Marc I. Rowe

The Other Side of the Pediatric Inguinal Hernia

Criteria for performing contralateral groin explorations are based on a study of a large group of pediatric patients operated upon at one institution by surgeons who used the same criteria for determining patency of the processus vaginalis and employed similar operative techniques for hernia repair and contralateral exploration.

Wind sock web of the duodenum

Abstract A web or diaphragm causing duodenal obstruction is difficult to diagnose and manage. The patients frequently have multiple congenital anomalies, incomplete rotation of the gastrointestinal tract, a second obstructing lesion, and occasionally situs inversus. The pathologic anatomy of the web can lead to confusion during operation. A plan of management is outlined to avoid the pitfalls associated with this form of duodenal obstruction.

The last fifty years of neonatal surgical management

Neonatal surgical mortality has steadily fallen over the last five decades. Improved survival does not appear to be related to the introduction of new operative procedures. Most of the basic procedures were developed by 1960. Eight developments appear to be responsible: (1) The growth of pediatric surgery resulted in widespread availability of neonatal surgeons and dissemination of knowledge about newborn surgical emergencies. (2) The parallel growth of pediatric anesthesia, beginning in 1946, provided specialized intraoperative management of the neonate. (3) Understanding neonatal physiology is the key to successful management; major advances occurred between 1950 and 1970. (4) New inventions revolutionized patient care; the transistor (1947) made it possible for medical devices to sense, amplify and control physiologic responses and opened the communication and computer age. (5) Neonatal mechanical ventilation had a prohibitive mortality and was seldom utilized; the development of CPAP and a continuous flow ventilator in the 1970s allowed safe ventilatory support. (6) Total parenteral nutrition (1968) prevented starvation that frequently affected infants with major anomalies. (7) The effective treatment of infection began with the clinical use of penicillin (1941); antibiotics have reduced mortality but infants suffering from the septic syndrome have a prohibitive mortality; cytokine, proinflammatory agent research, and the development of anti-inflammatory and blocking agents in the 1980s have not affected mortality. (8) The establishment of newborn intensive care units (1960) provided an environment, equipment, and staff for effective physiologic management.

Gastrografin-induced hypertonicity. The pathogenesis of a neonatal hazard.

Abstract Operative mortality in meconium ileus approaches 50 per cent. Recently, operation has been obviated by the administration of high Gastrografin enemas. However, the nonoperative therapy causes hypertonicity, manifested by rising hematocrit and serum osmolality and a decreased cardiac output and pulse rate. The suggested mechanism for hypertonicity is the attraction of plasma water into the gut by the concentrated “nonabsorbable” material. An alternate explanation involves absorption into the vascular system of osmolar active substances from Gastrografin. The purpose of this study is to clarify the pathogenesis of acute hyperosmolality. High Gastrografin enemas were administered to twenty-one neonatal puppies and serial blood studies were performed. A disproportionate rise in measured osmolality as compared to the calculated osmolality suggested significant absorption of the contrast material or its components through the puppys intact gut wall. The results indicate that the hyperosmolar state is due to a combination of agent absorption and plasma water decrease.

Hypoxia and the neonatal response to trauma

Abstract Thirty-one newborn piglets were studied. Four hours of breathing a mixture of 10% oxygen and 90% nitrogen resulted in a profound drop in arterial blood pO 2 , but base excess decreased only slightly and pH, cardiac index, pulse rate, and blood pressure were unchanged. A hemorrhage of 25% of the total blood volume was well tolerated by piglets breathing room air but produced a 56% mortality in the hypoxic animals. The results suggest that the hypoxic, immature organism responds ineffectually to a normally nonlethal physiologic insult.

A critical appraisal of two common “Neonatal” experimental subjects

A comparative study of 11 physiologic variables in 200 piglets and puppies during the first 7 days of life was done. Seven of 11 physiologic variables significantly changed in the 1st wk of the piglets life. Five of 11 variables significantly changed in the first week of the puppies life. Six of 11 variables were significantly different when the newborn piglet was compared to the newborn puppy. The rate and/or direction of 7 of 11 physiologic changes during the first day of life were significantly different when the piglet was compared to the puppy. It was concluded that there are marked physiologic differences between: the newborn piglets and the 7 day old piglet; the newborn puppy and the 7 day old puppy; the newborn piglet and the newborn puppy and the maturation rate of the piglet and the puppy.

Colloid versus crystalloid resuscitation in experimental bowel obstruction

The physiologic effects of fluid resuscitation were studied in 20 piglets with advanced small bowel obstruction. Two solutions were compared: 5% albumin in normal saline and normal saline. Animals resuscitated with albumin-containing solution showed higher serum colloid oncotic pressure, greater loss of peritoneal fluid, lower urine output, and progression of muscular dehydration, when compared to animals resuscitated with similar volumes of normal saline solution.

Physiologic Considerations in the Newborn Surgical Patient

Six aspects of newborn physiology–the birth weight gestational relationship, glucose metabolism, temperature regulation, calcium balance, infection, and fluid and electrolyte balance–are presented as examples of important consideration that must be understood to successfully manage the newborn surgical patient.

The Choice of Intravenous Fluid in Shock Resuscitation

Shock in the pediatric patient is usually the result of severe trauma and concomitant blood loss. The cornerstone of treatment remains quick replacement of lost volume but controversy still persists regarding the ideal solution. This article discusses current concepts and recent advances in the treatment of shock with balanced salt solution (Ringer’s lactate) and colloid-containing infusions (5 per cent albumin), or plasma as they apply to the pediatric patient.