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Biomedical subjects

A G Coran

Publications and source records attributed to A G Coran.

At least 19 recordsLinked to original sources
PubMed1992

Intestinal vaginoplasty for congenital absence of the vagina.

Congenital absence of the vagina is rare and occurs as a result of aplasia of the Müllerian ducts (46,XX) or complete androgen insensitivity syndrome (AIS--46,XY). Both syndromes are associated with normal female external genitalia and these patients are raised as females. These children are usually treated during adolescence with chronic dilatation of the shallow vaginal introitus (pressure tube technique) or by skin graft vaginoplasty (McIndoe procedure). Neither of these procedures is entirely satisfactory, as both may lead to neovaginal stenosis, inadequate length, poor lubrication, or all three. We have recently modified the operation first described by Baldwin in which a loop of sigmoid colon or small bowel is isolated, closed at one end, and brought down on its vascular pedicle as a neovagina and anastomosed to the hymenal ring. We have performed this operation on four adolescents (mean age, 15 years) and two infants (aged 4 days and 14 months) with excellent results (mean follow-up, 7.5 years for the adolescents and 1.8 years for the infants).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1992

Hypoxia-induced bacterial translocation in the puppy.

Because hypoxia is one of the most common major stresses to which a neonate is exposed, we postulated that it alone might be the cause of intestinal bacterial translocation, which could be the underlying etiology of neonatal sepsis. An animal model, in which hypoxia is the sole stress, was developed in our laboratory and tested in 18 puppies to determine the effect of hypoxia and reoxygenation on intestinal bacterial translocation. In group I (n = 8), following laparotomy and cannulation of the superior mesenteric vein (SMV), the FIO2 was decreased from 21% to 9% for 90 minutes followed by reoxygenation at 21% for 120 minutes. The abdomen was closed and the animals were allowed to recover. After 24 hours the mesenteric lymph nodes (MLNs), spleen, and liver were harvested for bacterial determination and the ileum and jejunum for histological evaluation. Group II (n = 7) was treated the same as group I with the FIO2 maintained at 21%. Group III (n = 3) animals were killed, without intervention, for bacterial analysis. In group I, the systemic PO2 decreased by 75%, SMV PO2 decreased by 64%, and oxygen delivery to the small bowel decreased by 80% in comparison with group II. The mean arterial pressure and cardiac output were not significantly different between group I and group II; however, the mucosal blood flow was decreased by 60% (P less than .001) in group I. Arterial and SMV blood lactic acid levels were unchanged in group I in comparison with group II, suggesting that anaerobic metabolism was not initiated in the splanchnic circulation during hypoxia.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1992

Extracellular fluid and total body water changes in neonates undergoing extracorporeal membrane oxygenation.

After being placed on extracorporeal life support (ECLS), newborn patients typically weight 5% to 30% more than their birthweight. Recovery and eventual decannulation from ECLS is associated with a return to baseline weight or birthweight values after a pronounced diuresis. It has been assumed that the increases in weight in these patients are due to increases in extracellular fluid (ECF) and total body water (TBW). This study was undertaken to prove or disprove this hypothesis. ECF space was measured using the compound sodium bromide and TBW was determined with the use of deuterium oxide (nonradioactive heavy water). Fluid compartment measurements were made prior to the institution of ECLS, immediately after placement on bypass, approximately every other day while on bypass, and a final measurement was made once the patient was off bypass. Sodium bromide concentration was analyzed by high-pressure liquid chromatography, and deuterium oxide concentration was measured by the falling drop method. Eight newborns with respiratory failure were placed on either venoarterial (4 patients) or venovenous (4 patients) ECLS for an average of 106 hours (range, 71 to 219 hours). Pre-ECLS TBW was high in the neonates (87% of total body weight v the normal of 75% to 80%). Mean values for each fluid compartment were corrected for the additional volume of the bypass circuit when the patient was on bypass. ECF increased immediately after the institution of ECLS; however, both ECF and TBW decreased during the bypass run, and post-ECLS levels of ECF and TBW were similar to those found prior to ECLS.(ABSTRACT TRUNCATED AT 250 WORDS)

Body Water↗
PubMed1992

Pericardial flap interposition for the definitive management of recurrent tracheoesophageal fistula.

