Peter K. Kottmeier

Tongue lesions in children.

A review of tongue lesions in children showed that there is a great variety requiring operative intervention, often in infancy. While the presenting symptoms may be related to dysphagia and dyspnea, the aim of operative intervention should not only be to salvage life by restoration of breathing and swallowing, but also to leave a tongue capable of adequate speech, taste, sensation, and normal orofacial development. Intimate knowledge of lingual anatomy and function is necessary to allow selection of the ideal procedure and appropriate timing of the therapy. While careful observation and nonoperative approach may be indicated in non-neoplastic macroglossia, early intervention is often necessary in diffuse neoplastic lesions such as lymphangioma, fibromatosis, or fibrolipomatous dysplasia. While malignant tumors are rare in childhood, they do occur and have to ruled out.

Jugular venous ectasia in children. A report of 3 cases and review of the literature.

Three cases of jugular venous ectasia in children were diagnosed preoperatively by selective venography. These rare lesions appear to be congenital dilatations of the veins and should not properly be called aneurysms, as their histological structure is normal. A typical history and complex of physical findings are associated with this entity. It is important to include it in the differential diagnosis of neck masses in children.

Choledochal cysts: Diagnostic and therapeutic problems*

Summary A review of eight patients with congenital biliary cysts showed that the correct diagnosis was only anticipated in two, that several patients underwent prolonged nonoperative treatment because of a mistaken diagnosis of hepatitis, and that even in patients with an abdominal mass the true character of the cyst was not suspected until a detailed radiographic work-up was completed. In contrast to previous publications, a review of our own cases and 138 cases reported during the last 4 yr indicates that choledochal cysts represent only one of various biliary cystic dilations that can occur in either an isolated or a multiple form. A review of operative procedures performed during the last decade reveals that excision and duct-enterostomy carry a mortality risk no higher than cyst-enterostomies, with fewer postoperative complications in a still-limited follow-up period.

Familial juvenile adenomatous polyposis

Most colonic polyps in children are of the juvenile type and occur either as single or scattered colonic polyps. The peak incidence occurs between 4 and 6 yr of age, with a spontaneous decline from 12 to 15 yr. Significant clinical symptoms are rare, and operative therapy is rarely indicated. Diffuse colonic juvenile polyposis, however, varies with different clinical, prognostic, and genetic implications. In infancy, colonic polyposis may be associated with diffuse gastrointestinal involvement leading to fatal complications unless treated aggressively. In childhood, colonic polyposis can occur with a genetic variance with an increased incidence of familial intestinal malignancies. Colonic polyposis in childhood, both familial and nonfamilial, can present with a mixed form of juvenile and adenomatous polyposis. In children with colonic polyposis, the biopsy of a single polyp that reveals the histologic appearance of a juvenile polyp does not rule out the simultaneous existence of adenomatous polyps.

Endorectal pull-through procedure for Hirschsprung's disease with and without primary anastomosis

Abstract The advantages of the endorectal pull-through procedure with primary anastomosis are: (1.) The absence of any pelvic dissection; (2.) the presence of normal propulsive colon right down to the anus; (3.) the preservation of the rectal muscular cuff and its sensory receptors; (4.) few, if any, anastomotic problems; (5.) the preservation of all sphincters and (6.) simple postoperative care. Although more time and experience are required to evaluate the procedure, we believe that its relative ease of performance, inherent safety, and physiologic soundness may make it the operation of choice for Hirschsprungs disease.

The complete release of the levator ani sling in fecal incontinence

Summary The complete release of the levator ani sling in patients with anal incontinence, due either to loss of sphincter or puborectalis muscle, is not only technically easier to perform but has shown improved results as compared with the partial release of the levator ani sling previously reported. 3 The effectiveness of the revised levator sling is based on the particular physiological properties of the levator muscle, resembling the sphincter muscle, and the anatomical position which permits a marked anterior angulation and compression of the rectum.

Diagnosis and treatment of neonatal adrenal hemorrhage

Summary Our experience with a small group of infants with adrenal hemorrhage has shown that the clinical course may vary depending upon the extent of the underlying hemorrhage and the presence or absence of adrenal insufficiency or infection. Increased awareness of the factors leading to adrenal hemorrhage and its subsequent complications should lead to early and prompt therapy. Depending upon the extent of the lesion and the ability to exclude neuroblastoma, therapy will range from nonoperative supportive therapy to immediate surgery.

Absence and retention of small bowel gas in infants with midgut volvulus: Mechanisms and significance

The radiographic pattern ofhigh intestinal obstruction — gastric and duodenal distension with absence of small bowel gas (ASBG) or a completely gasless abdomen — may be present in infants with midgut volvulus. In most instances, ASBG is associated with viable small bowel. However, when associated with abdominal distension and tenderness ASBG usually reflectsstrangulated midgut volvulus and bowel necrosis.In some patients with midgut volvulus there is a radiographic pattern oflow small bowel obstruction this is generally associated withnecrotic bowel.These seemingly opposite observations can be explained by reviewing the dynamics of gas absorption in normal bowel and in closed loop intestinal obstruction. Impaired blood supply can result in either gaslessness or gaseous distension under differing conditions.

Function of the replanted spleen in dogs

The function of replanted splenic fragments was studied by comparing three groups of five dogs each, one group with intact spleens; one, post-splenectomy; and one with splenic replantation. Fifteen fragments were implanted into the omentum. Howell-Jolly bodies appeared after splenectomy but cleared in the replanted group after several months. I125-tagged attenuated pneumococcal clearance studies showed a significant difference between control and replanted group compared with the splenectomized group. The increase of pneumococcal antibody titers after vaccination differed significantly between the splenectomized and the replanted group. All replanted fragments were viable and showed growth over a 2-year period. These studies demonstrate that omental replantation of the canine spleen leads to the maintenance of certain functional splenic parameters comparable to the normal spleen which are significantly different from the splenectomized animal.

Liver Trauma in Children

A review of our experience with urban children who sustained blunt abdominal trauma revealed that liver trauma occurred in one-third of all children. The cause of trauma, predominantly blunt in nature, led to a multitude of associated injuries which not only caused visceral and skeletal injury endangering the patient, but, more apparent even though less significant injuries delayed diagnosis and therapy of the underlying sever liver injury. Awareness of the possibility of liver injury in children with blunt abdominal trauma, prompt operative intervention wil injuries should significantly increase the salvage of these pediatric trauma victims.