Lester W. Martin

Pitfalls in the surgical management of the incomplete duodenal diaphragm

Abstract Twenty-one consecutive patients with incomplete duodenal diaphragms were treated without fatality. Observed and reported pitfalls for the surgeon include difficulty in diagnosis before and during laparotomy, coexistence with intestinal malrotation or intrinsic obstructions of the duodenum, stomach or anorectum, intimate anatomic relationship with the bile ducts, the confusing features of the windsock type diaphragm, and a tendency for malfunction of bypassing lateral anastomoses. Successful management has featured increased preoperative diagnostic effort, use of a Foley bag catheter or appropriate instrument to help locate and calibrate intrinsic obstructions, and a preference for excision of the diaphragm with protection of the bile ducts.

Neonatal necrotizing enterocolitis: Prevention of perforation

Abstract During a 24-mo period, 23 infants were treated for neonatal necrotizing enterocolitis. Diagnosis was established either at operation or by the triad of abdominal distention, gastrointestinal bleeding, and radiographic findings of pneumatosis intestinals. Fourteen of the 23 infants were admitted to the hospital before intestinal perforation had developed. They were treated with a therapeutic regimen which included nasogastric suction, intravenous fluids and blood, and both parenteral and topical antibiotics by gavage. None of the 14 babies developed free intestinal perforation. Our experience suggests that this method of treatment may improve the survival rate of infants with necrotizing enterocolitis, and merits further clinical trial.

Natural history and treatment of renal vein thrombosis in children

The general features and problems of renal vein thrombosis in children are first discussed. The records of 11 children with this condition, 7 ill neonates and 4 older children with burns, are then reviewed, indicating the clinical course of the disease, how they were treated, the results, and pathological findings. From this study, the natural history is assembled and a protocol for treatment is proposed. Supportive therapy is necessary in all cases to correct dehydration and sepsis. Many children will develop a consumptive coagulopathy. Others will develop pulmonary emboli associated with thrombosis of the inferior vena cava. Anticoagulation should be achieved for these two conditions. Nonvisualization of affected renal units upon initial urographic examination virtually assures an atrophic, functionless kidney later. Nephrectomy will be required because of hypertension, persistent infection, and scarring. Thrombectomy may be attempted when bilateral nonvisualization on urography is associated with a positive venacavogram.

Omphalocele and Gastroschisis

This brief article outlines our philosophy and management of omphalocele and gastroschisis based on personal experience with more than 200 patients.

Premature Infants with Patent Ductus Arteriosus and Respiratory Distress: Selection for Ductal Ligation

Abstract Operative treatment of patent ductus arteriosus (PDA) in premature infants with respiratory distress has been advocated when rapid and favorable response to medical management has not occurred. At Cincinnati Childrens Hospital from September, 1971, to January, 1975, 28 patients with respiratory distress syndrome (RDS) and PDA underwent ductal ligation after failing to respond to intensive medical management. There were 15 survivors and 13 deaths, for a survival rate of 53%. We have found the most reliable assessment of PDA and its response to medical management to be a reduction in left cardiac chamber size as evidenced by echocardiography. In 15 of the 28 infants who underwent ligation, echocardiography showed that they had failed to respond to medical management. Seven of the group survived. During the same period 15 infants with RDS and PDA responded favorably to medical management and showed return of left cardiac chamber size to normal by serial echocardiograms. Of these, 11 survived and 4 died of noncardiac causes. Clinical improvement was corroborated without exception by echocardiographic demonstration of a reduction in size of the left cardiac chamber. We believe that infants who follow this course should not have ductus ligation. We contend that the choice of surgical candidates should be more selective since a survival rate of only 50% has been obtained in this and other series. Further, we have found that only 8 of 14 long-term survivors in our series are free from pulmonary disease.

The laser in pediatric surgery

Abstract The clinical uses of the laser in children are discussed with particular reference to the angiomas. The possible future uses and hazards encountered are described. The need for extensive research in the use of the laser has been stressed. The laser remains a tool for research and, as yet, not for general use as a form of therapy. Its role, if any, in the field of surgery remains to be determined.

Oral fructose tolerance test as a means for determining Eck fistula patency in the experimental animal

Summary The development and technique of a simple test which appears to be reliable for determining the patency of portal-systemic venous shunts in dogs has been described. The test is based on the fact that orally ingested fructose is normally cleared from the portal circulation by one passage through the liver. In the presence of a shunt which bypasses the liver, the normally low renal threshold for fructose allows significant excretion of fructose to appear in the urine. With closure of the shunt, urinary fructose excretion is sharply reduced. For most valid interpretation, the fructose excretion should be determined preoperatively and at intervals in the postoperative period. It is suggested that such a test may have clinical application in the determination of patency of surgically created portal-systemic shunts in man.

Changing concepts of management of portal hypertension in children

Abstract A 14-yr experience with 25 children with bleeding esophageal varices is presented. A total of 43 operations were performed to control hemorrhage. The most satisfactory method of management for patients with intrahepatic block was a conventional side-to-side portacaval shunt. The most satisfactory method of management of extrahepatic block consisted of an end-to-side anastomosis of the portal vein to either the vena cava or the left renal vein near where it joints the cava. This type of shunt operation was successfully accomplished in the most recent nine consecutive children encountered with extrahepatic block of the portal vein. The shunts are all functioning and none of the children have required a second operation.

Hypoglycemia with hepatic glycogen depletion: A postoperative complication of pyloric stenosis

Abstract Three infants with congenital hypertrophic pyloric stenosis developed hypoglycemia, convulsions and cardiac arrest in the postoperative period coincident with discontinuance of parenteral glucose infusion. In one patient studied in detail, low levels of hepatic glycogen and normal levels of serum insulin suggest glycogen depletion as the mechanism for hypoglycemia. In seven non-hypoglycemic infants with pyloric stenosis, hepatic glycogen contents were within normal limits. Hypoglycemia should be suspected when the infant develops any unusual or unexplained symptoms following operation. Immediate treatment with intravenous glucose infusion should be initiated and continued until oral feedings are well established.

Giant "bathing trunk" nevus with malignant melanoma treated by excision and split thickness skin grafting.

Abstract The “BATHING TRUNK” NEVUS is a rare, congenital, giant pigmented and hairy nevus with an alarming propensity for melanomatous transformation. We have successfully treated an injant with this lesion, employing an aggressive surgical approach consisting of (1) diverting colostomy; (2) staged partial excisions of the nevus to the level of muscle fascia, including bilateral inguinal node dissections; (3) coverage with split thickness Tanner mesh grafts; and (4) closure of the colostomy.