Gustavo Stringel

Effect of dietary nucleosides on growth and maturation of the developing gut in the rat.

Dietary nucleoside (DN) as a precursor for nucleic acid synthesis may be important for rapidly dividing cells, since gut epithelial cells have limited capacity for de novo purine and pyrimidine synthesis. We evaluated in a controlled blinded study the effect of added nucleosides, 0.8% by weight, given for 2 weeks, on gut growth and maturation in 20 weanling rats. Mucosal protein and DNA in the proximal intestinal segment were 50% and 77% higher, respectively, in the DN-supplemented group (n = 10; p < 0.05). Villus height based on cell count was 25% greater in the DN group (p < 0.05). Maltase activity was significantly greater in proximal, middle, and distal intestinal segments, and the largest increase, 87%, was seen in the proximal gut mucosa. The maltase/lactase ratio was also higher in this segment. Increases in sucrase were less prominent. Lactase was minimally affected. The pattern of change in disaccharidase activity suggests that DN may enhance gut growth and maturation of the intestine in the weanling rat, the effects being more pronounced in the proximal segment. Diets free of nucleosides and nitrogenous bases may have adverse effects on the gut.

Lipoblastoma in infants and children.

Lipoblastoma and lipoblastomatosis are rare benign tumors of embryonal fat with a tendency to local invasion but not to metastasize. To date, there have been 60 cases described in the international literature. There has never been a report in a child older than 8 yr. The main clinical characteristics are the presentation, usually below 3 yr of age, the rapid growth of the mass and the peripheral location, mainly in the extremities. Although CT scan may show a fatty tumor, there is no single test to make the differential diagnosis (which includes benign lipoma, liposarcoma and myxoliposarcoma) and the treatment should be based on clinical findings. We have treated four patients with this condition. Two were intrathoracic, one was intraperitoneal, and one was a tumor of the upper arm. All presented as rapidly-growing tumors and were clinically assumed to be malignant. We recommend complete but conservative excision of the tumor; there are reported recurrences after inadequate excision. This is a benign tumor and radical cancer surgery should be avoided.

Torsion of the wandering spleen: Splenectomy or splenopexy

Torsion of the wandering spleen is a rare condition usually unsuspected preoperatively. In previously reported cases in the past, attempts at splenopexy have failed and splenectomy has been regarded as the treatment of choice. We are presenting two children with splenic torsion. In one complete infarction of the spleen had occurred and so splenectomy could not be avoided. In the second, the spleen was viable and splenopexy was successfully performed. The clinical presentation, etiology, diagnostic procedures and management are discussed, and a surgical technique for splenopexy is described.

Infantile mammary duct ectasia: a cause of bloody nipple discharge

Bloody nipple discharge in infancy has been rarely reported in the medical literature. Its cause is unknown. We report a three-year-old male infant and a five-month-old female infant with bloody nipple discharge. Because of persistent bloody discharge, a subcutaneous mastectomy was performed in the boy; the problem resolved in the girl after a period of observation. The specimen showed histologic changes identical to those seen in adult mammary duct ectasia. All the endocrinologic work-up was normal. We suspect that bloody nipple discharge in infancy is underreported. This is a benign condition with histologic changes similar to adult mammary duct ectasia and if persistent, should be properly investigated; biopsy or excision are not indicated.

Pheochromocytoma in children—An update*

Eight cases of pheochromocytoma in children were managed between 1958 and 1978. Headache, visual blurring, sweating, and hypertension were the most common findings. One patient presented with a hypertensive crisis during appendectomy. Three other children had a family history of pheochromocytoma and Hippel-Landau disease, thyroid carcinoma, and renal stones. The diagnostic approach was based on a high suspicion of the disease from the clinical picture. The most reliable laboratory investigations were urinary VMA, metanephrine, and catecholamines. I.V.P. and angiography were successful in localizing the tumor. In 4 cases, CT scan localized the tumor, although a second tumor was not seen in 1 case. Preoperative control of hypertension was achieved with phenoxybenzamine, propanolol, apresoline and reserpine in seven cases. The main anesthetic drugs used were pentothal, methoxyflurane, nitrous oxide, Innovar, and pancuronium. Tumors were located in the right adrenal in four, the left adrenal in two, both adrenals in one, and bilateral para-aortic sites in one. In two cases, hypertensive episodes during manipulation of the tumor were controlled with phentolamine. Ligation of the venous drainage from a tumor was associated with a sudden sustained fall in systemic blood pressure in six cases. In two, blood pressure remained elevated until a second tumor was found and removed. Hypotension was then corrected by the rapid infusion of fluid and blood, and vasopressors were not used. There were no postoperative complications and all children remained normotensive during the follow-up. The tumors of seven of the patients were benign. One tumor showed a low grade malignancy.

Primary omental infarct: conservative vs operative management in the era of ultrasound, computerized tomography, and laparoscopy.

PURPOSE Primary omental infarct is a rare condition in children. The preoperative diagnosis can be accurately accomplished using ultrasound (US) and computerized tomography (CT). This study aimed to elucidate the efficacy of conservative vs operative management. METHODS Cases of omental infarction in children diagnosed preoperatively in our institution since laparoscopy became the standard of care were reviewed. RESULTS Ten cases of omental infarction in children were treated. There were 6 males and 4 females (age, 5-14 years). The diagnosis was made preoperatively by CT in all cases; in 2 cases, US was also diagnostic. Conservative nonoperative management was successful in 4 cases, and laparoscopic omentectomy and appendectomy done in the other 6. There was no mortality. All children recovered uneventfully. Average hospital stay was 4 days for patients treated nonoperatively. Average postoperative stay was 2 days for children treated with laparoscopy. Three patients initially treated conservatively had surgery because of intractable pain. The preoperative stay was 3 days in these patients. CONCLUSIONS Children with omental infarct can be treated conservatively, and a short trial period is warranted. The indications for surgery are uncertain diagnosis, intractable relentless pain, and persistent peritoneal findings. Children treated with laparoscopy have a shorter length of stay and decreased use of narcotics.

