Kamthorn Sukarochana

Peritoneal drainage for necrotizing enterocolitis

This study evaluates the role of primary peritoneal drainage (PPD) in the management of neonatal necrotizing enterocolitis (NEC). Of 169 patients with definite NEC, 92 (55%) underwent operation: primary laparotomy, 41 patients (45%); and PPD, 51 patients (55%). Seventeen (33%) of the PPD infants had subsequent laparotomy within seven days. Pneumoperitoneum was the indication for operation in 37% of the primary laparotomy and 67% of the PPD infants. Following PPD, 34 patients (67%) showed clinical improvement. Operative survivals were as follows: primary laparotomy, 83%; PPD, 53%. Infants who had PPD had a significantly lower mean birth weight, gestational age, preoperative pH and platelet count, and a significantly higher incidence of intraventricular hemorrhage and patent ductus arteriosus. For infants weighing less than 1,000 g at birth, the survival was similar following primary laparotomy (57%) and PPD (52%); this occurred in spite of the higher incidence of adverse risk factors in the PPD infants. For infants weighing greater than 1,000 g, the survival was 86% following primary laparotomy and 62% after PPD; in this group, all the early deaths following PPD occurred in critically ill infants who died within 48 hours of drainage. The late survival rates were as follows: primary laparotomy, 76%; PPD, 35%. More than half of the late deaths following PPD were not related to NEC, reflecting the difference between the two patient populations. Primary peritoneal drainage is a useful adjunct to resuscitation of the critically ill infant with complicated NEC, particularly prematures less than 1,000 g birth weight with intestinal perforation. Primary peritoneal drainage is not an alternative to laparotomy, which is recommended when an optimal clinical response has been achieved.

Reconstruction of penile agenesis by a posterior sagittal approach

Penile agenesis is a rare condition requiring gender reassignment and staged perineal reconstruction. This report describes two children reconstructed by taking advantage of the posterior sagittal approach. This approach allows a precise anatomic dissection, construction of a neovagina and accurate positioning of all perineal orifices. We think that this is the preferred approach for this rare condition.

The hidden mortality in surgically treated necrotizing enterocolitis: Fungal sepsis

From 1979 to 1986, 82 infants underwent surgical treatment for necrotizing enterocolitis (NEC), with 36 deaths. The records of 30 of the 36 infants who died were available for review. Fungal colonization and sepsis, the sites of infection, and timing of diagnosis and therapy were determined. Sixteen of 30 (53%) neonates had no evidence of fungus. Six (20%) were colonized with Candida species. Eight (27%) had fungal sepsis, with two of these eight found only at necropsy. Positive fungal blood cultures were a late finding. In only four of the six patients with positive blood cultures were the results known in time to initiate treatment with amphotericin B. Two of these four babies received less than 2 days of amphotericin B treatment prior to death. Fungal sepsis is a significant lethal factor in the surgical mortality of NEC. Vigorous efforts at earlier diagnosis are mandatory.

Neonatal abdominal calcification: Is it always meconium peritonitis?

Intraluminal meconium calcifications are a rare cause of neonatal abdominal calcifications and can easily be misinterpreted as meconium peritonitis. We report three patients with anorectal anomalies, rectourethral fistula, and intraluminal calcified meconium. Intestinal stasis and mixing of urine and meconium may be predisposing factors for the calcification of meconium. Intraluminal calcifications appear as discrete punctate flecks within the distribution of the bowel, in contrast to meconium peritonitis, where the calcifications are linear and plaque-like, occurring anywhere in the abdominal cavity and scrotum. Careful differentiation of abdominal calcifications will allow more appropriate planning of the need and timing of surgery and can suggest the possibility of other anomalies that may not be suspected initially.

Red cell mass determinations in infancy and childhood, with the use of radioactive chromium**

Summary The evolution of a method for determining red cell mass in infancy and childhood with the use of radioactive chromium has been outlined. The results of utilizing this method are recorded in the cases of 78 infants and children, most of whom underwent an operation. The practicality and accuracy of the isotope method have been evaluated.

Vesicointestinal fissure revisited

This complicated anomaly of bladder exstrophy, intestinal fistula, and various degrees of colonic atresia with imperforate anus is readily recognizable. The long-term result of conventional management has been disappointing. Fecal and urinary incontinence have been unavoidable and a source of disappointment to patients and parents. An alternative method of total management is detailed. This variation of management may result in earlier and more complete social acceptability of the child so afflicted. At as young an age as possible, the vesicointestinal connection is detached and the bladder defect as well as the intestinal opening closed. The short colon is freed and transected at its midpoint. The right half of the colon is brought out through a separate wound as a colostomy. The distal half of the divided colon is brought out as mucous fistula on the left. This distal colonic segment is the proposed future colonic loop for urinary diversion to be fashioned in the first year of life. The exstrophied bladder is removed at a later date. Epispadias in the male may be repaired later. A Pediatric Ostomy Club has been organized to include a pediatric stomal therapist and involved nurses and physicians. The group gives the parents advice and moral support. We believe that this approach will permit the child to go to school and carry on relatively normal activity and to be socially acceptable. An overview of our total experience in the management of 25 patients with vesicointestinal fistula details the result in 9 surviving patients.

Bilateral thoraco-abdominal skin defects in the newborn

Abstract Two neonates with bilateral thoraco-abdominal skin defects had successful management by conservative means.