Sylvain Kleinhaus

On the Nature and Etiology of Vascular Ectasias of the Colon: Degenerative lesions of aging

Vascular lesions of the right colon are being diagnosed increasingly as a cause of lower intestinal bleeding, but their nature and occurrence, primarily in the elderly, remains unexplained. Colons from patients with clinical and angiographic diagnoses of cecal vascular lesions were studied by injection and clearing, and by histological sections. In all injected specimens one or more mucosal vascular ectasias were identified. The mucosal lesions appeared to be secondary to dilated tortuous submucosal veins which were the more prominent feature and were often present without the mucosal ectasia. This suggests that ectasias are caused by chronic, intermittent, low grade obstruction to submucosal veins with dilation and tortuosity initially of submucosal veins, then of venules, capillaries, and arteries of the mucosal vascular unit. Ultimately, precapillary sphincters lose their competency, producing small arteriovenous communications. The concept that ectasias are degenerative lesions was evaluated by studying 15 right colons resected for carcinoma with no history of bleeding. Mucosal ectasias were identified in four colons and submucosal ectasias in eight. These investigations suggested that these lesions: (1) are vascular ectasias developing as a degenerative process of aging, (2) are present with or without bleeding in a significant portion of the population over 60 years of age, (3) are multiple more often than single, and (4) may represent the commonest cause of major lower intestinal bleeding in the elderly.

Idiopathic intestinal perforations in the newborn: An increasingly common entity*

Between 1982 and 1987 seven neonates ranging in age from 24 hours to 1 week were treated for idiopathic intestinal perforations at the Montefiore Medical Center, Albert Einstein College of Medicine. Four of the infants were born prematurely; three were full term. Five were being treated in an intensive care nursery when the perforation was diagnosed. All infants whose perforations were due to necrotizing enterocolitis, appendicitis, Hirschsprungs disease, meconium ileus, intestinal atresias, or drug therapy are excluded from the series. None of the infants had associated anomalies. The sites of the perforations were as follows: two in the jejunum, two in the ileum, one in the cecum, and two in the transverse colon. Six of the perforations were on the antimesenteric aspect of the bowel; one was on the mesenteric aspect. The sizes of the perforations ranged from pinhole to 1 cm in diameter. All the infants did well. Pathologic examination of the resected specimens failed to reveal an etiology for the perforations. There were no cases of duplication or muscular hypoplasia. We believe the etiology of this condition may be ischemic necrosis, secondary to a localized vascular accident in the wall of the affected viscus, but we do not have a good explanation for the upsurge in cases we are seeing.

Possible new syndrome of microcephaly with cortical migration defects, Peters anomaly and multiple intestinal atresias: A multiple vascular disruption syndrome

A possible new multiple vascular disruption symdrome is described. The male patient had microcephaly with cortical migration defects, Peters anomaly and multiple inestinal atresias.

Vitelline artery and vein remnants as a cause of intestinal obstruction

Summary Intestinal obstruction was produced by vitelline vascular remnants in three patients. The level of intestinal obstruction in these patients and the nature of the obstructing adhesive bands is explained by a review of the embryology and development of the vitelline vessels and their relationship to the gastrointestinal tract.

The management of surgery in infants and children with the acquired immune deficiency syndrome

Between January of 1981 and June of 1984, 53 infants and children with the diagnosis of AIDS were seen at our institution. Twenty-one of these patients have required 35 operations to determine or administer the proper therapy. We have taken every precaution to minimize the risks of exposure of all health care personnel.

Evolution of individualized management of tracheal obstruction

Tracheal stenosis may be congenital or acquired. It may occur in the subglottic area, near a tracheostoma, or more distally, and it may involve the mucosa and submucosa or the deeper structures, including cartilage. Increasing use of prolonged endotracheal intubation has resulted in more children with acquired tracheal stenosis. Recently, authors have developed and introduced new methods of managing these strictures both with and without tracheostomy, dilatations, stents, fulgurations, and local or systemic steroids. The use of these techniques is demonstrated in 8 children. Three children had congenital stenosis, 2 children had past-intubation stenosis, 1 child had stenosis secondary to resection of a mucosal tumor of the trachea, 1 child had stenosis following a long-term tracheostomy, and 1 child had stenosis following acute tracheobronchitis complicated by a high tracheostomy. Early in our experience all children were managed by tracheostomy followed by dilatations. With the advent of the new endoscopes, our management has evolved into a graduated use of the new techniques, with emphasis on avoidance of tracheostomy, if possible. Initial attempts to dilate the lesions are made without tracheostomy, and local injections of steroids and minimal fulgurations of granulation tissue are also used. To avoid excess edema, gradual repeated gentle dilatations are performed rather than vigorous ones. More extensive fulguration, systemic steroids, and tracheostomy are added if the lesions do not respond. No stents have been necessary. Our last 2 children have been managed without tracheostomy; we have used dilatation, fulguration, and steroid injection. All tracheostomies have been removed, and all 8 children are asymptomatic. Two stenoses that were present for several years have been successfully corrected. Our results with tracheal stenosis have improved with this graduated approach to management. individualized plans of treatment may permit correction of stenoses without the need for tracheostomy and its related problems.