H. William Clatworthy

Combined therapy in childhood rhabdomyosarcoma: An analysis of 42 cases

Abstract Forty-two cases of rhabdomyosarcoma in infants and children are presented. The relation of survival to age, site, cell type, stage of disease and therapeutic management is evaluated. The majority of survivors are between one and 3 years, have localized disease of embryonal or alveolar cell type and have been treated with combined surgery, radiation and chemotherapy. Postoperative survival of 2 years without evidence of recurrence relates well to a cure. In instances of rhabdomyosarcoma in infants and children, radical operation, postoperative regional radiation in combination with simultaneous and prolonged repeated courses of Actinomycin D and Vincristine appear justified and are recommended.

Carcinoma in a Colon Conduit Urinary Diversion

In recent years urinary diversion by means of the colon conduit has gained popularity because of the failure to exhibit reflux and the lower incidence of stomal stenosis. However, colon conduit diversion may be associated with adenocarcinoma, as is ureterosigmoidostomy. We report the first occurrence of adenocarcinoma in a colon conduit and, perhaps more important, in a colon conduit in which there had never been a fecal stream.

The Other Side of the Pediatric Inguinal Hernia

Criteria for performing contralateral groin explorations are based on a study of a large group of pediatric patients operated upon at one institution by surgeons who used the same criteria for determining patency of the processus vaginalis and employed similar operative techniques for hernia repair and contralateral exploration.

The meconium plug syndrome revisited

Abstract The intelligent management of newborn infants who have symptoms or signs of intestinal obstruction requires a familiarity with the meconium plug syndrome. Although recognized and described a decade ago, 1 this syndrome has not yet been widely discussed in the surgical and pediatric literature. Some questions arose at the time of the original report, particularly related to the etiology and the relationship of this type of obturant obstruction to meconium ileus associated with fibrocystic disease and to dyskinetic colonic function associated with congenital aganglionic megacolon. Although we have acquired little additional information regarding the etiology of the meconium plug syndrome, sufficient time has now elapsed to provide a greater body of experience for analysis and to bring to the readers attention some of the problems that we have encountered in the management of this entity. For these reasons we propose to reconsider the meconium plug syndrome and to recount our experience with the nine originally reported infants and 21 additional patients treated at the Columbus Childrens Hospital.

Accidental Perforation of the Colon and Rectum in Newborn Infants

PERFORATION of the gastrointestinal tract in the newborn infant is a major catastrophe that causes death in over three fourths of the babies, despite the availability of modern diagnostic and thera...

Hemodynamic and manometric observations in experimental air-block syndrome

Abstract In experimental air block, interstitial emphysema is characterized by early tachypnea, arterial hypertension, and hypoxemia. Pneumomediastinum causes a significant rise in central venous pressure and an initial respiratory and subsequent metabolic acidosis. This is a result of a reduction in venous return, cardiac output, and tissue perfusion. Pneumopericardium and coronary and systemic arterial air emboli were observed when vigorous insufflation pressures were used. Animal deterioration was characterized by severe hypoxia, metabolic and respiratory acidosis, arterial hypotension, and cardiac arrhythmias leading to cardiac arrest. These observations point out the potential dangers of vigorous resuscitation in small infants and suggest that vena caval and esophageal manometrics, arterial blood pressure, pH, and blood gas tension determinations indicate significant changes in pulmonary and mediastinal hemodynamics. Monitoring these factors in addition to pulse, respiration, and the EKG would permit early detection of critical changes and allow for prompt respiratory support and, hopefully, improved survival rates in infants with air-block syndrome.

Primary Mediastinal Neoplasms in Infants and Children

Abstract Primary mediastinal tumors were observed in 62 infants and children. Thirty-nine of the tumors were located posteriorly, 16 anteriorly, and 7 in the middle mediastinum. Neurogenic tumors occurred in 36 patients, with neuroblastoma accounting for 25. Lymphoma was noted in 20 patients, teratoma in 5 patients, and a rare lipoma in 1. Overall, 47 patients had malignant tumors, and 16 survived. All 15 patients with benign tumors survived. Because of the high incidence of primary malignancy in this age group, all childhood mediastinal lesions should be explored. Although dismal results were obtained with lymphoma (1 patient is alive, a survival of 5%) a 56% survival (14 patients) was achieved with mediastinal neuroblastoma. Patients under 1 year of age with neuroblastoma had an 88% survival rate (8 of 9 patients). Those diagnosed after 1 year had a 37.5% survival rate (6 of 16). Results were more favorable with mediastinal lesions (56% survival) than with retroperitoneal neuroblastoma (19% survival), regardless of the patients age. Complete or partial extirpation and radiation therapy yielded the most success, while chemotherapy offered significant palliation.

Vascularized Appendiceal Transplants in Biliary and Urinary Tract Replacement

Abstract Vascularized appendiceal transplants were prepared in 20 dogs. In ten dogs completely obstructed by bile-duct ligation, the neck of the appendix was anastomosed to the duodenum. One week later, the blind end was anastomosed to the gallbladder or obstructed common bile duct in five dogs each. All dogs survived and rapidly recovered both clinically and chemically from biliary obstruction. Intravenous cholangiograms and contrast barium swallow showed neither obstruction nor reflux. At sacrifice the transplants were viable and patent and showed no evidence of stricture, bile, stasis, or stone formation. In ten dogs the right ureter was divided and anastomosed to the tip of the prepared appendix. The open appendiceal base was brought out as a urinary stoma. The left ureter was kept intact for control. Vascular injury aborted one procedure. Prompt urinary function was observed in nine dogs. Intravenous pyelogram showed prompt function without dilatation in three. One animal showed poor function on pyelogram, but no obstructions were observed on loop-o-gram. Significant infection occurred in only one case due to stomal stricture. At sacrifice (up to 10 mo postoperatively) functional anastomoses, no stones, and normal renal architecture were observed. The use of the small and relatively short appendix for urinary diversion provides a minimal reservoir for urinary statis and electrolyte absorption, and avoids the necessity of bowel anastomosis. This study suggests that autogenous vascularized appendiceal transplants are suitable biliary and urinary tract conduits in the experimental animal. Further investigation of their use in bile-duct replacement and urinary diversion is clearly indicated.

Omphalocele: A prognostic classification

A classification for infants born with an omphalocele is proposed that is based on the recognition of four syndromes and two common associated anomalies. The recognition of these syndromes and anomalies in our newborns with an omphalocele provided a better estimate of expected mortality and morbidity than the size of the omphalocele, preoperative rupture, delay in treatment, or low birth weight. This classification should aid the physician in determining priorities regarding the timing and type of treatment for the omphalocele itself.

Big Shunts for Small Patients With Portal Hypertension: A Bit of History

This is a brief resume of my personal experiences that led to the development of two portosystemic shunt procedures designed to be used in small patients with bleeding varices and portal hypertension. Both enable one to decompress the congested protal venous system in the preschool-aged group when about two thirds of such patients begin to suffer their first life threatening bleeding episodes.