From 1974 to 1988, six children with fistula recurrence following primary tracheoesophageal fistula (TEF) repair have been managed at our hospital. Reclosure of the fistula with pleural flap interposition was used as the initial corrective procedure in five patients, with an 80% incidence of second TEF recurrences. Due to these discouraging results, we have abandoned this technique and instead favor fistula reclosure with interposition of a pedicle of vascularized pericardium between the esophageal and tracheal suture lines. The pericardial pedicle is easy to mobilize, effectively isolates the tracheal and esophageal suture lines, and eliminates the often difficult task of finding sufficient pleural tissue for fistula interposition in small infants. Furthermore, the vascularized pedicle serves as a template for the ingrowth of neomucosa from the existing esophageal mucosa should an anastomotic leak occur. Since adopting this approach, we have used this technique on four children, three of whom had second recurrences after pleural interposition, and have had no evidence of recurrent fistula formation at follow-up ranging from 2 to 6 years. With at least a 20% incidence of second recurrences reported following conventional management with fistula closure and pleural interposition, we believe use of a pericardial flap in the management of the recurrent TEF is the most appropriate surgical procedure.

Humans↗
PubMed1992

Ibuprofen intervention in canine septic shock: reduction of pathophysiology without decreased cytokines.

This study was undertaken to evaluate the effect of a cyclooxygenase inhibitor, ibuprofen, at various time intervals in a live Escherichia coli model of canine septic shock. Group I (control) animals (n = 5) received a LD100 dose of 10(9) live E. coli per kilogram were given no further treatment. Group II animals (n = 5) received a 10 mg/kg bolus of ibuprofen 10 min prior to bacterial infusion. Group III animals (n = 5) received ibuprofen 15 min after the bacterial infusion. Statistical analysis revealed the following: Group II animals had significantly higher MABP and significantly lower levels of serum fluorescent products (superoxide radical activity), plasma thromboxane B2, prostaglandin E2, and endotoxin levels compared to Group I animals (P less than 0.05). Plasma levels of tumor necrosis factor (TNF) and interleukin-6 (IL-6) were significantly elevated (P less than 0.05) from baseline in all animals (Groups I, II, and III), but ibuprofen treatment failed to either increase or decrease these levels. This study demonstrates that ibuprofen treatment can significantly reverse the deleterious hemodynamic and metabolic effects commonly seen in live E. coli septic shock without depressing the endogenous production of TNF or IL-6. These data support the hypothesis that sepsis initiates a cascade of mediators with the cytokines TNF and IL-6 being proximal events which in turn stimulate the next level, with ibuprofen probably exerting its inhibitory effect distal to this point in the cascade.

Animals↗
PubMed1992

Appendiceal transection in a child associated with a lap belt restraint: case report.

The seatbelt syndrome refers to the spectrum of injuries associated with lap belt restraints and includes intestinal tears, perforations, and transections; mesenteric disruptions; and lumbar distractions, dislocations, and fractures. We report a case of appendiceal transection associated with a lap belt restraint in a small child.

Accidents, Traffic↗
PubMed1992

Intravenous nutrition for the pediatric patient.

Nutritional management of infants and children differs from that of adults because of the extra requirements for growth and the limitations of physiological immaturity. Although parenteral nutrition (PN) is an accepted practice and a potentially life-saving therapy for pediatric patients who cannot be fed through their gastrointestinal tract, it is associated with the risk of serious metabolic, mechanical, and infectious complications. Candidates for PN should be selected according to well-defined indications, with initial nutritional assessment and with careful attention given to fluid, electrolyte, vitamin, trace element, and caloric requirements. Total calories should be administered so that the nonprotein-calorie to gram-nitrogen ratio is in the range of 150 to 250:1. Although short-term supplemental nutritional support can be administered through a peripheral vein, long-term total PN is best delivered by central venous access. PN should be initiated and monitored in accordance with well-established protocols. The lowest complication rate and highest cost-effectiveness are achieved by an interdisciplinary team that includes one or more nurses, dietitians, pharmacists, and physicians. The development of safe, reliable, and miniaturized intravenous pumps with built-in monitors has made home parenteral nutrition possible and desirable in selected patients.

