James S. Simpson

The conservative management of splenic trauma.

Abstract Of 32 cases of suspected splenic rupture in children occurring from 1948 to 1955, only six required splenectomy. Sixteen of the remaining cases treated conservatively were studied in detail. Although the feasibility of conservative management of splenic injury following blunt abdominal trauma was demonstrated, laparotomy should be performed where major splenic trauma or other serious intraabdominal injuries, or both, are suspected.

Nonoperative management of traumatized spleen in children: How and why

In the absence of the apleen, overwhelming infection is a real threat. Therefore, there is a trend to try to preserve all spleens. Recognizing this, and realizing that not every damaged spleen must be removed, a nonoperative approach has been advocated and practiced for 35 yr at the Hospital for Sick Children in Toronto. This experience is recorded herein, providing indications and methods of management. The results are considered to be very satisfactory.

Ruptured spleen—When to operate?

Sixty-three patients with splenic injuries were treated during a 5-yr period from 1974-1979. The decision to operate was based on the patients clinical course, not on the presence of splenic injury alone. Those who were stable on admission or after initial resuscitation were treated nonoperatively. This consisted of strict bed rest, nasogastric suction, and i.v. fluids--including blood--as required. Those who bled massively were operated on promptly. At operation, the spleen was repaired if possible or excised if damaged beyond repair. Forty patients were treated nonoperatively. Sixteen of these required blood transfusions (mean 31.2 +/- 5.3 ml/kg). One patient in this group developed a large defect on spleen scan at 3 wk post injury. There was no other morbidity and no mortality following nonoperative treatment. Nineteen required operation all within 16 hr of admission. Fifteen underwent splenectomy, 2 partial splenectomy, and 1 splenorrhaphy. In 1 the bleeding had stopped. All required blood before operation (mean 80.4 +/- 10.1 ml/kg). Seven in this group died (6 from head injuries and 1 from bleeding). Thus surgery was avoided in 2 out of 3 and the spleen saved in 3 out of 4 patients with documented splenic injuries. We believe that where adequate facilities exist nonoperative treatment of splenic injuries is both safe and effective. When bleeding is massive from the beginning or replacement requirements exceed 40 ml/kg, operation is indicated.

The morbidity and mortality of splenectomy in childhood.

One hundred and eighty-two patients undergoing splenectomy in infancy and childhood were followed for periods of 2 to 15 years. Serious infections occurred in 11 patients (6%) with death in 6 (3.3%). In 10 patients the infection was sepsis, and in all but one patient the infection occurred within 2 years of splenectomy. Among children over 2 years of age the risk of infection was still appreciable except when the spleen was removed incidentally or for traumatic rupture. Splenectomy for thalassemia and portal hypertension resulted in an increased risk of serious infections when compared with removal of the spleen for hereditary spherocytosis, idiopathic thrombocytopenic purpura, trauma, or for technical reasons in the course of another operation. Post-splenectomy infections tended to follow a characteristic pattern. The infecting organism was predominantly pneumococcus, the course was fulminating and the mortality high.

Nonsurgical management of appendiceal mass in late presenting children.

Thirty-seven late presenting children with appendiceal mass were treated between 1965 and 1975 with i.v. fluids, alimentation according to the state of gastrointestinal function, and no antibiotics. They ranged in age from 18 mo to 16 yr and all had had symptoms for at least 5 days (mean 8.7), an abnormal WBC (mean 19.9), and a fixed palpable mass without rebound tenderness. Children were discharged when clinical findings resolved. All returned for interval appendectomy. Eighty-one percent (31 children) had clinical improvement within 5-22 days (mean 10.9). Nineteen percent (7 children) had recurrence or worsening of symptoms and required abscess drainage within 2-10 days after observation began. No child in either group received antibiotics nor did any die. Only one recurrence of symptoms after discharge was recorded before interval appendectomy. Pathologic specimens revealed fibrosis in 46%, subacute inflammation in 35%, and acute inflammation in 19%. Nonoperative management of the appendiceal mass without antibiotics in children is safe as long as diligent observation is maintained. Interval appendectomy can be performed as late as 20 wk after symptom resolution or drainage, however, over 50% of the interval appendectomy specimens reveal acute and subacute inflammation.

