R. Daum

Impalement and anorectal injuries in childhood: A retrospective study of 12 cases

BACKGROUND/PURPOSE Because of the small numbers of impalement and anorectal injuries in childhood, a standardized therapeutic approach is necessary to avoid major complications. On the basis of a retrospective analysis of 12 children with such injuries treated from 1986 to 1996 in our department, the authors tried to establish guidelines for their treatment. METHODS Additional therapeutic problems and main complications are elucidated after meticulous analysis of three selected cases. RESULTS In two cases of anorectal impalement and a primary colostomy, no complications occurred. However, in three cases involving anorectal injury a primary fecal diversion was not performed, making a secondary colostomy necessary afterwound infection. CONCLUSIONS The current standard principles in the treatment of severe anorectal injuries in children are fecal diversion, wound drainage, and broad spectrum antibiotics. A primary reconstruction in cases of impalement can be recommended only after exclusion of anorectal injury.

Three years' experience with large ovarian cysts diagnosed in utero.

Thirteen fetuses with abdominal cystic tumors were diagnosed by routine prenatal ultrasonography between the 28th and 36th week of gestation. Postnatal ultrasonography of the full-term newborns confirmed the findings. Laparotomies were performed in all cases except one. Patients who were operated on had large ovarian pseudocysts with volumes between 24 and 120 cc. In seven patients (54%), the cysts arose from the left ovary; this included four cases in which the postnatal ultrasound was interpreted as showing the cysts in the right abdomen. Very thin cystic walls threatening perforation were found in 91%. In 33%, we found salpingotorsion on the affected side. Small contralateral ovarian cysts were found in 66% of the patients. One infant required resection of 30 cm of necrotic jejunum because adhesions to the cyst had caused bowel volvulus. Histology of the cysts showed hemorrhage and calcifications, but ovarian stroma was absent in all but one patient. Serum estradiol-17 beta, progesterone follicle-stimulating hormone, and luteinizing hormone were normal in all cases, and similar levels were found in the cyst fluid. These results show that large abdominal cystic masses in full-term infant girls with normal gonadotrophin levels and normal serum estradiol-17 beta and progesterone levels are very likely to require surgery; this is in contrast to preterm neonates with elevated gonadotrophins who can be treated with medroxyprogesterone acetate in the absence of clinical signs necessitating surgery.

Total and superior sternal clefts in newborns: a simple technique for surgical correction.

The authors discuss six cases of superior and total sternal clefts treated in their department in the last 34 years and discuss the problems of this congenital malformation. The inferior sternal clefts including Cantrells pentalogy and the total ventral clefts were excluded because in these cases severe associated anomalies require another approach. In superior and total sternal clefts, cardiac, vascular anomalies in lungs and abdomen and craniofacial dysgenesias are rarely present. In these cases a primary repair during the first weeks of life should be performed. Furthermore, the authors describe their own surgical approach, consisting of the conversion of the partial cleft into a total one. Then the rims are trimmed, and a complete approximation of the two segments is possible.

Specific and nonspecific lymphadenitis in childhood: etiology, diagnosis, and therapy

Over a period of 4 years, 39 children with lymphadenitis were treated surgically; in 31 cases cervical lymph nodes were the main location. In 9 cases the lymphadenitis was caused by mycobacterial infection.Staphylococcus aureus was the most frequent causative organism of unspecific lymphadenitis (11 cases). The therapy of choice appears to be surgical treatment and medical care after operation. Especially in mycobacterial lymphadenitis, complete surgical excision of the lymph node is decisive for definitive healing. There was only 1 case of therapy-resistant, relapsing cervical lymphadenitis that needed a second operation. Causative organisms in this case wereMycobacterium avium andMycobacterium intracellulare. All other patients showed an uneventful postoperative clinical course. We believe that a consequent diagnostic process and cooperation between the pediatric surgeon and pediatrician are necessary for effective therapy.

Continuous extracorporeal stool-transport system: a new and economical procedure for transitory short-bowel syndrome in prematures and newborns

Between May 1994 and June 1995, nine newborns underwent surgery due to mechanical ileus or intrauterine perforation of the small bowel. Three were very-low-birth-weight infants weighing between 520 and 1,200 g. Surgery was performed in the first 2 days of life and split ileo- or jejunostomas were implanted. Early oral nutrition was initiated. To avoid non-use of the distal bowel and shortbowel syndrome, the aboral stoma was irrigated a few days later with the proximal feces. A new technique was applied to transport the chyle continuously from the oral to the aboral stoma: the stool was collected in an especially constructed stoma bag and transported distally by a roller pump. No major complications were seen. The general outcome was excellent in all cases, and reanastomosis under optimal bowel conditions was achieved in all patients without further problems.

