Keith M. Schneider

Roentgen diagnosis of midgut malrotation: Value of upper gastrointestinal radiographic study

Abstract Thirty-two cases of malrotation of the bowel were reviewed and the radiographic findings analyzed in an attempt to correlate plain-film patterns with underlying surgical pathology, particularly the presence of volvulus. Although certain patterns were more common than others in various clinical and pathologic groups, no clearcut conclusions can be drawn from plain radiographs, with the exception of evidence of small-bowel obstruction that strongly suggests volvulus and possible intestinal ischemia. Barium studies are necessary for specific diagnosis in the majority of cases. An upper gastrointestinal examination is of greater diagnostic value than a barium enema, the former being a direct approach to the demonstration of obstruction located high in the gut, as well as being easier to interpret.

Linear growth following surgery in children and adolescents with Crohn's disease: Relationship to pubertal status

Studies of the effect of surgery on growth failure in adolescents with Crohns disease have revealed conflicting data. To better determine the role of surgery for growth delay, growth data from 26 patients with Crohns disease with intestinal resections and/or ileostomies were reviewed, 3 of whom had surgery twice. Operations were performed on 14 Tanner Stage I, 1 Tanner II, 1 Tanner III, and 13 Tanner IV or V patients. In the prepubertal group, 13 of the 14 had growth impairment, only one of whom had surgery primarily for that growth failure. One year after operation, 11 of 13 Tanner I growth failure patients experienced an increase in height velocity of 5.38 +/- 1.18 cm/yr (mean +/- SE;P less than 0.01); 9/11 achieved normal height velocity for Tanner I. Two attained their preillness height percentiles at one year follow-up, while 5 patients attained their preillness height percentiles 2.5 to 10 years following surgery. Of the four who failed to achieve normal height velocity, 3 had early recurrence of active disease. The Tanner Stage II and III patients both had growth failure, and both had a growth spurt following surgery. Of those who were Tanner Stage IV or V at the time of surgery, 5 of 13 had growth failure. Following surgery, none had an increase in height velocity. These data suggest that when patients with Crohns disease and growth failure are prepubertal and surgery is performed primarily because of failure of medical therapy and/or other complications, a postoperative growth spurt may be expected within one year.

An ectopic gastric duplication arising from the pancreas and presenting with a pneumoperitoneum

This case report describes a large gastric duplication, which had no attachment to the stomach, and it was found in the pancreas. The second unusual feature of this duplication was that it had eroded into the splenic flexure of the colon, resulting in a large pneumoperitoneum.

Recurrent chylous ascites associated with intestinal malrotation and lymphatic rupture

An 11-yr-old female with abdominal distension since birth, underwent four operations because of intractable and debilitating chylous ascites. The curative procedure consisted of preoperative ingestion of the lipophilic dye, a secondary Ladds procedure, lysis of extensive adhesions, and ligation of an easily identifiable ruptured lymphatic.

Tubular duplication with autonomous blood supply: Resection with preservation of adjacent bowel

This 10-mo-old patient represents an unusual small bowel duplication in that: (1) the duplication involved almost the entire small intestine; (2) the technetium scan was diagnostic; and (3) the duplication was resected, leaving the majority of normal bowel intact. Bremer, in his original discussion of the embryology of intestinal duplications, hypothesized the situation that was found in this patient, i.e., separate blood supplies, which, at first glance, appear to be contained within a single mesentery. This anatomical arrangement permitted the duplication to be resected, leaving the adherent normal small intestine.

Chronic Insertion of Foreign Bodies Into the Mature Breast

A large assortment of foreign bodies have been introduced into all of the body apertures. This case is unique for two reasons: I) the insertion of sharp objects deep into breast tissur via the nipple; and 2) the chronicity of this aberrant behavior. This 2Oh year old white female was in good health until she developed encephalitis at 12 years of age. Following this illness, it was apparent that she had suffered permanent brain damage. Since that time, she has been treated by a psychiatrist. Three years prior to the present admission, she began puncturing her left nipple with sharp objects including needles, pins and tooth picks. She claimed that this activity alleviated her anxiety. The breast did not appear to be damaged by these self-inflicted injurites. Her psychiatrist was aware of this behavior, and was unable to convince her to stop. Two days prior to admission, she inserted a hair pm (bobh! pin) into the self made left nipple sinus tract, which penetrated the breast deeper than usual. She could not retrieve it. She was brought to the hospital, where x-rays of her breast (Fig. I) were performed. She had a low grade fever. and srro-sanquinous drainage was noted issuing from a sinus opening in her left nipple. There was slight erythema and induration of the lower outer quadrant of the left breast. This arca of her breast was tender. Tuo cultures of the nipple discharge were sterile. Through an inferior circumareolar incision, the well formed sinus tract was easily probed: it measured IO cm. The bobby pin was found deeply imbedded in the lrft axilla. The end of the tract was sealed.

Low molecular weight dextran and reexploration in the management of ischemic midgut-volvulus

Administration of low molecular weight dextran and reexploration in 36-48 hr, is recommended in cases of ischemic midgut volvulus. Five cases are presented utilizing this technique and many centimeters of small bowel were saved that would have been resected at time of the original exploration. One patient died as a result of sepsis due to central intravenous nutrition: the others are alive and well.

The surgical treatment of ulcerative colitis in childhood — a study of 38 cases

Abstract Ulcerative colitis in childhood has a prognosis even more serious than that in the adult and in recent years has been increasing in frequency. There may be a remarkable retardation of physical and sexual development with ulcerative colitis in childhood. Of 38 children operated on for ulcerative colitis at 16 years or younger, 22 were boys and 16 were girls. Fifteen were operated upon prior to the introduction of steroids and 23 after steroids were introduced. Steroids have not increased the interval between disease onset and surgery, but have changed the indications for surgery. Surgery for chronic invalidism is now a more common indication than acute exacerbation. Ileostomy and subtotal colectomy has been the most common operation. In the past 10 years there have been no deaths following subtotal colectomy or proctocolectomy.

Urethroperineal-rectal fistula in Crohn's disease

A 19-year-old white male with Crohns disease, who complained of passing urine per rectum and having retrograde ejaculations, was noted to have a urethroperineal-rectal fistula. The fistulous communication remained patent despite pharmacologic therapy, a diversion ileostomy, and a total proctocolectomy. A fistulectomy and definitive urethral repair finally resulted in resolution of the problem.