Richard J. Bower

Alimentary tract duplications in children.

This report reviews the experience with 78 alimentary tract duplications found in 64 patients over a 40 year period at the Childrens Hospital of Pittsburgh. Ten patients had the duplication discovered at autopsy. Multiple duplications were found in 15% of patients. The symptoms and physical findings of a duplication varied with location, size and mucosal pattern. About one-filth of the duplications contained ectopic mucosa, usually gastric. Two-thirds of the patients were diagnosed prior to one year of age. Vertebral anomalies, as a clue to the presence of the lesion, were present in 15% of the patients. The most common indications for surgery included a mediastinal or abdominal mass, intestinal obstruction, and gastrointestinal bleeding. The results of surgery were favorable, with a mortality of 20%. Surgical complications accounted for six deaths, while four children died of severe associated anomalies. Three others died without surgical treatment, but with symptoms from the duplication.

Optimum Concentration of Bupivacaine for Combined Caudal-General Anesthesia in Children

Caudal epidural anesthesia has become widely accepted as a means of providing postoperative pain relief and intraoperative supplementation to general anesthesia for children. To determine the best concentration of bupivacaine for combined general-caudal anesthesia in children, 122 children aged 1-8 yr scheduled for outpatient inguinal herniorrhaphy were randomized to receive, in a double-blind fashion, caudal anesthesia with bupivacaine in one of six concentrations (0.125, 0.15, 0.175, 0.2, 0.225, or 0.25%). After incision, a programmed reduction in inspired halothane resulted, if tolerated by the subject, in an inspired halothane concentration of 0.5% 10 min after incision. End-tidal halothane concentration at hernia sac ligation for subjects receiving 0.175% bupivacaine (0.55 +/- 0.03%) was less than that for subjects receiving 0.15% bupivacaine (0.75 +/- 0.05%; P less than 0.05). Subjects receiving 0.175% bupivacaine also were discharged earlier from the postanesthesia care unit (PACU) (27 +/- 1 min) than were subjects receiving 0.15% bupivacaine (38 +/- 5 min; P = 0.05). Children receiving greater than or equal to 0.2% bupivacaine tended to complain more of leg weakness after surgery; however, the difference did not reach statistical significance (39 of 67 vs. 16 of 47; P = 0.057). The incidence of complaints of leg weakness and paresthesia was positively correlated with bupivacaine concentration (r = 0.706; P = 0.05). Subjects receiving 0.125% bupivacaine had higher pain scores on arrival to the PACU than did those receiving 0.2% bupivacaine (P = 0.05); there were no other differences in pain scores.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical and histologic indications for extensive pancreatic resection in nesidioblastosis

Nine children with nesidioblastosis underwent pancreatic resection at St. Louis Childrens Hospital. Four of these underwent 99 percent of near-total resection. Only one child required permanent insulin therapy postoperatively. Pathologic examination of the resected pancreases revealed a diffuse disturbance of the pancreatic architecture. Prolonged hypoglycemia can have devastating neurologic sequelae. Based on clinical experience and the pathologic demonstration of a diffuse process in the affected pancreas, it is advocated that near-total (99 percent) pancreatectomy is the primary procedure of choice for this disease.

Management of breast lesions in children and adolescents.

The records of 207 patients evaluated and treated for breast abnormalities during a 10-yr period were reviewed. Patients ranged in age from 1 wk through 16 yr. Seventy-eight per cent were female. Operative procedures were performed in 134 patients (64%). Most common diagnoses were fibroadenoma, premature thelarche, and precocious puberty in the females, and pubertal gynecomastia in the males. Age and sex separate patients into natural subgroups. In females beyond the neonatal period, premature thelarche and precocious puberty are the most likely cause of breast enlargement. Breast biopsy is only rarely indicated for a distinct mass lesion in the prepubertal breast. Mass lesions in the breast of adolescent females require excisional biopsy. In the male, pubertal gynecomastia is the most common form of breast enlargement and only occasionally requires subcutaneous mastectomy for cosmetic and psychologic reasons. Careful evaluation of all children with breast enlargement is indicated to uncover underlying causes and to avoid unnecessary operative procedures.

