H. Roth

Peritoneal morphology in children treated by continuous ambulatory peritoneal dialysis

Fifty peritoneal biopsies (PB) from 35 patients with end-stage renal disease, treated by continuous ambulatory peritoneal dialysis (CAPD) and aged 2 months to 18 years, were examined by light microscopy (n=50) and/or scanning electron microscopy. PB were performed during surgical procedures immediately before the start of, during, or after the cessation of CAPD treatment. PB from 15 children without renal disease undergoing laparatomy were examined similarly. Before the start of CAPD, a scarcity and shortening of the mesothelial microvilli was observed by scanning electron microscopy. During and after CAPD, variable alterations of mesothelium, interstitium and capillaries were found. The mesothelial layer was absent in all 5 PB obtained during episodes of active peritonitis. In patients treated by CAPD for longer than 6 months, mesothelial denudation was observed more frequently (6/11) than in children treated for shorter periods (1/7) (P<0.08). Fibrosis of the peritoneal membrane was present in about 50% of patients during or after the cessation of CAPD without impairment of peritoneal function. No correlation was found between the presence of fibrosis and the frequency of peritonitis or the duration of CAPD treatment.

Three years' experience with large ovarian cysts diagnosed in utero.

Thirteen fetuses with abdominal cystic tumors were diagnosed by routine prenatal ultrasonography between the 28th and 36th week of gestation. Postnatal ultrasonography of the full-term newborns confirmed the findings. Laparotomies were performed in all cases except one. Patients who were operated on had large ovarian pseudocysts with volumes between 24 and 120 cc. In seven patients (54%), the cysts arose from the left ovary; this included four cases in which the postnatal ultrasound was interpreted as showing the cysts in the right abdomen. Very thin cystic walls threatening perforation were found in 91%. In 33%, we found salpingotorsion on the affected side. Small contralateral ovarian cysts were found in 66% of the patients. One infant required resection of 30 cm of necrotic jejunum because adhesions to the cyst had caused bowel volvulus. Histology of the cysts showed hemorrhage and calcifications, but ovarian stroma was absent in all but one patient. Serum estradiol-17 beta, progesterone follicle-stimulating hormone, and luteinizing hormone were normal in all cases, and similar levels were found in the cyst fluid. These results show that large abdominal cystic masses in full-term infant girls with normal gonadotrophin levels and normal serum estradiol-17 beta and progesterone levels are very likely to require surgery; this is in contrast to preterm neonates with elevated gonadotrophins who can be treated with medroxyprogesterone acetate in the absence of clinical signs necessitating surgery.

Specific and nonspecific lymphadenitis in childhood: etiology, diagnosis, and therapy

Over a period of 4 years, 39 children with lymphadenitis were treated surgically; in 31 cases cervical lymph nodes were the main location. In 9 cases the lymphadenitis was caused by mycobacterial infection.Staphylococcus aureus was the most frequent causative organism of unspecific lymphadenitis (11 cases). The therapy of choice appears to be surgical treatment and medical care after operation. Especially in mycobacterial lymphadenitis, complete surgical excision of the lymph node is decisive for definitive healing. There was only 1 case of therapy-resistant, relapsing cervical lymphadenitis that needed a second operation. Causative organisms in this case wereMycobacterium avium andMycobacterium intracellulare. All other patients showed an uneventful postoperative clinical course. We believe that a consequent diagnostic process and cooperation between the pediatric surgeon and pediatrician are necessary for effective therapy.

Peritoneal Access for Dialysis in Infants and Children

The introduction of continuous ambulatory peritoneal dialysis (CAPD) has opened new horizons in the treatment of children with end-stage renal disease (ESRD). Early reports on the application of this new mode of treatment in the young [1–7] were followed by more comprehensive descriptions on the technique and results of CAPD in the pediatric population [8–12]. CAPD has become a true alternative to regular hemodialysis, especially for those children who earlier were regarded as candidates for home hemodialysis [13, 14].

Motility Malfunction of the Gastrointestinal Tract by Rare Diseases — Fibrosis of the Intestinal Wall

We report on two children who were admitted with chronic ileus without mechanical obstruction. In the 4-month-old female newborn, high-dose radiation was applied after extirpation of a sympathicoblastoma. Within a few years a metaplasia of the muscle coat of the small intestine developed with a resulting malabsorption syndrome. Although the damaged part of the intestine was resected, the process progressed and the child died. In the second case, a chronic ileus developed at the age of 10 years as a result of fibrosis of the intestinal tract. Repeated laparotomies were performed, and no mechanical obstruction could be found. The most probable diagnosis is a form of scleroderma affecting mainly the alimentary tract without any skin involvement. The patient died in a severe cachexia.

Splenic surgery in childhood

In recent years efforts have been made to preserve the spleen after childhood injuries because of the increased risk of lethal sepsis following childhood splenectomy. The recent literature reveals that overwhelming postsplenectomy infection (OPSI) occurs with an incidence of 3.2% among splenectomized children, with a mortality of 45%. The incidence of OPSI is highest between birth and 2 years; children whose splenectomy was due to trauma had an incidence of 1.5%. OPSI after splenectomy for other diseases results in a higher incidence (5.6%). The case mortality rates are 17.6% and 55.6%, respectively. Splenic rupture constitutes an indication for total splenectomy, particularly when the rapture involves the splenic hilum (stage IV rupture, Barret et al. [1]). We performed anatomic studies of the splenic arterial supply, which showed that an identifiable superior splenic artery served the upper splenic pole in 60% of cases, offering the possibility that the upper pole might be salvaged even in cases of serious rupture. We report a series of 23 children treated for splenic injury in the last 5 years. Using fibrin-glueing techniques in stage I and II ruptures and segmental or subtotal resection in Stage III and IV ruptures, we successfully preserved functioning splenic tissue in every patient, even in cases of complete rupture of the main splenic artery. Functional preservation was documented by splenic scintigraphy and screening for hematologic signs of hyposplenism. Spleen ultrasonography was also performed as an additional follow-up examination. We observed no cases of OPSI in the above-mentioned series.

