Joseph O. Sherman

The treatment and postoperative complications of congenital megacolon: A 25 year followup.

In 1948 one of us (O.S.) proposed a new method of treatment, abdominoperineal resection, for patients with congenital megacolon. Since then, 483 patients have been treated by 13 pediatric surgeons in Chicago and Boston using this technique. Two hundred and eighty-two of the patients were last interviewed and examined more than 5 years after the resection. There were 16 postoperative deaths (3.3%) and 6 late deaths (1.2%) from enterocolitis. Both early and late complications were infrequent and are discussed in detail. Almost 90% of the patients reported that they now have normal bowel habits. None of the patients developed urinary incontinence or impotence, although ten patients (2.1%) reported permanent fecal soiling. This is the first large group of patients treated for congenital megacolon who have been followed to adulthood. The low incidence of postoperative complications and minimal frequency of long-term complications indicate that the abdominoperineal resection is a safe, effective method of treatment for congenital megacolon.

Megarectum: A rare complication of imperforate anus repair and its surgical correction by endorectal pullthrough

Nine patients ranging in age from 3 mo to 15 yr presented with severe constipation and/or increasing incontinence. All had a huge, dilated atonic rectum and rectosigmoid demonstrated by barium enema. Six patients underwent resection of the abnormal bowel by an endorectal pull-through procedure with good to excellent results while 1 patient was corrected by a Swenson procedure.

Ultrasound of the distal pouch in infants with imperforate anus

Optimal surgical management of the newborn with imperforate anus depends on accurate determination of the level of the rectal pouch. Eighteen children with imperforate anus were evaluated with ultrasound. The distance from the end of the pouch to the perineum was measured. Ultrasound correctly predicted the level of the distal pouch in all 12 children who had confirmation of the pouch level by surgery or by distal contrast stomagrams. Six children have not yet had definitive surgery. Five children with a pouch to perineum (P-P) distance of less than or equal to 10 mm and three of six children with a P-P distance of 10 to 15 mm had successful correction by a simple perineal anoplasty. Three of six children with a P-P distance of 10 to 15 mm and all of those (seven) with a P-P distance greater than 15 mm were diverted with colostomies.

Use of an oral elemental diet in infants with severe intractable diarrhea

Twenty-seven infants from 1 day to 9 months of age with severe intractable diarrhea were fed an oral elemental diet (Vivonex) consisting of crystalline amino acids, glucose, electrolytes, and vitamins by continuous nasogastric drip. Complete control of diarrhea was achieved in 24 patients (89 percent) who had an average weight gain of 28 gm/day. Nitrogen balance and plasma amino acids were measured in five patients while they received 2.25 gm of amino acid/kd/day for two weeks and 4.58 gm of amino acid/kg/day for two weeks; the nitrogen balance and weight gain in three patients was proportional to the amino acid intake. When compared to normal levels, plasma amino acids were not appreciably increased with the lower amino acid intake. With the higher amino acid intake, there were significant increases in plasma values for 11 amino acids.

Irrigation of the peritoneal cavity for appendicitis in children: A double-blind study