Intra-atrial ECG recording: A new and safe method for implantation of Broviac catheters in children

Radiologic confirmation of central venous catheter (CVC) position is mandatory due to possible complications associated with false positioning. During the last 1.5 years, we used intra-atrial electrocardiogram (ECG) recording for intraoperative placement and documentation of CVCs, in 77 cases. We recorded the extremity and intra-atrial ECGs and then performed an intraoperative X-ray, comparing the results. Intra-atrial ECG recording is a new, inexpensive, quick, and safe method for surgical positioning and documentation of Broviac catheters in children.

Motility Malfunction of the Gastrointestinal Tract by Rare Diseases — Fibrosis of the Intestinal Wall

We report on two children who were admitted with chronic ileus without mechanical obstruction. In the 4-month-old female newborn, high-dose radiation was applied after extirpation of a sympathicoblastoma. Within a few years a metaplasia of the muscle coat of the small intestine developed with a resulting malabsorption syndrome. Although the damaged part of the intestine was resected, the process progressed and the child died. In the second case, a chronic ileus developed at the age of 10 years as a result of fibrosis of the intestinal tract. Repeated laparotomies were performed, and no mechanical obstruction could be found. The most probable diagnosis is a form of scleroderma affecting mainly the alimentary tract without any skin involvement. The patient died in a severe cachexia.

Removal of a simple testicular cyst from an infant: preoperative imaging, diagnostic, therapeutic and histopathologic aspects

After an extensive review of the literature, we believe this to be the first case description of the removal of a simple testicular cyst from an infant. The 1 1/2-month-old infant was admitted to the Department of Pediatric Surgery after the mother had noticed a swelling in the right testicle. The tentative clinical diagnosis by ultrasound was a cystic formation in the testis. Alpha-fetoprotein was normal. The intratesticular cyst was extirpated and sent for histologic examination. Preoperative imaging and diagnostic, therapeutic, and histopathologic aspects of this case are discussed.

Amnion as a prosthetic material in congenital defects

In pediatric surgery, amniotic membranes taken from autologous placenta are occasionally used as an implant in cases of large ventral abdominal clefts. The questions arise, which part of this organ should be used and how to use it in the recipient organism. Amniotic membranes consist anatomically of amnion and chorion, which are of fetal origin, and maternal decidua. In our experimental studies, we used the fetal parts of the amniotic membrane as an implant in a standardized rat model and investigated the utilization and possible foreign-body reaction (FBR) induced. Fifteen, 30, and 90 days after implantation the macroscopic appearance, light microscopy, and immunohistology of the specimens were examined. Adhesions to parenchymal organs and omentum were present irrespective of the side facing the abdominal cavity. Amnion induced a rapid FBR that diminished with time. Chorion and parts of the amnion were resorbed within the examined period after infiltration with recipient cells and neovascularization. Our studies have shown that for best results, only amnion in its anatomical definition and parts of the chorion should be prefered as an implant.

Ist die Pyloromyotomie eine Indikation für einen laparoskopischen Eingriff

In unserem Bemuhen, der Kosmetik unter Wahrung von sicheren und optimalen Operationsbedingungen gerecht zu werden, modifizierten wir den Zugang fur die Pyloromyotomie. Durch einen supraumbilikalen Schnitt wurde die Linea alba eroffnet, der hypertrophe Pylorus wurde herausluxiert und konventionell gespalten. Wirhaben diese Methode bei 14 Sauglingen ohne Komplikationen angewandt. Das Verfahren ist im Vergleich zur laparoskopischen Pyloromyotomie gleich minimal invasiv. Hospitalisationszeiten sind kurz und die Narben sind fast unsichtbar. Die reine Operationszeit betrug durchschnittlich 21 min. Auch in laparoskopisch geiibten Handen ist diese Zeit nicht zu unterbieten. Daruber hinaus ist un sere Operationsmethode urn ein vielfaches preiswerter. Nach unserer Erfahrung bietet die Laparoskopie bei der Pyloromyotomie keine Vorteile.