypothesized.

Foreign Bodies in the Pediatric Tracheobronchial Tree

From the Division of Pediatric Surgery, Departments of Surgery and Pediatrics, University of Florida College of Medicine, Gainesville, Florida. Correspondence to: Farhat Moazam, M.D., Division of Pediatric Surgery, Box J286, J. Hillis Miller Health Center, University of Florida, Gainesville, FL 32610. Received for publication May 1982, revised June 1982, and accepted July 1982. FOREIGN BODY aspiration is responsible for approximately 2,000 deaths a year in children under six years of age. 1,2 In most children the aspiration is manifested by a triad of choking while eating, coughing, and wheezing; but the presentation may be more subtle, resulting in prolonged and misguided therapy for asthma and pneumonia prior to correct diagnosis.’-’ A high index of suspicion is necessary for early diagnosis and extraction of the aspirated foreign body.

Spontaneous perforation of a colonic duplication

Alimentary tract duplications are rare anomalies that present with a wide spectrum of clinical manifestations. Mass lesions or obstructive symptoms predominate in infancy, while pain and hemorrhagic complications often herald their recognition in childhood. Spontaneous perforation, a rarely encountered complication, accounted for the acute exacerbation of previously chronic abdominal pain in a three-year-old girl. This case emphasizes the potential for these benign lesions to present with progressive abdominal symptoms and ultimately pressure-induced ischemic perforation.

Magnetic resonance imaging of bicornuate uterus with unilateral hematometrosalpinx and ipsilateral renal agenesis.

A complex solid and cystic pelvic mass in a young patient was demonstrated by computed tomography (CT) and ultrasound (US). These modalities failed to accurately characterize the solid components as bicornuate uterus and the cystic areas as hemorrhage. Magnetic resonance imaging (MRI) using multislice multiecho spin echo (SE) sequences made it easier to characterize the mass, clearly depicting the abnormality in transaxial and coronal planes and at the same time demonstrating ipsilateral renal agenesis.

Surgical management of massive ventral hernias in children

The management of 7 children with massive abdominal wall hernias is reviewed, utilizing a technique of stabilizing the defect by insertion of a Teflon mesh prosthesis followed by pneumoperitoneum and staged reduction. Teflon mesh has proven ideally suited for this purpose because of its flexibility, elasticity, and relative nonreactivity, allowing it to be applied directly over the surface of exposed bowel without inducing fistula formation. Although the mesh is securely incorporated into the fascial perimeter of the abdominal wall, a pseudomembrane is formed at the point of contact with the bowel surface which allows subsequent dissection and removal of the prosthesis with relative ease. Having limited the size of the defect by insertion of the mesh, an ideal situation is created for use of pneumoperitoneum to expand the peritoneal cavity and stretch the normal tissues of the abdominal wall, thus facilitating subsequent operative reduction of the ventral hernia. Utilizing this approach, excellent cosmetic and functional results have been achieved in all 7 patients.

A preliminary study of age-related difference in resistance to sepsis in the rat model

Although the pathophysiology of intraabdominal sepsis is well established in the adult animal, there is a paucity of similar information in the newborn animal. Using the Wichterman (K.A. Wichterman, A.E. Baue, and I.H. Chaudry, Journal of Surgical Research 29: 189, 1980) model of intraabdominal sepsis, 42 Sprague-Dawley suckling rat pups and 42 adults underwent cecal ligation followed by a single needle puncture of the cecum. Whereas a mortality of 47.6% was noted in the adult animals, only 7.1% of the suckling animals succumbed by the end of 1 week. After the ip LD50 of Escherichia coli was determined independently in each age group, appropriate doses of the bacteria were injected into the peritoneums of 36 suckling and 30 adult rats. The peritoneal fluid was aspirated at 0, 2, 4, 8, 24, and 48 hr and the bacterial concentration in the suspension was determined. The rate of bacterial clearance from the peritoneum of the suckling rats was found to be significantly greater at 2, 4, and 8 hr as compared with the adult animal. In vitro assay of the phagocytic activity of the peritoneal macrophages demonstrated a significantly higher activity in the cells obtained from the suckling rats than in those from the adult (P less than 0.05). A more efficient bacterial clearance and a higher phagocytic activity in the peritoneal macrophages of the suckling rats may contribute to the difference in the mortality between the two age groups.

Acute scrotal lesion secondary to barium peritonitis in an infant

We report on an acute scrotal lesion occurring secondary to barium peritonitis in an infant with a patent processus vaginalis. To our knowledge, this has not been described previously. Treatment of the peritonitis may be sufficient for the scrotal lesion.