Catheterization, Central Venous↗
PubMed1992

Etiology and management of respiratory complications after repair of esophageal atresia with tracheoesophageal fistula.

This article reviews the cause and management of respiratory symptoms after repair of esophageal atresia with tracheoesophageal fistula (TEF). Postoperative respiratory symptoms developed in 31 (46%) of 68 patients and included apnea and bradycardia, respiratory arrest, aspiration, and recurrent pneumonia. The respiratory symptoms were initially attributed to gastroesophageal reflux (GER) in 20 patients (64%), tracheomalacia in 4 patients (13%), recurrent TEF in 4 patients (13%), and anastomotic stricture in 3 patients (10%). Three patients with GER and the three patients with a stricture were initially managed nonoperatively. The remaining 25 patients underwent surgical correction of the underlying cause of the respiratory symptoms. Despite aggressive management of this problem, 14 (45%) of these 31 patients had persistent or recurrent respiratory symptoms. Although GER is the most common cause of respiratory complications in patients who have undergone prior TEF repair, other factors are often responsible for these symptoms and should not be overlooked.

Esophageal Atresia↗
PubMed1991

Redo fundoplication in infants and children with recurrent gastroesophageal reflux.

The Nissen fundoplication is well established as the surgical treatment for medically refractory gastroesophageal reflux (GER) in childhood. Recurrent GER following fundoplication is a challenging problem with a reported incidence ranging from 0% to 12%. From January 1974 to January 1989, 286 children have been treated for GER with Nissen fundoplication and gastrostomy tube placement at the University of Michigan C.S. Mott Children's Hospital; 242 of these children have been followed for an average of 30 months, the remaining 44 have been lost to follow-up. Twenty-nine children (12%) have developed recurrent reflux following fundoplication. Medical management with thickened upright feelings, gastrostomy feedings, or gastrojejunostomy tube feedings has been successful for 11 children with control of reflux symptoms. Five additional children who were treated nonoperatively died of coexistant medical problems within 2 months following documentation or recurrent reflux. The remaining 13 children have required redo fundoplication for wrap disruption or herniation, and an additional six children, initially treated at other institutions, have also undergone redo fundoplications. One other child treated at this hospital required redo fundoplication for a postoperative partial gastric volvulus causing gastric outlet obstruction. Of the 20 children who have undergone a second Nissen fundoplication, 16 (80%) are doing well without recurrent GER. Four children have developed recurrent GER with wrap disruption; 1 is doing well following a third fundoplication, 2 have been managed successfully with continuous feedings via gastrojejunostomy feeding tubes, and a fourth child died of complications related to a recurrent tracheoesophageal fistula. Conservative management with gastrojejunal tube feedings should be considered in the initial management of children with recurrent GER following fundoplication.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1991

Surgical management of ambiguous genitalia in the infant and child.

