Orvar Swenson

Duplications of the gastrointestinal tract

Summary 1. Thirteen examples of duplication of the gastrointestinal tract are reported. All 13 patients underwent successful operative treatment. 2. In all instances symptoms were present during infancy; the severity of the symptoms was dependent on the location of the duplication. 3. Preoperative diagnosis in most instancesis difficult. The treatment of choice of these congenital lesions is surgical correction. 4. Duplications of the alimentary tract in infants and children are more important pediatric problems than is generally believed, and awareness of these lesions will lead to earlier diagnosis and treatment.

Long-term results of surgical treatment of imperforate anus

DURING the past few years there has been a tendency to classify various types of imperforate anus according to a simpler plan than that proposed by Ladd and Gross. 2 The salient feature of the new classification is that it is based on readily distinguishable anatomic features. The levator ani muscle, which forms the pelvic floor, contributes considerably to continence; and consequently, whether the colon ends above this structure or perforates it normally, probably determines, to a considerable degree, the functional result. The surgical procedure required to correct the anomaly is also determined by whether or not the colon has traversed the levator ani. Preoperatively, one can determine the relationship of the colonic pouch anti the levator ani by examining a roentgenogram, made in the lateral projection, with the patient held upside down so that the gas accumulates in the end of the colon, then by drawing a line between the sacrococcygeal junction and the lower border of the pubic symphysis the exact position of the end of the colon can be seen and one can determine whether or not the colon has perforated the levator ani.4 It would seem reasonable to predict that when the colon has perforated the muscular diaphragm of the pelvis, the anomaly is less extensive than when this has failed to take place and, in this case, the fuactior:ai resuit should be more sat~sfactory. On the other hand, when the colon

Wound dehiscence in infants and children

Abstract The 10-yr wound dehiscence rate after celiotomy was 0.97%. The dehiscence rate for midline incisions was 3.37%, for paramedian incisions 1.46%, for transverse incisions 0.2%, and for gridiron-type incisions 0%. The most common contributing factors were deep wound infection and abdominal distention. The overall mortality rate was 19.2%. This study indicates the superiority of transverse and gridiron-type incisions in preventing wound dehiscence in infants and children and also suggests that a child whose course and wound appear benign several days after celiotomy can be discharged safely with little risk of dehiscence.

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.

Biliary duct hypoplasia

Summary Eight infants with extrahepatic biliary duct hypoplasia have been followed for periods ranging from 9 mo to 8 yr. Two have died. Although there may be a temporary clinical improvement following operative cholangiogram, the long-term prognosis is poor in patients with biliary duct hypoplasia.

Repair of Inguinal Hernia in Infants

The key to successful repair in children is high ligation of the hernial sac; in otherwise healthy babies, it is seldom necessary to carry out a plastic repair of the abdominal wall, and the child can usually be discharged in a few hours. Also discussed are relevant aspects of gonadal embryology, possible complications, and the question of contralateral exploration when, as in 80% of cases, the patient presents with a unilateral hernia.

Significance of serum N-acetyl-β-D-glucosaminidase in tissue rejection

SummaryBy determining the release of various enzymes in serum, it was possible to distinguish between the ischemic damage resulting from the surgical procedure and by the rejection process in canine renal transplantation. The enzyme release during rejection was preceded by an increase of the lysosomal N-acetyl-B-glucosaminidase activity. Serum-N-acetyl-β-glucosaminidase activity was also elevated during the rejection of skin grafts in rats. The elevation of this enzyme was suppressed by intraperitoneally injected Imuran. The serum enzyme activity did not increase secondarily in skin autografts. Based upon the observation that normal guinea pig serum contains N-acetyl-β-glucosaminidase activities tenfold higher than in other animals, the properties of this enzyme in serum were investigated in diluted guinea pig serum and inhibition studies were performed.The potential clinical significance of these observations and the question of the origin of the serum N-acetyl-β-glucosaminidase are discussed.ZusammenfassungDurch die Bestimmung verschiedener Serum-Enzyme konnte bei Nierentransplantationen beim Hund zwischen einer ischämischen Schädigung durch die Operation und einer Abstoßund unterschieden werden. Der Enzymfreisctzung bei einer Abstoßung ging ein Anstieg der lysosomalen N-Acetyl-β-Glucosaminidase-Aktivität voraus. Die Serum-Aktivität dieses Enzyms war bei der Abstoßung von Hauttransplantaten bei der Ratte ebenfalls erhöht, und ließ sich durch Imuran intraperitoneal unterdrücken. Die Serum-Enzymaktivität zeigte keinen sekundären Anstieg bei Haut-Autotransplantationen. Aufgrund der Beobachtung, daß normales Meerschweinchenserum eine 10fache Aktivität an N-Acetyl-β-Glucosaminidase enthält als bei anderen Spezies, wurden die Eigenschaften des Enzyms in verdünntem Meerschweinchenserum untersucht und Hemmungsversuche durchgeführt. Die mögliche klinische Bedeutung der Beobachtungen und die Fragen des Ursprungs der Serum N-Acetyl-β-Glucosaminidase werden diskudiert.