Management and follow-up of arterial thrombosis in the neonatal period

The management and follow-up of 12 patients with major aortic thrombus formation occurring in the neonatal period between 1982 and 1987 are reported. Umbilical arterial catheters were inserted in 8 of the 12 patients before thrombus formation. Two patients had congenital thrombi. Hypertension, oliguria, hematuria, and elevated blood creatinine concentration were found at the time of diagnosis of the thrombus; nine of the patients had a patent ductus arteriosus. Supportive care was instituted in seven patients who were hemodynamically stable. Five of the patients had congestive heart failure, shock, or both, and were treated with surgical thrombectomy. Thrombolytic therapy was not used in either group. The five surgically treated patients and six of seven medically treated patients survived. Ultrasound examination suggested resolution of the thrombus in all survivors in 6 to 30 days. Sequelae from thrombus formation were present in all patients at the time of discharge and included hypertension in 9 of the 11 survivors and decreased renal function in six of them. Follow-up at 1 to 3 years revealed normal blood pressure, good growth, and good renal function in 10 of the survivors.

Perforated stress ulcers in infants

During a 5-yr period, 10 infants less than 1 yr of age developed gastroduodenal perforation during treatment for severe underlying illness. Brisk gastrointestinal hemorrhage preceded perforation in most patients. In contrast to stress ulceration in adults, infants appear to have a higher frequency of single ulcers, perforation, and duodenal (rather than gastric) location. The mortality of 40% in this group, and in those patients reported in the literature who have been treated since 1960, implies that effective preventive and therapeutic measures are not yet available and also emphasizes the serious nature of the underlying disorder.

Appendectomy in childhood: Analysis of 105 negative explorations

Laparotomy with a preoperative diagnosis of acute appendicitis disclosed a normal appendix in 105 children (22.1 percent). In less than half of these, another condition was found or later identified, which explained the symptoms leading to operation. Ovarian lesions, acute ileocolitis, and serositis were the most frequently identified abnormalities. Twelve patients (11 percent) underwent definitive procedures in addition to appendectomy. Among patients in whom no abnormality was identified at laparotomy, peritoneal cultures yielded a broad range of organisms in 42 percent of those who had cultures. This may represent a mild form of acute primary peritonitis and may explain the symptoms which were confused with acute appendicitis.

The microbial flora and antimicrobial therapy of neonatal peritonitis

Data from 31 infants with gastrointestinal perforation were analyzed to determine the microorganisms usually present in the peritoneum and blood, and the antibiotic susceptibility of those organisms. Multimicrobial contamination of the peritoneal cavity was present in over one-half of the patients and 23% were found to have mixed aerobic-anaerobic peritoneal flora. Most common organisms were E. coli and Bacteroides species. Blood cultures were positive in 32% of patients, most frequently growing E. coli. Among numerous antibiotics tested, only gentamicin was effective against all Enterobacteriaceae isolated. Clindamycin was 99% effective against Bacteroides species isolated and 90% against other anaerobes. Group D streptococcus was the most frequently isolated gram positive aerobe. Based on these findings, empiric therapy with ampicillin, gentamicin and clindamycin is recommended for neonates with gastrointestinal perforation. Adjustments in therapy for individual patients should be based upon culture and sensitivity data.

Preduodenal portal vein.

Abstract We have reviewed 32 cases of preduodenal portal vein, including our three new cases. Duodenal obstruction was the most frequent indication for surgery. The etiology of obstruction can be the ectopic portal vein, but many other congenital duodenal causes are reported. Malrotations, situs inversus, and a variety of cardiovascular lesions have been associated with preduodenal portal vein. It is also important to recognize the portal vein because of the potential technical problems.

Colo-colic intussusception due to a hemangioma

A six-qrar old white male *as admitted to Children’s Hospital of Pittsburgh with a 2 mo history of lethargy. occasional vomiting, intermittent crampy abdominal pain, and occasional hematochezin. Since age 3, the patient passed small amounts of blood per rectum evrrq 6 to 8 months. Abdominal examination revealed a 5 cm left lower quadrant mass. The mass was mild14 tender and mobile. The mass could not bc palpated rectally and there was no blood in the rectum. Bowl sounds were present. There was mild abdominal distension but no guarding. No cutaneous Iesinm wcrc present. A diagnosis of intussusception was tentatively made and plain tilms of the abdomen showed u distended transverse colon. A barium enema was administered and a mass was seen in the sigmold v+hich was interpreted as the intussuscrptum of an intussusception. This was reduced to the