Biomedical subjects
Publications and source records attributed to C A Stephens.
Investigation to determine the cause of vomiting in a 14-mo-old child revealed partial obstruction at a narrowed segment of mid small bowel, with local deficiency of circular muscle and ballooning proximally. The pathogenesis of this apparently unique lesion is uncertain.
From 1968 to 1976 inclusive, 69 neonates with diaphragmatic hernias had corrective surgery within 18 hr of birth and the survival rate was 41%. During the same time, all babies with similar hernias who were operated on later than 18 hr from the time of birth survived. Our present interest has been focused on the pulmonary artery and its hypertension with the subsequent development of right to left shunting through the patent ductus arteriosus. During 1977 and 1978, we attempted to enter 19 consecutive newborns 18 hr of age or less with symptomatic Bochdalek diaphragmatic hernias into a "Collins protocol" for treatment. This included four stages: newborn nursery initial resuscitation, operation, cardiac catheterization, and ICU monitoring and pharmacological therapy. There was a total of seven survivors (36%), however for a number of reasons only eight babies really had a complete entry into this protocol and of these eight, five survived. Although this study is far from complete, some initial information and concepts are forthcoming. It is now apparent to us that there are three distinct groups into which these very early newborns fall: minimal pulmonary hypoplasia, unilateral hypoplasia and bilateral hypoplasia. The first group probably does not need pharmacologic support, while in the last it probably does not help. Further interest in other more specific pulmonary pharmacologic agents is now being considered as well as some way of early recognition of which baby is going to fit into which group, so that only the ones that need this treatment will get it.
Thirty-seven late presenting children with appendiceal mass were treated between 1965 and 1975 with i.v. fluids, alimentation according to the state of gastrointestinal function, and no antibiotics. They ranged in age from 18 mo to 16 yr and all had had symptoms for at least 5 days (mean 8.7), an abnormal WBC (mean 19.9), and a fixed palpable mass without rebound tenderness. Children were discharged when clinical findings resolved. All returned for interval appendectomy. Eighty-one percent (31 children) had clinical improvement within 5-22 days (mean 10.9). Nineteen percent (7 children) had recurrence or worsening of symptoms and required abscess drainage within 2-10 days after observation began. No child in either group received antibiotics nor did any die. Only one recurrence of symptoms after discharge was recorded before interval appendectomy. Pathologic specimens revealed fibrosis in 46%, subacute inflammation in 35%, and acute inflammation in 19%. Nonoperative management of the appendiceal mass without antibiotics in children is safe as long as diligent observation is maintained. Interval appendectomy can be performed as late as 20 wk after symptom resolution or drainage, however, over 50% of the interval appendectomy specimens reveal acute and subacute inflammation.
The Allison, Belsey, and Nissen antireflux operations have been widely used over the last 15 yr. A number of problems have followed from these procedures that have prompted us under certain circumstances to seek alternative operations. In the last 2 yr, in selected patients, we have done a partial gastric wrap-around (Dor-Nissen) operation on 16 children from age 2 wk to 13 yr for the following reasons: failed Allison and Nissen repairs, two infants with such a small stomach that only a partial stomach wrap-around was possible, with a Heller cardiomyotomy, and for reflux with or without an accompanying hiatal hernia. All of these Dor-Nissen partial wrap-around operations were technically easy to do and all the postoperative patients have been problem-free both clinically and radiologically. Moreover, the gass bloat syndrome seen with the Nissen fundoplication has not been encountered. We recommended this partial wrap-around antireflux operation as a primary procedure, an alterative to one of the more widely used operations, or when re-operating for recurrence of gastroesophageal reflux.
In the absence of the apleen, overwhelming infection is a real threat. Therefore, there is a trend to try to preserve all spleens. Recognizing this, and realizing that not every damaged spleen must be removed, a nonoperative approach has been advocated and practiced for 35 yr at the Hospital for Sick Children in Toronto. This experience is recorded herein, providing indications and methods of management. The results are considered to be very satisfactory.
Since 1964 gastric tube replacement of the esophagus has been done in 30 infants and children. This report reviews and brings up to date our entire series, which includes follow-up of 15 children over 5 yr, 7 of whom have been followed for more than 10 yr. The two-stage proximally based reversed antiperistaltic gastric tube placed retrosternally is still our procedure of choice, although since our last report in 1973 several other methods (one-stage, transthoracic, subcutaneous) have been used, and the spleen has not been removed in our more recent operations. Whether the esophagogastric tube anastomosis is primary or secondary or is in the chest or neck, leakage is still the most common complication (63%), with all but three closing spontenously. A continuing problem may be an anastomotic stricture (43%) that will require some dilatations. Mild sacculation or tortuosity of the gastric tube has been encountered only once. Despite the above problems, the eventual outcome in the growing child with a gastric tube replacement continues to be a satsifying one. We continue to use the gastric tube operation when replacement of the esophagus is required.
