Zacharias Zachariou

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.

Comparison of porcine and human coagulation by thrombelastometry

INTRODUCTION Although the pig is a standard model for the evaluation of various diseases in humans, including coagulopathy, it is not clear whether results in animals can be extrapolated to man. MATERIALS AND METHODS In 75 anesthetized pigs, we assessed reagent-supported thrombelastometry (ExTEM®), platelet-blocked thrombelastometry (FibTEM®), and aprotinin thrombelastometry (ApTEM®). Results were compared to values from 13 anesthetized humans. RESULTS (MEDIAN, 95% CI): ExTEM®: While clot strength was comparable in pigs (66 mm, 65-67 mm) and in humans (64 mm, 60-68 mm; NS), clotting time in animals was longer (pigs 64 s, 62-66 s; humans 55 s, 49-71 s; P<0.05) and clot formation time shorter (pigs 52 s, 49-54 s; humans 83 s, 67-98 s, P<0.001). The clot lysis index at 30 minutes was lower in animals (96.9%, 95.1-97.3%) than in humans (99.5%, 98.6-99.9%; P<0.001). ApTEM® showed no hyperfibrinolysis in animals. Modification of the anesthesia protocol in animals resulted in significant ExTEM® changes. FibTEM®: Complete platelet inhibition yielded significantly higher platelet contribution to clot strength in pigs (79%, 76-81%) than in humans (73%, 71-77%; P<0.05), whereas fibrinogen contribution to clot strength was higher in humans (27%, 24-29%) than in animals (21%, 19-24%; P<0.05). CONCLUSIONS Maximum clot firmness is comparable in human and porcine blood. However, clot lysis, platelet and fibrinogen contribution to clot strength, as well as initiation and propagation of clotting, are considerably different between pigs and humans. In addition, anesthesic drugs seem to influence thrombelastometry in animals. Accordingly, coagulation abnormalities in pigs subjected to diseases may not necessarily represent the coagulation profile in sick patients.

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.

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.

Hemostasis Management in Pediatric Mechanical Circulatory Support

In a 9-year-old boy, bridging to transplantation was successful with an external biventricular device, the Berlin Heart Excor (Berlin Heart, Berlin, Germany), during a 7-month period. Main long-term complications consisted of infection and hypercoagulability with clotting inside the chambers necessitating six pump exchanges, but without thromboembolic events. This report reviews hemostasis monitoring and management of long-term mechanical circulatory support.

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.

Postoperative sepsis in infants below 6 months of age

BackgroundSepsis is a threatening postoperative complication especially in small infants. Regarding the advances in perinatal medicine, its incidence is unknown to date. We aimed to investigate the incidence, risk factors, laboratory findings and outcome of postoperative sepsis in infants younger than 6 months old.MethodsWe examined postoperative sepsis in babies below 6 months of age during a 4-year period at a tertiary pediatric institution.ResultsThe rate of postoperative sepsis was 6.9%. Laparotomy with enterotomy, thoracotomy and diaphragmatic hernia repair (P<0.05, respectively) as well as low postnatal age and long operation time (P<0.001, respectively) were correlated with the incidence of sepsis. Significant independent predictors for the development of sepsis were the presence of a central venous catheter and perioperative antibiotic treatment (P<0.001, respectively). Coagulase negative Staphylococci were the major infecting organism associated with postoperative sepsis, accounting for 53% of monomicrobial infections. Complete blood counts with differential were not different between infants with sepsis and controls, who had undergone the same surgical procedures. Outcome was favorable in all cases; however, the length of hospital stay was significantly longer in sepsis patients (P<0.05).ConclusionsPostoperative sepsis syndrome is a frequent complication in infants below 6 months of age and causes significant prolongation of hospital stay. Adequate prevention and therapeutic strategies warrant further prospective investigations.

Effects of potato-derived protease inhibitors on perianal dermatitis after colon resection for long-segment Hirschsprung’s disease

BackgroundAfter resection of long-segment Hirschsprung’s disease, severe perianal dermatitis (SPAD) may occur because of high stool frequency and elevated concentrations of fecal pancreatic proteases. We investigated prospectively the effect of potato-derived protease inhibitors (PPI) on skin conditions in children with postoperative SPAD.MethodsFour children (aged 12 to 24 months) with therapy-resistant SPAD after transanal endorectal pull-through for long-segment Hirschsprung’s disease received topical PPI (1% in 20% zinc ointment) with each diaper-change. Parents noted down a subjective dermatitis score daily. Photo documentation and outpatient visits were made to assess the treatment results.ResultsNo adverse effects were observed after treatment with PPI. A remarkable improvement of the dermatitis in 3 of the 4 patients as well as improvements in pain and sleep disorders were observed during the PPI-treatment course.ConclusionThe results of the study suggest that PPI may reduce otherwise intractable protease-induced skin irritation in infants.

Hematometra presenting as an acute abdomen in a 13-year-old postmenarchal girl: a case report

IntroductionMost underlying diseases for abdominal pain in children are not dangerous. However some require rapid diagnosis and treatment, such as acute ovarian torsion or appendicitis. Since reaching a diagnosis can be difficult, and delayed treatment of potentially dangerous diseases might have significant consequences, exploratory laparoscopy is a diagnostic and therapeutic option for patients who have unclear and potentially hazardous abdominal diseases. Here we describe a case where the anomaly could not be identified using a laparoscopy in an adolescent girl with acute abdomen.Case presentationA 13-year old postmenarchal caucasian female presented with an acute abdomen. Emergency sonography could not exclude ovarian torsion. Accurate diagnosis and treatment were achieved only after an initial laparoscopy followed by a laparotomy and after a magnetic resonance imaging scan a further laparotomy. The underlying disease was hematometra of the right uterine horn in a uterus didelphys in conjunction with an imperforate right cervix.ConclusionThis report demonstrates that the usual approach for patients with acute abdominal pain may not be sufficient in emergency situations.