Medad Schiller

Evaluation of colonic replacement of the esophagus in children.

Abstract Replacement of the thoracic esophagus with an interposed segment of colon was done in 29 children with esophageal atresia, stricture, or varices. There were no deaths. One failed because of vascular insufficiency of the transplant. The incidence of early postoperative complications was high. Long-term clinical and radiological evaluations were generally quite satisfactory in terms of normal growth, absence of pulmonary and intestinal symptoms, and rapid emptying of the transplant.

Multiple arterial aneurysms

An 8 1/2-yr-old boy presenting with excruciating abdominal pain had two abdominal aortic aneurysms excised. Angiography demonstrated additional aneurysms of the right brachial artery, right renal artery, right internal iliac artery and multiple aneurysms of the right popliteal and tibialis posterior arteries. The patient does not suffer from any of the conditions generally recognized to be associated with aortic and multiple arterial aneurysms. No similar case could be found in the English language literature.

Varicocele in children: “To treat or not to treat” — Venographic and manometric studies

The management of varicocele is still controversial in spite of its high incidence (15%) in prepubertal boys and young adults and although it is believed to represent a major contributing factor to male subfertility. Fifty boys between 6 and 14 years of age were operated on for left varicocele, and a long segment of the left internal spermatic vein was excised. Thirty-four of them underwent preoperative retrograde left renal venography and pressure readings in both renal veins and inferior vena cava. In all 50 patients, intraoperative antegrade (via internal spermatic vein) left renal venography was performed. This examination revealed impaired renal venous drainage in 38 patients (group A) and normal venous return through the left renal vein in 12 patients (group B). In all 34 patients (from both groups) on whom retrograde venography was performed, there was marked renospermatic reflux. The pressure readings in the left renal vein were significantly increased in group A only. Our data strongly suggest that left varicocele is caused by renospermatic venous reflux and that this condition is probably irreversible. The reflux in group A is explained by the impaired venous drainage through the left renal vein. In group B, it is our impression that the reflux is a result of a congenitally valveless left internal spermatic vein. If varicocele is indeed a major cause for infertility, then our data logically point toward surgery.

Congenital colonic atresia and stenosis.

Five more cases are added to the 88 reported cases of successfully treated newborns with congenital colonic atresia and stenosis. Because colonic atresia and stenosis are lethal conditions when untreated, early diagnosis and operative treatment are major requisites for survival. A two-stage procedure consisting of an emergency colostomy for decompression as the first stage and an elective resection with anastomosis a few months later is recommended. The need for thorough exploration of the abdomen is emphasized because atresias may be multiple or may be associated with additional gastrointestinal anomalies.

Excessive morbidity resulting from the prevention of intestinal adhesions with steroids and antihistamines

Summary Serosal abrasion of the distal ileum was performed in 133 rats. Survival in control animals was 80%, with massive to moderate adhesions noted in 85%. Of the animals receiving promethazine and dexamethasone in large doses, 80% had minimal or no adhesions; however, survival was only 62%. Deaths were due primarily to peritonitis and pneumonia. Complications such as wound infection and dehiscence were prevalent despite the use of postoperative antibiotics. Saline controls had a 10% mortality rate, with moderate to massive adhesions noted in 30%. These observations suggest that although PMZ and DMS treatment clearly reduces the incidence of intestinal adhesions, significant morbidity and mortality rates question their routine applicability. These date imply that such therapy should be avoided in instances of potential or overt peritoneal sepsis.

Congenital aneurysms of the deep veins of the lower extremities

This is a report of our experience with seven children with congenital aneurysms of the deep veins of the lower extremities. All the patients had various clinical features of angiodysplasia. With the use of ascending functional phlebography the patients were divided into two groups: four patients with fusiform aneurysms and three patients with saccular aneurysms. Patients in group 1 had venous reflux and a mild degree of venous insufficiency, which were surgically treated. Three patients with saccular aneurysms (group 2) showed no signs of venous insufficiency and are still being carefully followed. Anatomic and functional assessment of the deep venous system by ascending functional phlebography is essential for planning an appropriate treatment for this rare clinical entity.

Giant cystic hygroma associated with venous aneurysm

Complete excision of giant cystic hygroma requires meticulous dissection of the multilocular lymphatic cysts from the adjacent vascular and neural structures. The association of venous aneurysms with cystic hygroma is extremely rare. We report two infants with cystic hygroma in whom preoperative diagnosis of venous aneurysm was helpful in planning complete excision of the lymphatic lesions.

Neonatal hyperinsulinism—Surgical and pathologic considerations*

Hyperinsulinism in infancy is most often associated with a diffuse pancreatic lesion designated islet-cell dysmaturation syndrome. This disease is commonly associated with persistent hypoglycemia which usually results from inappropriate secretion of insulin. Urgent medical therapy consisting of hypertonic glucose infusion, frequent feeding, and diazoxide is mandatory in order to prevent central nervous system damage. Where medical means of therapy are not effective, an early 85% subtotal pancreatectomy with preservation of the spleen, is indicated. Nine infants who suffered from hyperinsulinism are reported. In two, medical measures were sufficient to control the disease. One of these patients in whom treatment was started late, remained slightly mentally retarded. Seven patients underwent 85% pancreatectomy. In one of these, an additional 7.5% of the pancreas had to be removed and in a second patient total pancreatectomy was performed in order to control the disease. One patient died on the eighth postoperative day after acute gastric perforation. There was no evidence of residual brain damage in the patients who underwent subtotal pancreatectomy.

The ileocecal segment: an anti-reflux conduit for hepatic portoenterostomy.

This paper describes an approach to prevent reflux and ascending cholangitis after hepatic portoenterostomy for biliary atresia. The method utilizes the terminal ileum and right colon as the conduit and a Nisson-type plication to the area of the ileocecal valve. It was used in one patient.

Surgical treatment of gastroesophageal reflux with esophageal stricture in infancy and childhood

During the past 5 years, 26 infants and children with gastroesophageal reflux were operated on. The results have been highly satisfactory and unattended by serious complications or mortality. Barium fluoroscopy was the most reliable diagnostic method. The indications for operation were persistent vomiting with failure to thrive, recurrent aspiration pneumonia, gastrointestinal bleeding and peptic stricture of the esophagus, not relieved by medical treatment. The high incidence of peptic stricture of the esophagus (50 percent) may reflect delay in diagnosis and medical treatment, which is successful in 60 to 87 percent of the infants with gastroesophageal reflux. Surgical treatment consisted of Nissen fundoplication combined with gastrostomy in cases of esophageal stenosis where dilatations were indicated. Complications related to the operation were minimal. In a follow-up period of 9 months to 5 years, all patients had obtained relief of symptoms of reflux and had excellent nutritional status and normal growth.