Gerard Weinberg

The irreducible ovary: A true emergency

The management of a child with an irreducible ovary remains inconsistent in pediatric surgical centers. An informal survey of senior pediatric surgeons and an extensive review of the literature showed a prevailing view that the trapped ovary is not at significant risk of vascular compromise. Two recent cases prompted a review of our experience from 1984 to 1989, during which 1,699 children with inguinal hernias underwent operation, 386 (23%) of whom were girls. Fifteen girls (4%) had irreducible ovaries present at the time of operation and in 4 of the 15 (27%) the ovary was twisted and infarcted. Two of the 4 girls were known to have an irreducible ovary prior to the day of operation--1 was noted 2 months earlier and 1 was noted 1 month earlier. At the time of the initial diagnosis, neither patient had physical findings of vascular compromise of the ovary. In the other two girls, evidence of an infarcted ovary was present when the hernia was first diagnosed and an emergency operation was performed. A 27% incidence of torsion and strangulation of irreducible ovaries appears to be high, but reports of strangulated ovaries have been reported in 2% to 33% of other series. The normal anatomy is altered when an ovary is trapped in a hernia sac, and these changes make torsion more likely. Although an irreducible ovary is not at great risk of compression of its blood supply, this report identifies a significant risk of torsion. This risk warrants treating the asymptomatic irreducible ovary as any other incarcerated hernia--as a true emergency.

Transcutaneous Oxygen Monitoring in Shock and Resuscitation

Transcutaneous oxygen tension (TcPO2), arterial oxygen tension, pulse, blood pressure, cardiac output and base excess or deficit were serially measured in 18 piglets, 7 to 14 days of age, subjected to a 35% hemorrhage and reinfusion of shed blood. Eight of 18 pigs died. There is a strong correlation between TcPO2 and PaO2 during normal flow, but a marked discrepancy develops during hemorrhage. Cardiac output, base deficit, and TcPO2 all follow a similar pattern during hemorrhage, but TcPO2 decreases more rapidly and remains at a low level in the nonsurviving animals. TcPO2, therefore, appears to be a sensitive, noninvasive indicator of low flow and the adequacy of resuscitation.

Idiopathic intestinal perforations in the newborn: An increasingly common entity*

Between 1982 and 1987 seven neonates ranging in age from 24 hours to 1 week were treated for idiopathic intestinal perforations at the Montefiore Medical Center, Albert Einstein College of Medicine. Four of the infants were born prematurely; three were full term. Five were being treated in an intensive care nursery when the perforation was diagnosed. All infants whose perforations were due to necrotizing enterocolitis, appendicitis, Hirschsprungs disease, meconium ileus, intestinal atresias, or drug therapy are excluded from the series. None of the infants had associated anomalies. The sites of the perforations were as follows: two in the jejunum, two in the ileum, one in the cecum, and two in the transverse colon. Six of the perforations were on the antimesenteric aspect of the bowel; one was on the mesenteric aspect. The sizes of the perforations ranged from pinhole to 1 cm in diameter. All the infants did well. Pathologic examination of the resected specimens failed to reveal an etiology for the perforations. There were no cases of duplication or muscular hypoplasia. We believe the etiology of this condition may be ischemic necrosis, secondary to a localized vascular accident in the wall of the affected viscus, but we do not have a good explanation for the upsurge in cases we are seeing.

Reduction of neonatal heat loss by an insulated head cover

When exposed to a cool environment, the newborn infant responds by nonshivering thermogenesis. The increased heat production is at the expense of body fuel and energy stores. A significant quantity of heat is lost from the head because of its large surface area and the high metabolic activity of the neonatal brain. The purpose of this study was to determine whether dry cranial heat loss could be significantly reduced by covering the head with highly insulated material, and to determine whether plastic lined hats decreased evaporative heat loss. A total of 46 fullterm and premature infants were studied. Hats insulated with material made of olefin and polyester reduced cranial dry heat loss by 73% and 63%. Plastic lined hats reduced evaporative heat loss by 68%. The insulated and lined hats proved to be a simple and safe method of effectively reducing dry and evaporative heat loss.

The management of surgery in infants and children with the acquired immune deficiency syndrome

Between January of 1981 and June of 1984, 53 infants and children with the diagnosis of AIDS were seen at our institution. Twenty-one of these patients have required 35 operations to determine or administer the proper therapy. We have taken every precaution to minimize the risks of exposure of all health care personnel.

Choledochal cyst imaging by telepaque-enhanced computed tomography

A choledochal cyst is an uncommon anomaly of the biliary system requiring surgical intervention. A case of a choledochal cyst imaged by computed tomography following oral administration of cholangiography contrast material (Telepaque) is reported. Telepaque-enhanced computed tomography is an easy, noninvasive method to demonstrate pertinent preoperative anatomy in cases of choledochal cysts, and is especially useful in the pediatric patient.

Acute gastrointestinal hemorrhage in infancy from gastric duplication: imaging findings.

We report two cases of duplications, occurring along the greater curvature of the stomach, both complicated by acute gastrointestinal hemorrhage, and review the findings on various imaging studies. Special attention is directed to the plain film findings, as this may be the initial study performed in the emergency department setting.