Proper gender assignment to a neonate born with ambiguous genitalia is a social emergency of the newborn period. Once an appropriate sex assignment has been made, the next critical step is performance, if needed, of a reconstructive procedure in a timely fashion. In an attempt to evaluate our experience with this unique group of patients, we have retrospectively reviewed the course of 69 children with ambiguous genitalia managed surgically at this institution between 1974 and 1989. This series consists of 32 genotypic females with congenital adrenal hyperplasia (CAH), 10 children with mixed gonadal dysgenesis (MGD), 10 male pseudohermaphrodites, 3 true hermaphrodites, 8 genotypic females with urogenital sinus anomalies (UGS), and 6 genotypic males with bilateral undescended testes and penoscrotal hypospadius. All newborns initially seen at this institution received proper sex assignment within the first week of life. Prior to 1980, 17 of the children with CAH underwent clitorectomy and vaginoplasty and three underwent clitoral recession and vaginoplasty. After 1980, 10 patients with CAH were managed with clitoral recession and vaginoplasty and 2 with vaginoplasty alone. Eight of 10 cases of MGD were given a female sex assignment and all 8 underwent gonadectomy due to the high risk of gonadoblastoma; the other 2 children were raised as males. There were 3 true hermaphrodites of which 2 were assigned female gender roles and were managed with a clitoral recession and vaginoplasty. All 10 male pseudohermaphrodites were raised as females and all underwent bilateral orchidectomy. The 8 children with UGS were raised as females and underwent vaginal reconstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1991

The role of surgery in American Burkitt's lymphoma in children.

The records of 28 children with the pathological diagnosis of American Burkitt's lymphoma were reviewed. Twenty-three of these children (82%) presented with primary abdominal tumors and 5 with disease located in the head and neck. Twelve required an emergency operation for either intestinal obstruction (3), intussusception (5), or appendicitis (4); the others underwent an elective exploration for tissue diagnosis. Ten patients had disease localized to one particular site. Seven of these 10 children underwent complete resection of the tumor including a right colectomy (4), small bowel segmental resection (1), tonsillectomy (1), and appendectomy (1). Eight children had a subtotal resection of the tumor (less than 90% of tumor burden) and the rest underwent incisional biopsies. Following the diagnosis, all patients received chemotherapy; 8 (29%) also were treated concurrently with radiation therapy. Nineteen patients (70%) remain long-term survivors with a mean survival time of 3.6 years. Eight patients died of either recurrent disease (6) or sepsis secondary to their chemotherapy, with a mean survival time of 6 months. Sixteen patients (57%) developed complications during their hospitalization that required surgical consultation or intervention (acute renal failure [9], pleural effusion [2], intestinal obstruction [5], gastric outlet obstruction [1], and wound infection [1]). No subsequent treatment of these complications resulted in mortality or morbidity. The significant positive determinant for survival was the initial absence of either bone marrow or central nervous system involvement (P less than .05). In those children who had complete resection of their tumor, survival time was greater than 3.7 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1991

Long-term follow-up of brain-damaged children requiring feeding gastrostomy: should an antireflux procedure always be performed?

Due to the frequent presence of latent gastroesophageal reflux (GER) in mentally impaired children, it is now standard to perform upper gastrointestinal contrast (UGI) and pH probe studies in all children referred for feeding gastrostomy, even if they are without clinical evidence for GER. For patients with documented GER, an antireflux operation performed in conjunction with gastrostomy is usually considered mandatory. Some authors have suggested that a "protective" antireflux operation be performed at the time of gastrostomy placement in all brain-damaged children, citing a high incidence of postoperative GER in this group of patients following gastrostomy, even with a negative preoperative evaluation for GER. To evaluate this theory, we prospectively studied, over the past 6 years, all mentally retarded children referred for feeding gastrostomy with UGI contrast and esophageal pH probe studies. In total, 148 children were studied; 105 had a positive evaluation for GER and underwent gastrostomy and antireflux surgery. Of the 43 children with a negative preoperative evaluation for GER, 37 are doing well following gastrostomy alone without clinical reflux at an average follow-up of 21 months. Six of the 43 (14%) developed symptomatic GER occurring at an average of 10 months following gastrostomy placement. Five of these children have been successfully treated with an antireflux operation and the sixth patient has been successfully managed nonoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1991

A long-term experience with biliary atresia. Reassessment of prognostic factors.