An assessment of the surgical treatment of adhesive small bowel obstruction in infants and children

At The Hospital for Sick Children, Toronto, Canada, adhesive small bowel obstruction (SBO) ranks seventh as a cause of pediatric bowel obstruction. Between January 1968 and December 1979, 131 infants and children had adhesive SBO proven at laparotomy or autopsy: 123 had 1; 7 had 16 adhesiotomies; 1 died without surgery; 100 had 1 prior operation; and 31 had multiple operations. Over 80% of the SBOs developed within 2 yr of the prior operations. Appendectomy and subtotal colectomy were the most common prior operation. Postoperative morbidity occurred in 29 children; 20 were observed longer than 24 hr before laparotomy. The rate of wound infection ranged from 4% to 50%; it was lowest for those children who had lysis of adhesions only, and highest for those who had lysis and decompressive enterotomy or perforation repair. Results indicate that delaying adhesiotomy and entering the GI tract during adhesiotomy are associated with increased morbidity (p less than 0.01), and therefore should be avoided. Prophylactic antibiotics may have a protective role during anterolysis.

Recurrent tracheoesophageal fistulas seventeen-year review

Twenty-three pediatric patients had recurrent tracheoesophageal fistulas during the 17-year period from 1965 to 1982 after 250 repairs of esophageal atresia and TEF. There were 13 males and 10 females. Four babies had their newborn repair at other hospitals. Sixteen atresias had end-to-end repairs (none under tension) while there were seven Duhamel repairs (six under tension). There were 9 postoperative leaks and 10 strictures; 8 babies had neither. The recurrent fistulas were diagnosed from 7 days to 9 years after newborn operation and more than 50% within two months. All but three had some coughing, choking, gagging, cyanosis, apnes, dying spells, wheezing, and recurrent chest infection. Each fistula was diagnosed by barium swallow, although in four patients as many as six x-rays were needed before it was identified. Not one bronchoscopy in seven infants was diagnostic. All fistulas but one were repaired. No fistula closed spontaneously. They were repaired between 1 day and 14 months after diagnosis, most within 7 months. Recovery in the majority of cases was uneventful. However, 5 of the 22 repairs had a second recurrent TEF presenting in similar fashion between 2 weeks and 2 years; all but one within 11 months. All were repaired within 9 months of discovery. The DuHamel anastomosis was more prone to recurrent fistulization than the more common end-to-end type. More of our own patients had their original anastomosis done without any tension. Under these circumstances the esophageal anastomosis is in close proximity to the tracheal closure and a leak or local abscess could easily result in a reconnection between the esophagus and trachea. Any TEF baby who has signs and symptoms related to feeding and/or chest infections must be considered to have a recurrent TEF and a persistent and diligent search should be made for it.

Use of abdominal wall muscle flap in repair of large congenital diaphragmatic hernia

Abstract Occasionally a congenital diaphragmatic defect is too large to be repaired in the conventional manner. With the use of a subcostal incision for exposure a pedicle flap of abdominal wall muscle can be used to give a strong repair with no significant deformity of the rib cage or abdominal wall.

Fourteen years of gastric tubes

Since 1964 gastric tube replacement of the esophagus has been done in 30 infants and children. This report reviews and brings up to date our entire series, which includes follow-up of 15 children over 5 yr, 7 of whom have been followed for more than 10 yr. The two-stage proximally based reversed antiperistaltic gastric tube placed retrosternally is still our procedure of choice, although since our last report in 1973 several other methods (one-stage, transthoracic, subcutaneous) have been used, and the spleen has not been removed in our more recent operations. Whether the esophagogastric tube anastomosis is primary or secondary or is in the chest or neck, leakage is still the most common complication (63%), with all but three closing spontenously. A continuing problem may be an anastomotic stricture (43%) that will require some dilatations. Mild sacculation or tortuosity of the gastric tube has been encountered only once. Despite the above problems, the eventual outcome in the growing child with a gastric tube replacement continues to be a satsifying one. We continue to use the gastric tube operation when replacement of the esophagus is required.

Perforating appendicitis and antibiotics

Abstract In a retrospective study of 550 children with perforating appendicitis it appears that our patients were no more prone to develop complications due to infection than were patients in other published series who had received antibiotics. Antibiotics cannot supplant sound surgical principles and techniques in the treatment of perforating appendicitis.