L. Patrick Brennan

Renal homotransplantation in children

Twenty-three children, aged 2 to 17 years, received 24 renal homotransplants from both live related donors and cadaver donors. Twenty-two children and 19 kidneys are surviving 1 to 32 months after transplantation. The clinical course of renal transplantation in children is described.

Renal transplantation in young children

Abstract Thirty-one children, aged one and a half to twelve years, received thirty-six renal allografts from fourteen living related donors, one living unrelated donor, and twenty-one cadaver donors during a five year period of study. Twenty-five of the thirty-one children (81 per cent) are presently alive with functioning allografts (twenty first and five second transplants); five children (16 per cent) have died and one child (3 per cent) is undergoing repetitive hemodialysis while awaiting a subsequent graft. The medical and surgical complications and rehabilitative aspects of the treatment program are delineated in detail to emphasize the acceptability of young children as candidates for renal transplantation.

Hypertension after renal transplantation in children

Hypertension persisted for longer than 6 mo or developed de novo after the first month following transplantation in seven of 77 pediatric recipients of renal allografts; concomitantly there were an elevation of PRA and renal angiographic abnormalities. In two of the four patients who developed RAS there was evidence of diminished allograft function. Successful correction of the stenotic lesion in these two recipients resulted in a return of the blood pressure, PRA, and biochemical function of the allograft to normal. Unsuccessful attempts at surgical repair led to loss of the allograft in the other two patients with RAS. Intrarenal vascular and/or parenchymal lesions were evident in the other three recipients with hypertension. Although an explanation was not apparent, subclinical rejection was hypothesized. Treatment effected reduction of the hypertension in these three patients and no deterioration of allograft function was observed for periods of 5, 34, and 38 mo, respectively. Renal angiographic studies and determinations of PRA are recommended in any pediatric recipient of an allograft who develops hypertension after the first month following transplantation or has hypertension which persists for longer than 6 mo after transplantation.

Renal artery stenosis in pediatric transplant recipients.

From 1967 through 1985, 400 cadaveric transplants were performed at Children Hospital of Los Angeles. Of these 400, 31 were later identified as having renal artery stenosis. No live related graft developed RAS. Of the 31 grafts, 11 were from donors less than 2 years of age. The major feature suggesting stenosis was hypertension: either persistent or a sudden exacerbation often associated with hypertensive encephalopathy. In individuals with hypertension without obvious cause, renal angiography should be promptly conducted under controlled conditions to avoid complications. The stenotic lesion involved 13 end-to-end and 19 end-to-side arterial anastomoses. Surgery for revascularization of RAS was performed in 21 of 31 with success or improvement in 14, no change in 2, and graft loss in 5. Percutaneous transluminal angioplasty was performed in 4. Two were unsuccessful, 1 was successful and 1 graft was lost. The 7 remaining patients were treated medically.

An improved technique for the correction of congenital duodenal obstruction in the neonate

Summary Fourteen newborn infants with congenital duodenal obstruction were managed by producing an incomplete rotation of the midgut in order to perform a duodenoduodenostomy. There were no deaths or anastomotic complications, and all infants were taking a regular diet by mouth by the tenth postoperative day. None of the patients has as yet experienced any problems related to the repositioning of the midgut.

CADAVERIC RENAL TRANSPLANTATION IN CHILDREN

Abstract 29 children aged 18 months to 18 years received 32 cadaveric renal transplants between February, 1968, and August, 1970. 25 children (86%) and 22 allografts (69%) are surviving 6 to 32 months after transplantation. Growth has occurred in 4 of 5 children whose bone age was less than 12 years at the time of transplantation and who survived more than a year with good allograft function. Knowledge of the source of the kidney did not interfere with emotional adjustment or rehabilitation.

Management of Hirschsprung's disease with the swenson procedure

Abstract Forty-one patients with Hirschsprungs disease treated with the Swenson pull-through procedure are reported. There was no operative mortality; one death occurred 10 mo postoperatively from enterocolitis. There are no rectal strictures or instances of urinary dysfunction. Of the 24 patients old enough to evaluate, rectal function is excellent in 14, good in five, and fair in four. The one poor result occurred in a child with Downs syndrome.

Pitfalls in the management of Hirschsprung's disease

Summary Forty complicated cases of Hirschsprungs disease were reviewed for errors in management. We found that there were 9 common pitfalls in diagnosis, surgical technic, and postoperative care. Diagnosis 1.Abdominal exploration of a neonate with low small bowel obstruction or severe ileus, not obviously due to meconium ileus, without a prior barium enema. 2.Failure to recognize that diarrhea and abdominal distention during infancy may be due to enterocolitis associated with Hirschsprungs disease, particularly if there is a history of delayed passage of meconium. 3.Failure to recognize that severe prolonged ileus or partial low small bowel obstruction in infancy associated with a normal barium enema may represent total aganglionosis of the colon. Surgical Technic 4.Failure to place the colostomy where ganglion cells are present, preferably in the terminal portion of the normal colon. 5.Failure to resect all but 1 to 2 cm. of the aganglionic rectum. 6.Pulling through and anastomosing aganglionic colon to the rectal cuff. 7.Performing the anastomosis under tension. Postoperative Management 8.Failure to treat an anastomotic leak with an immediate colostomy. 9.Failure to recognize and treat with rectal irrigations enterocolitis developing in the early postoperative period. This review of complicated cases has reaffirmed our impression that the treatment of Hirschsprungs disease is an intricate and dangerous undertaking. The details of barium enema interpretation, preoperative preparation, rectal biopsy, colostomy and pull-through technics, and postoperative care are of equal importance. A mistake made in any one of these areas usually results in a less than satisfactory course, and occasionally a permanent colostomy or fatality.

Use of a subclavian venous catheter for short- and long-term hemodialysis in children

Vascular access for hemodialysis in children poses problems not encountered in adults because of the small size of the vessels available. The increasing use of peritoneal dialysis has created a large number of patients who need prompt access for hemodialysis for days to weeks during episodes of peritonitis. There are also occasional patients who have exhausted available fistula sites and still require hemodialysis. To address these problems, we designed a series of catheters for insertion in the subclavian vein. The catheters are stiffer than the Hickman type catheter to allow for higher flow rates without collapse. Seventy-five catheters were implanted in 58 patients with a mean age of 14 years. Twelve catheters were inserted in ten children for long-term (over 3 months) access; they have been in place for a mean of 259 days and used for a mean of 64 dialyses. In two children, the catheter has been the sole site for hemodialysis for over a year. Fifty-eight catheters were implanted in 43 patients for short-term hemodialysis. They were in place for a mean of 29 days and used for a mean of 13 dialyses. The major complications encountered were clotting of the catheter and migration out of position. Four catheters were removed because of infection. These new catheters provide effective hemodialysis for children as small as 7 kg with an acceptable morbidity rate and may be used for extended periods of time if necessary.

Bronchogastric fistula, pulmonary sequestration, malrotation of the intestine, and Meckel's diverticulum—A new association

Two female children, each who had a bronchogastric fistula and pulmonary sequestration (communicating bronchopulmonary foregut malformation, CBPFM) and associated malrotation of the intestine and Meckels diverticulum are presented. Each child also presented with severe gastroesophageal reflux. The association of malrotation of the intestine and Meckels diverticulum with a CBPFM never has been reported as a distinct entity. The concept of association of anomalies is discussed briefly.