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Biomedical subjects

G W Holcomb

Publications and source records attributed to G W Holcomb.

At least 19 recordsLinked to original sources
PubMed1992

Complications of trichobezoars: a 30-year experience.

We have reported the case of a mildly retarded woman in whom an obsessive-compulsive disorder of hair eating (trichophagia) had begun between 2 and 3 years of age. Over the next 30 years, multiple complications of trichophagia included trichobezoars, malnutrition, intestinal obstruction, and ulceration with bleeding. One of the bouts of intestinal obstruction was associated with the superior mesenteric artery blocking the duodenum. This complication has not been reported previously in this disorder. The patient's trichotillomania (hair pulling) was treated with psychotherapy, behavior modification, and various medications, without success. The tricyclic antidepressant clomipramine (Anafranil) may be of benefit in such cases.

Barium Sulfate↗
PubMed1991

Laparoscopic cholecystectomy in the pediatric patient.

Since June 1990, five girls and one boy have been evaluated for biliary colic. Gallstones were documented by sonography. Two girls, ages 8 and 14 years, had hereditary spherocytosis, and a 9-year-old boy had sickle cell disease. The other three girls, ages 13, 13, and 15 years, developed cholelithiasis and biliary colic without a history of hematological disease. Three children weighed less than 90 lb, with the smallest weighing 45 lb. All patients underwent laparoscopic cholecystectomy without complications. Operative cholangiography was performed in five of the six children. The KTP-532 laser was used for dissection of the gallbladder from the liver bed in two patients, and electrocautery was used in the remaining four. The average operating time was 1 hour 45 minutes. This is a report of the use of laparoscopic cholecystectomy in pediatric patients. The advantages of its use include a shorter hospitalization, decreased postoperative discomfort, and a much shorter interval between the surgical procedure and return to normal activities such as school and play. At this time, it is recommended for those children without complications from their cholelithiasis such as common duct obstruction and gallstone pancreatitis.

Adolescent↗
PubMed1991

Postoperative intussusception: increasing frequency or increasing awareness?

Postoperative intussusception in children is a rare but well recognized phenomenon. The diagnosis is often delayed due to the protean manifestations of the disorder (ileus, distention, and nausea and vomiting) which, when encountered shortly after an abdominal operation, usually result in a low index of suspicion because they are common after laparotomy. Experience with two cases of postoperative intussusception within 24 hours heightened our index of suspicion. Review of our records indicated we had diagnosed and treated postoperative intussusception in 14 children during the preceding 4 years. Patient ages ranged from 4 months to 12 years (mean 39 months, median 20 months), and symptoms appeared on postoperative days 3 to 36 (mean 10 days, median 6 days). Initial operations included excision of a retroperitoneal or abdominal tumor (five cases), Nissen fundoplication and gastrostomy (three), ileal resection (two), Ladd procedure (one), Duhamel operation (one), and operative reduction of ileocolic intussusception (the two most recent cases). Eleven patients had appendectomy (five by the inversion technique), and three had placement of a transgastric small bowel feeding tube. Nine children had had either barium enema or upper gastrointestinal studies because of the postoperative suspicion of obstruction; one patient had both. Diagnostic studies were not done in four patients. Operative reduction was successful in all but one child, who required bowel resection.

Child↗
PubMed1991

Parapneumonic empyema in children: decortication hastens recovery in patients with severe pleural infections.

The medical records of 61 children 0 to 18 years of age treated for empyema complicating pneumonia from 1977 to 1989 were reviewed with attention to clinical presentation, bacteriology, treatment and outcome. Streptococcus pneumoniae was the most common infecting organism, followed by Staphylococcus aureus, other streptococcal species, anaerobes, Haemophilus influenzae type b, Pseudomonas aeruginosa, and Eikenella corrodens. No organisms were recovered in 39% of patients. Twelve patients were treated successfully with antibiotics and thoracentesis alone, 23 patients underwent close tube thoracostomy and 26 required decortication. A thickened pleural "peel," scoliosis and opacification of a hemithorax on chest radiograph, as well as low pleural pH and glucose concentration, were associated with a poor response to medical management. A scoring system was developed to define the severity of pleural disease. In patients with severe pleural infections, decortication allowed more rapid defervescence (2.2 vs. 6.5 days) and earlier hospital discharge (4.4 vs. 12.4 days) than did closed tube thoracostomy (P less than 0.001).

Adolescent↗
PubMed1990

Alcohol and the adolescent trauma population.

Trauma is the leading killer of children and adolescents between 1 and 21 years of age. Alcohol-impaired driving represents the single greatest cause of mortality and morbidity of children over the age of 6. We retrospectively reviewed 878 consecutive adolescent (age range, 16 to 20 years) trauma admissions for blood alcohol concentration (BAC). Four hundred sixty-seven patients had BAC drawn, 258 were BAC-negative (group I), 209 (48%) were BAC-positive (group II). The adolescent drinkers were then compared with a group of 748 adult drinkers (group III). Groups I and II differ in sex, age, time of day of the accident, Injury Severity Score, Glasgow Coma Score, and Revised Trauma Score, whereas group II and III differ by type of accident, type of injury, socioeconomic factors (bad debt), time of day of the injury, and BAC. There were no significant differences in TRISS predicted survival, actual survival, nor mean length of stay. We conclude that (1) alcohol is a significant contributor to injury during adolescence, and (2) adolescent drinkers differ from adult drinkers in their habits, demographics, and socioeconomic status. These socioeconomic differences have implications for the access to and cost-effectiveness of interventions.