Thirty-four infants with biliary atresia were primarily treated at our institution between 1974 and 1987. The mean age at diagnosis was 8.8 weeks. The Kasai portoenterostomy was used in 11 patients (32%) and the Sawaguchi modification in 23 infants (68%). Overall survival was 47% (16/34), with a mean follow-up of 45 months. Fifteen survivors (94%) are jaundice free, with two having undergone liver transplantation. Survival was not influenced by earlier age at operation, size of ductal remnants, or the use of an external biliary vent. Good bile flow was predictive of a favorable outcome. The incidence of cholangitis was increased in the Kasai (87%) versus the Sawaguchi groups (45%) (p less than 0.05), but 1-year survival rates were similar (55% vs 64%). The authors conclude that portoenterostomy offers a reasonable chance for success and should be the initial procedure for biliary atresia.

Bile↗
PubMed1991

Contribution of demographic and environmental factors to the etiology of gastroschisis: a hypothesis.

We examined the clinical literature on congenital abdominal wall defects to confirm our impression that gastroschisis had become more common than omphalocele. We then examined the teratology literature and noted that congenital abdominal wall defects were frequently induced by teratogens. This lead us to review the antenatal history of 19 infants with gastroschisis and 54 control infants born with a congenital anomaly unrelated to gastroschisis. When compared to controls, mothers of infants with gastroschisis were more likely to have used aspirin during pregnancy and to have been taking oral contraceptives at the time of conception. Additionally, an increased incidence of illegal drug use (particularly cocaine) was noted among the study mothers. We conclude that gastroschisis is becoming the more common congenital abdominal wall defect, and that it could be related to exposure to an environmental teratogen.

Abdominal Muscles↗
PubMed1991

Arterial aneurysms in children: clinicopathologic classification.

Thirty-one arterial macroaneurysms in 23 pediatric-aged patients (16 boys and 7 girls) were treated at the University of Michigan. The average age at time of diagnosis was 10.2 years (range 6 months to 18 years). Vessels involved the aorta (4), as well as hepatic (1), splenic (2), gastroepiploic (1), renal (12), iliac (1), superficial femoral (4), popliteal (1), brachial (1), radial (2), and ulnar (2) arteries. Twelve children exhibited overt clinical manifestations including presence of a mass (7), local pain (3), hematemesis (1), and painless obstructive jaundice (1). Eleven children had asymptomatic lesions. Aneurysm existence was confirmed by arteriography or operation. All but one child underwent surgical therapy, with 20 long-term survivors (mean follow-up 3.5 years). One operative death occurred and one death occurred 6 years after surgery. This experience and a review of previously reported cases served as a basis for categorization of childhood aneurysmal disease as true aneurysms associated with (I) arterial infection, (II) giant-cell aortoarteritis, (III) autoimmune connective tissue disease, (IV) Kawasaki's disease, (V) Ehlers-Danlos syndrome or Marfan's syndrome, (VI) other forms of noninflammatory medial degeneration, (VII) arterial dysplasias, (VIII) congenital-idiopathic factors, as well as (IX) false aneurysms associated with extravascular events causing vessel wall injury or disruption. Knowledge of the varied clinicopathologic characteristics of arterial aneurysms in children is important in treating these patients.

Adolescent↗
PubMed1991

Abdominal aneurysms in childhood: report of a case and review of the literature.

Abdominal aneurysms are rare in children and are usually found in association with congenital cardiac or aortic malformations, connective tissue disorders, trauma, or previous arterial catheter placement. A 4-year-old girl who had a common iliac artery aneurysm, who had no history of arterial catheter placement or trauma, and who had no evidence of Marfan's or Ehlers-Danlos syndrome, arteritis, coarctation of the aorta, or other diseases associated with childhood aneurysms is presented. Resection of the aneurysm and arterial reconstruction were performed without the use of prosthetic material or vein graft. Pathologic examination showed no evidence of inflammation or medial degeneration in any of the layers of the arterial wall. This is the fourth report found in the literature of documented idiopathic abdominal aneurysm in a child. The conditions associated with abdominal aneurysms in childhood are discussed, and the literature is reviewed.

Abdomen↗