Two children presented with abdominal tumors invading the upper inferior vena cava. To facilitate removal of the tumors, cardiopulmonary bypass with profound hypothermia and circulation arrest were utilized. This technique simplifies tumor excision and is worthwhile even in children with advanced malignant disease.
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One hundred and eighty-two patients undergoing splenectomy in infancy and childhood were followed for periods of 2 to 15 years. Serious infections occurred in 11 patients (6%) with death in 6 (3.3%). In 10 patients the infection was sepsis, and in all but one patient the infection occurred within 2 years of splenectomy. Among children over 2 years of age the risk of infection was still appreciable except when the spleen was removed incidentally or for traumatic rupture. Splenectomy for thalassemia and portal hypertension resulted in an increased risk of serious infections when compared with removal of the spleen for hereditary spherocytosis, idiopathic thrombocytopenic purpura, trauma, or for technical reasons in the course of another operation. Post-splenectomy infections tended to follow a characteristic pattern. The infecting organism was predominantly pneumococcus, the course was fulminating and the mortality high.
alpha-N, epsilon-N-Dipalmitoyl-L-lysine, alpha-N-monopalmitoyl-L-lysine, and epsilon-N-monopalmitoyl-L-lysine were compared with 18% casein and lysine HCl as sources of lysine in the diets of weanling rats. The lysine derivatives and lysine HCl were added to a basal diet containing 14.1% of an amino acid mixture with no lysine. Weight gain, food intake, plasma lysine, and urine and fecal lysine were determined. Animals fed the basal and lysine derivative diets lost weight over the 10-day study period. They had lower food intake, urine and plasma lysine content, and a higher fecal lysine content than animals fed the other diets. alpha-N-Monopalmitoyl-L-lysine was absorbed whereas the epsilon-N-monopalmitoyl-L-lysine and the alpha-N, epsilon-N-dipalmitoyl compounds were not.
In an unselected series of 49 children with Wilms' tumour treated in 1969-74 the 5-year relapse-free survival and survival rates were 78% and 81%, respectively, whereas in the series of children treated in 1963-68 the corresponding rates were 49% and 70%. The significant improvement in the relapse-free survival rate was a result of adjuvant treatment with actinomycin D and vincristine (AMD + VCR), which, in some patients, eradicated occult metastatic disease. In the treatment of lung metastases the combination of whole-lung irradiation and maintained chemotherapy with AMD + VCR proved excessively toxic: in 5 of 11 patients acute diffuse pneumonitis developed, and it was fatal in 3. Adjuvant AMD + VCR therapy is advocated in all patients with Wilms' tumour except children less than 12 months old with a tumour of moderate size, limited to the kidney and completely resectable.
There were 422 cases of intussusception at the Hospital for Sick Children, Toronto, over a 12-yr period between 1959 and 1970. The histories of all patients who had no pain recorded were evaluated and the duration of signs and symptoms and the treatment required assessed. When compared with those who had pain, it was noted that the children with painless intussusception presented later, hydrostatic reduction was less likely to be effective, and operative reduction and resection was required more often.
The crude 5-year survival rate among children with Wilms' tumour increased from 54% for those diagnosed from 1960 to 1965 to 81% for the period 1966 to 1971. This resulted from an increased ability to cure metastatic disease and, to a lesser extent, to an increased ability to prevent relapse. It is proposed that, after resection and postoperative irradiation, maintained combination chemotherapy with actinomycin D and vincristine should be used electively to prevent relapse, but that this use should also be selective in order that overall morbidity be minimized. Of urgent priority, therefore, is improved delineation of present-day prognostic factors in children with Wilms' tumour.
Data from retrospective review of 16 patients treated for acute cholecystitis indicate that the cause of this disease is different in children than in adults. The incidence of acute acalculous cholecystitis is higher in children. Congenital abnormalities of the gallbladder or bile ducts were not found in our patients. Cultures of the bile failed to establish a relationship with preceding infection, although infection seems to be an important etiologic factor. Diagnosis should be based on clinical signs and cholecystography. Early cholecystectomy is the treatment of choice. In patients with jaundice, operative choledochography is recommended.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.