Idiopathic perforation of the biliary tract in infancy

Idiopathic perforation of the bile duct is rare in children. Sixty-seven cases were reported in the English literature to 1980. It is, nevertheless, the second commonest surgical cause of jaundice in the neonate. The etiology is unknown though distal obstruction and weakness in the bile duct wall have been postulated. Limited surgical treatment with external drainage is the preferred therapy. In isolated cases internal drainage procedures or repeated aspiration have been successful. The diagnosis should be suspected in the presence of jaundice and ascites with or without abdominal pain and signs of peritoneal irritation. We describe a 3-month-old girl presenting with anemia, vomiting, jaundice, and ascites. This was initially diagnosed as hepatitis but bilious fluid was found on paracentesis. Computerized tomography with cholangiography and 99 MTC Diisopropyl IDA cholescintigraphy confirmed the diagnosis. The latter seems to be more accurate than I-131 Rose Bengal. The perforation was at the junction of the hepatic and cystic ducts. It was treated successfully by external drainage and a cholecystostomy. Direct attempts to close the perforation, or more complicated surgical procedures, are unnecessary while nonoperative treatment carries a high mortality. At follow-up after 1 year the IV cholangiogram and liver-function tests are normal. Cholecystostomy provided good drainage of the biliary ducts as well as easy access for follow-up cholangiography.

Laparoscopic-assisted percutaneous endoscopic gastrostomy☆

The authors report the successful use of laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) in two children. Attempts at simple percutaneous endoscopic gastrostomy in both patients had failed. Subsequently, LA-PEG was easily accomplished. This technique consisted of a combination of upper gastrointestinal endoscopy and laparoscopy. The gastrostomy was placed under direct vision in the lesser gastric curvature, hence minimizing the risk of developing gastroesophageal reflux.

Treatment of choledochal cyst by excision

Since 1969 excision of choledochal cyst and establishment of bile drainage by Roux-en-Y hepaticojejunostomy has been performed in 7 children whose ages ranged from 10 mo to 11 yr. In 3 children, the cyst had been treated 5 yr, 4 wk, and 3 wk previously by cystduodenostomy, cystjejunostomy, and cholecystduodenostomy, respectively; further surgery was indicated for biliary obstruction and severe cholangitis. The other four children were not acutely ill. All cysts were located distal to the confluence of the right and left hepatic ducts. The volume of the smallest cyst was 25 ml and the largest 500 ml. In all children a small remnant of distal cyst was not excised to avoid injury to the duodenum and pancreas. In four children a remnant of proximal cyst was left attached to the hepatic duct to allow a large biliary intestinal anastomosis and minimize the possibility of stricture. No serious intraoperative problems were encountered. Prolonged drainage (2-3 wk) from Penrose drain sites in two children were the only postoperative complications. Liver function tests have remained normal in all and no episodes of cholangitis or jaundice have been noted during follow-up (median: 4.5 yr). This experience supports recent reports that indicate that cyst excision is associated with low mortality and morbidity. Cyst excision is preferred over traditional internal drainage procedures because it (A) eliminates a reservoir for bile stasis, (B) removes a mechanism which allows continuous reflux of pancreatic juice into the cyst, and (C) probably prevents the occurrence of bile duct carcinoma which has been noted in 3.0% of patients with choledochal cyst.

Use of Decubitus Radiographs in the Diagnosis of Foreign Body Aspiration in Young Children

Background: Lateral decubitus radiographs are often obtained in young children with suspected foreign body aspiration. Their usefulness has not been well studied. Objectives: To assess the value of decubitus radiographs in detecting foreign body aspiration in young children and compare their value to history and physical examination. Methods: Retrospective review of children younger than 4 years with suspected foreign body aspiration who had decubitus radiographs and underwent bronchoscopy over a 5-year period. Patients with proven foreign body aspiration were compared with those without foreign bodies for differences in symptoms, signs, location and character of the foreign body, and the diagnostic value of standard and decubitus chest radiographs. Results: Twenty-eight of 41 children who underwent bronchoscopy for possible foreign body aspiration had decubitus radiographs. Foreign bodies were identified in 22 patients (79%). A total of 27% of children with foreign body aspiration and 33% of children without a foreign body had suggestive decubitus radiographs (P = not significant). As a measure of detecting foreign body aspiration, positive decubitus radiographs had a sensitivity of 27%, a specificity of 67%, a positive predictive value of 75%, and a negative predictive value of 20%. The odds ratio of finding a foreign body with suggestive decubitus radiographs was 0.75 (95% confidence interval [CI], 0.1-5.2; P = 0.57). Foreign body aspiration was confirmed in 94% of children if there was both a sudden onset of symptoms and a witnessed choking episode (odds ratio, 13.3; 95% confidence interval, 1.3-138.9; P = 0.02). Conclusion: Decubitus chest radiographs, at least as routinely performed and interpreted, seem to add little to the evaluation of young children with suspected foreign body aspiration. A history of a witnessed choking episode combined with a sudden onset of respiratory symptoms remains the most important indication for bronchoscopy.