INTRAPERITONEAL ANTIBIOTICS have been used for over 30 Deyr. spite numerous experimental and clinical investigations, their role in clinical peritonitis has not been clarified. A number of retrospective studies have included patients of varying ages with peritonitis of diverse origins. Appendicitis, with generalized peritonitis in children is still a major clinical problem. The benefits of systemic antibiotics in these cases remains controversial and the use of intraperitoneal antibiotics has not been widely reported. At the Childrens Memorial Hospital we have carried out a double-blind controlled study of the effects of intraperitoneal and wound irrigation with kanamycin in cases of perforated appendicitis. METHODS Children with perforated appendicitis and established peritonitis undergoing operation from April 1969 to July 1974 were included in this study. Cultures of peritoneal fluid or pus were obtained on each patient. The use of systemic antibiotics and ~.eritoneal or wound drainage was left to the discretion of the surgeon. Kanamycin and placebo solutions were supplied in numerically coded vials, previously randomized by Bristol Laboratories. These were added to identically coded 500 ml bottles of normal saline by the hospital pharmacy prior to use. Before closure of the peritoneum the peritoneal cavity and the wound were irrigated with either a 0.25% solution of kanamycin or with normal saline. No attempt was made to suction all of the irrigant. A volume of 20 ml/kg of body weight was used up to a maximum of 500 ml. Irrigation with the kanamycin solution delivered 50 mg of drug/kg body weight. Each patient was specifically observed during the intraoperative and postoperative periods for signs of respiratory depression. None exhibited any sign of depression or other evidence of drug toxicity. The postoperative courses of 79 patients with perforated appendicitis were analyzed. This patient population included 37 boys and 42 girls. Nineteen were black, 59 white, and one oriental. Forty-eight per cent were between six and 10 yr of age; 24% were 13 mo to 5 yr; and 28%, 11-16 yr. Wound infections that necessitated the drainage of a primarily closed wound or prevented a planned delayed primary closure were distinguished from wounds showing only prolonged or purulent drainage at sites of peritoneal or wound drains. Localized intra-abdominal abscesses requiring operative drainage have been listed separately from presumed pelvic phlegmons that resolved spontaneously.

The association of low imperforate anus and Down's syndrome

Downs syndrome is the most frequent chromosomal anomaly in humans and is associated with an incidence of anorectal anomalies many times greater than that found among the general population. The anorectal malformation associated with Downs syndrome uniformly consists of a low-lying rectal pouch without a genitourinary or perineal fistula. This type of imperforate anus may often be adequately treated by simple perineal anoplasty. Since our recognition of this association, several neonates have avoided temporary fecal diversion, and several older infants with colostomies have not required anticipated pull-through procedures.

Effect of ionizing irradiation on normal lymphatic vessels and lymph nodes

Forty dogs were divided into five groups: (A) control, (B) 1000 rads, (C) 2400 rads, (D) 3000 rads and (E) 3600 rads. The medial aspect of one pelvic limb was irradiated through a port measuring 12 × 8 cm. Prior to irradiation and at intervals after, the pelvic limb lymphatics and popliteal lymph node were visualized by an indirect technique of lymphangiography. The afferent and efferent lymphatic vessels in the control and treated animals remained essentially unchanged except in four animals. These four animals, one in the 2400 rad group and three in the 3600 rad group, exhibited rupture of the afferent lymphatic vessels at the junction of irradiated and nonirradiated tissues several months after treatment. All treated animals showed a marked permanent decrease in size of lymph nodes several months after treatment. There was no evidence of lymphatic obstruction in any group. The authors conclude that ionizing irradiation appears to have little effect on lymphatic vessels. As reported previously, the lymph node undergoes fibrosis without obstruction.

Ovarian granulocytic sarcoma as the primary manifestation of acute infantile myelomonocytic leukemia

The first known instance of granulocytic sarcoma of the ovary as the presenting manifestation of acute nonlymphocytic leukemia in infancy is reported. The clinical and laboratory findings for a 3‐month‐old infant who had anemia and a lower abdominal mass subsequently found to represent bilateral ovarian granulocytic sarcomas are discussed. Results of light and electron microscopic examination of bone marrow biopsy specimen were consistent with a diagnosis of acute myelomonocytic leukemia. Hematopoietic (and lymphoproliferative) disorders must be included in the differential diagnosis of ovarian masses in children.

Parenteral hyperalimentation. A useful surgical adjunct.

The authors have used parenteral hyperalimentation in many pediatric patients, and three case reports of its use in small infants are presented, together with techniques for mixing the solution, caring for the catheter, and administering the solution.

Operative correction of duodenomegaly

Summary Two cases of nonfunctioning postoperative duodenomegaly in infants are presented with a discussion of the complications associated with this problem. A new surgical approach of longitutinal resection or imbrication of the duodenal wall to reduce its effective diameter and thus restore peristaltic function is presented.