William B. Kiesewetter

Hypertrophic pyloric stenosis at the children's hospital of pittsburgh from 1912 to 1967 A critical review of current problems and complications

Abstract Review of 1215 patients treated for hypertrophic pyloric stenosis during the period from 1912 to 1967 inclusive, demonstrates that the mortality has decreased to 0.5 per cent and the rate of complications to 9.5 per cent. Infections, usually pneumonia, have been the principle cause of death in the 27 infants who did not recover following pyloromyotomy. Postoperative complications now most commonly observed are incisional infections and gastroenteritis. Roentgen examination was used to aid in the diagnosis of pyloric stenosis in 254 infants. In 154 instances, it was probably unnecessary. When pyloric stenosis is present in an infant with a cleft lip and palate, diagnosis may be difficult and delayed. Such infants require special care. Nine infants in this series required a second pyloromyotomy. Only 35 per cent of the patients in this series never vomited postoperatively. Postoperative vomiting of varied degree occurs frequently after successful pyloromyotomy and probably represents variations in the return of gastric peristalsis.

Imperforate anus: II. The rationale and technic of the sacroabdominoperineal operation

Sucessful treatment of the child with imperforate anus yields an individual with satisfactory continence and a healthy urinary tract. These goals are achieved by accurate evaluation of the newborn, optimal technical results, and conscientious follow-up. The infant born with one of these malformations frequently has a serious associated anomaly which also requires early specific diagnosis and management. When the bowel has passed through the puborectalis in utero, the deformity can often be definitively treated in the neonate by dilations or anoplasty. However, if a urinary or high vaginal fistula is present, or if the anomaly is of the supralevator type, definitive surgery is best postponed some months and the neonate given a colostomy. We have found the sacroabdominoperitoneal approach to be the most satisfactory pullthrough procedure for the supralevator lesion. The children with high, supralevator anomalies have higher mortality rates and, in one out of four cases, have suboptimal fecal continence. They require the utmost in technical skill and continuing care if they are to lives free of social stigma. The mortality rate in all other types is low and the functional continence uniformly acceptable.

Imperforate anus: A survey from the members of the Surgical Section of the American Academy of Pediatrics+

T ttlS REPORT is based on a survey of the experience of members of the Surgical Section of the American Academy of Pediatrics with imperforate anus for the 5-yr period 1965 through 1969. The authors are the committee appointed to compile d~tta from answers to a questionnaire circulated to 301 members, including honorary overseas members. Many of the members reported as groups from the same institution. The survey represents the experience of pediatric surgeons reporting on 1166 patients from 51 institutions, including childrens hospitals and general hospitals.

Imperforate anus: I. Its surgical anatomy

Summary A detailed dissection of 9 newborn imperforate anus pelves and postoperative follow-up of 12 older children with imperforate anus were carried out. From the dissections, the following observations were made: 1. the external sphincter is always present in imperforate anus; 2. the internal sphincter is minimally present if at all; 3. the puborectalis muscle is at, but not above, the pubococcygeal line if the blind pouch is at or above that line; 4. the puborectalis muscle is as much below the pubococcygeal line as the bowel has descended below that line and it is wrapped around the bowel in sling fashion; 5. there is rarely approximation and coordination of the external sphincter and puborectalis, except in the lowest types of imperforate anus. The salient points uncovered in the follow-up of the postoperative patients include: 1. sensation was intact in its entirety in all cases where the distal bowel was undisturbed; 2. there was a suggestion of some sensory receptors in the puborectalis muscle itself; 3. there was apparent mucosal ingrowth of sensory fibers from the mucocutaneous line for a minimum distance of 1 to 2 cm. in all cases.

Histologic changes in the testis following anatomically successful orchidopexy.

Abstract For decades the family of a child with an undescended testis or testes has been told that surgical placement in the scrotum was necessary. We are unaware of work indicating the degree of histologic improvement that can be expected from an anatomically successful orchidopexy. This study was undertaken to try to determine what effect scrotal placement had on the architecture of the testis.

Rhabdomyosarcoma in infants and children: Factors affecting long-term survival

Abstract Thirty-three cases of rhabdomyosarcomas from the Childrens Hospital of Pittsburgh have been reviewed alone, and in combination with 117 cases from two other institutions as reported in the literature give a larger series for evaluation. Survival was 43% in our series and 29% in the larger series. No relationship was observed between the age of the patient at the time of diagnosis and survival. Patients under 1 yr of age did poorly, particularly when compared with cases of other common embryonal tumors. As might be expected, those patients whose tumors presented as resectable lesions did far better than those with nonresectable lesions. Tumors that arise in the orbit and the extremities result in a better survival rate than do those in other primary sites. The best regimen appears to be one that makes use of surgery, irradiation, and chemotherapy.

Sacrococcygeal teratomas in children

Abstract Forty-four patients with sacrococcygeal teratomas are reported, and their surgical management discussed. Early complete excision with removal of the coccyx is recommended and was practiced in 33 cases. Such management eliminates recurrence, with its increased chance of neoplastic change. The mortality in this series from all causes was 27%.

Meconium ileus: A critical review of treatment and eventual prognosis

Abstract Forty-six patients with meconium ileus were treated from 1951 to 1969, of whom 23 (50%) patients died in the immediate postoperative period. Fourteen of the remaining are now alive and are 2 to 14 years of age. Long-term survival does not differ from other patients with cystic fibrosis. One-half of the patients survived to leave the hospital, one-half of the remainder succumbed to cystic fibrosis, leaving one-quarter of the total to live a reasonably normal life but under the constant regimen to which all children with cystic fibrosis must submit. The majority of these patients (24) were treated by enterotomy and hydrogen peroxide or acetylcystine irrigation.

The response of colonic muscle to drugs: An in vitro study of Hirschsprung's disease

Abstract An in vitro pharmacologic study was conducted with muscle from 14 cases of Hirschsprungs disease and eight normal controls. The circular muscle from an aganglionic segment was less sensitive to ACh and physostigmine than from segments of proximal ganglionic bowel or normal controls. The degree of insensitivity to ACh had a significant correlation with the clinical severity of obstruction. It appeared that variably increased cholinesterase activity in the aganglionic colon might be responsible for the insensitivity to ACh. These findings suggest the hypothesis that, in addition to the absence of intramural ganglia, there is an imbalance between release of ACh and hydrolysis by ChE which produces the variable clinical symptoms.

Red cell mass determinations in infancy and childhood, with the use of radioactive chromium**

Summary The evolution of a method for determining red cell mass in infancy and childhood with the use of radioactive chromium has been outlined. The results of utilizing this method are recorded in the cases of 78 infants and children, most of whom underwent an operation. The practicality and accuracy of the isotope method have been evaluated.