49. Infektionsrisiko und chirurgische Konsequenzen des Milzverlustes im Kindesalter

SummaryAmong 1882 splenectomized children with a mean follow-up period of more than 5 years the incidence of sepsis was 3.2 % with a mortality of 1.4 %. As expected the lowest risk (1,6%) was found in case of trauma. Susceptibility to sepsis increases after splenectomy caused by severe disease. It was highest (9.8 %) in case of M. Hodgkin, portal hypertension and thalassemia. The younger the patient the higher the risk of PSI. 55 % of the affected patients suffered from sepsis within the first two years, 35 % after three up to six years. Vaccination and antibiotic prophylaxis are recommended including information about the risk of sepsis. Preservation of orthotopic splenic tissue, if indicated, should be the surgical consequence in childhood.ZusammenfassungUnter 1882 Kindern wurde nach Splenektomie bei einer mittleren Nachbeobachtungsdauer von mehr als 5 Jahren eine Sepsisincidenz von 3,2 % mit einer Mortalität von 1,4% ermittelt. Erwartungsgemäß fand sich beim Trauma mit 1,6 % das geringste Risiko. Mit der Schwere der Grunderkrankung nahm die Sepsisanfälligkeit eindeutig zu. Beim M. Hodgkin, der portalen Hypertension und der Thalassämie lag sie mit 9,8 % am höchsten. Je jünger der Patient, desto größer war das PSI-Risiko. 55 % der Betroffenen erkrankten innerhalb der ersten 2 Jahre, weitere 35% nach 3–6 Jahren. Neben der Impf- und Antibioticaprophylaxe einschließlich Risikoaufklärung ist als chirurgische Konsequenz die orthotope Milzerhaltung im Kindesalter bei gegebener Indikation anzustreben.

29. Cystische Duplikaturen des cervicalen Oesophagus

SummaryCystic duplications in the cervical region are very rare. In most cases compression of the trachea leads to severe symptoms of respiration. Two cases of cystic duplication are described - a nine months old child and a newborn baby. In the first case the cyst was localized on the right side of the thyroid. Extirpation could be done without any complications. The operation on the second case was difficult. The tumor was localized between oesophagus and trachea rotating the larynx.ZusammenfassungCystische Duplikaturen im cervicalen Bereich sind selten. In den meisten Fällen führt die Atemnot infolge Kompression der Trachea zur akut lebensbedrohlichen Situation. Es wird über 2 seltene Fälle berichtet — ein 9 Monate alter Säugling und ein Neugeborenes. Im ersten Fall gelang die Exstirpation der rechts von der Schilddrüse lokalisierten Cyste mühelos. Im zweiten Fälle gestaltete sich die operative Entfernung technisch schwierig, da der cystische Tumor sich zwischen Oesophagus und Trachea entwickelt und den Larynx um 90° verdreht hatte.

Ist die Pyloromyotomie eine Indikation für einen laparoskopischen Eingriff

In unserem Bemuhen, der Kosmetik unter Wahrung von sicheren und optimalen Operationsbedingungen gerecht zu werden, modifizierten wir den Zugang fur die Pyloromyotomie. Durch einen supraumbilikalen Schnitt wurde die Linea alba eroffnet, der hypertrophe Pylorus wurde herausluxiert und konventionell gespalten. Wirhaben diese Methode bei 14 Sauglingen ohne Komplikationen angewandt. Das Verfahren ist im Vergleich zur laparoskopischen Pyloromyotomie gleich minimal invasiv. Hospitalisationszeiten sind kurz und die Narben sind fast unsichtbar. Die reine Operationszeit betrug durchschnittlich 21 min. Auch in laparoskopisch geiibten Handen ist diese Zeit nicht zu unterbieten. Daruber hinaus ist un sere Operationsmethode urn ein vielfaches preiswerter. Nach unserer Erfahrung bietet die Laparoskopie bei der Pyloromyotomie keine Vorteile.

Ileitis hyperplastica follicularis Golden: Surgical or conservative treatment?

The authors report on four cases of Goldens syndrome, a rare disease with unknown etiology and controversial therapy. The first two 7-year-old boys had gastrointestinal bleeding; their hemoglobin levels were 7.0 g% and 7.3 g%, respectively. A blood transfusion was required. Both patients underwent gastroscopy and rectoscopy, and no source of bleeding was found. Biopsies were taken during laparotomy, after terminal ileotomy in case one and coecotomy in the other. Bowel resection was not necessary in either case. The third and fourth boys (5 and 6 years old, respectively) were treated conservatively with parenteral nutrition; blood transfusion was not necessary. All four patients recovered within several days. Control colonoscopies 6 months later showed normal mucosa. The authors discuss their diagnostic and therapeutical regime, stressing that in their experience, this rare disease does not require surgical intervention.