Accidents, Traffic↗
PubMed1990

Management of congenital microgastria.

Congenital microgastria is a rare anomaly. Only 22 cases have been reported in the literature. Its clinical manifestations depend on the stage at which the embryologic development of the stomach is arrested. The outcome of most patients with severe microgastria previously reported has either been death or extreme malnutrition. Since 1978, four patients with congenital microgastria have been managed at The Children's Hospital of Philadelphia. All patients had severe feeding intolerance and associated congenital malformations. Three patients were treated with a double lumen Roux-en-Y jejunal reservoir (Hunt-Lawrence pouch). This treatment improved the nutritional management of these patients. On follow-up two patients are at the 50th percentile for height and weight, and one is at the 25th percentile. One patient with associated severe congenital heart disease was treated nonoperatively. Her nutritional management was difficult, and she ultimately died of congestive heart failure at 3 years of age. In patients with the most severe forms of microgastria, early operative treatment improves nutritional management and facilitates the achievement of normal growth and development.

Anastomosis, Roux-en-Y↗
PubMed1990

Chylous peritonitis in children: case report and literature review.

Sixty-one cases of acute chylous peritonitis have been reported in all age groups in the surgical literature. Only seven of these cases have been noted in children. We report an additional case of a 7-year-old child who presented with acute peritoneal irritation and, at laparotomy, was found to have chyle in the peritoneal cavity and retroperitoneum. Proposed etiologies and management of this surgical entity are reviewed.

Acute Disease↗
PubMed1990

Carcinoma of the male breast: a review of 41 cases.

We reviewed the cases of 41 consecutive men treated for breast carcinoma from 1950 through 1987 at Vanderbilt University Affiliated Hospitals to examine controversies in and methods of therapy for this disease. Twenty-two patients (52%) had stage I or II lesions potentially curable by operative therapy. The overall 5-year survival rates were 100% for stage I, 65% for stage II, 56% for stage III, and 0% for stage IV. Radical mastectomy offered no advantage over modified radical mastectomy in terms of survival or rate of recurrence. Diagnosis at an early clinical stage and no finding of disease in axillary lymph nodes were important factors in survival in this series of patients. All tumors evaluated for hormone receptors were positive. Although experience was limited, encouraging results were obtained with the use of tamoxifen citrate in adjuvant as well as palliative roles. With the exception of a predominance of centrally located lesions and a uniquely high frequency of positive hormone receptor status, carcinoma of the male breast appears biologically similar to the disease in women, and treatment should be guided by similar principles.

Actuarial Analysis↗
PubMed1990

Cholelithiasis in infants, children, and adolescents.

During the past two decades, cholelithiasis has been recognized in increasing numbers of pediatric patients. This diagnosis should be considered in the event of upper abdominal complaints, particularly when one or more risk factors are evident. The etiology may be unknown or may be related to risk factors, including hemolytic conditions. In recent years, it has become evident that approximately 80% of gallstones in children are not due to hemolytic disease and that the remaining 20% are related to recurring hemolysis. The diagnosis of gallstones is best confirmed with ultrasonography. Routine ultrasonographic evaluation should be performed at intervals for all children who received TPA for more than 4 weeks, particularly those who have had ileal resection or have had chronic enteritis (Crohn disease). Cholecystectomy is the procedure of choice for symptomatic children with cholelithiasis, regardless of age. Cholecystectomy is recommended for the asymptomatic child younger than 3 years of age when echogenic shadows have been present for at least 12 months following resumption of oral feedings or when the gallstones are radiopaque. Also, cholecystectomy is advised for asymptomatic children who are older than 3 years of age if ultrasonographic studies confirm that echogenic foci with shadowing are true stones and not echogenic sludge. Complications of common bile duct obstruction, pancreatitis, perforation with bile peritonitis, and life-threatening sepsis may thus be prevented. Morbidity and mortality following cholecystectomy are expected to be relatively low in the pediatric age group.

Adolescent↗
PubMed1990

Nutrition and cancer in children.

The information generated to date regarding the nutritional status of children with cancer indicates that malnutrition is seen in patients in the later stages of their malignant disease or is iatrogenic because of their intensive therapy. Malnourished children suffer from inadequate growth, including the potential of delayed cerebral development, and they are more susceptible to infection. Nutritional therapy has been shown to reverse the malnutrition independent of the cancer treatment. In doing so, the nutritional support aids in the delivery of and tolerance to the antitumor therapy. What is not possible, however, is making ineffective or marginally effective anticancer therapies effective by nutritional support. Therapy that is ineffective, such as chemotherapy for Stage III or IV neuroblastoma in children, cannot be altered by nutritional support. However, a patient's nutritional state may affect the disease outcome in that complication rates are much higher in malnourished patients. In such children with PCM, nutritional support may make delivery of therapy possible, but it will not affect the ultimate disease outcome unless the anticancer therapy is inherently successful. A well-nourished child is easier to treat and is physiologically more stable. Such children, therefore, have an improved prognosis and lower morbidity and mortality, provided effective therapy is available for the cancer.

Cachexia↗
PubMed1990

Primary hyperparathyroidism in a hypothyroid child.

Congenital hypothyroidism may result in severe mental retardation if this condition is not diagnosed in the neonatal period. Primary hyperparathyroidism in children is even more uncommon, and by 1977 had been reported in only 60 children under the age of 16 years. To our knowledge, we are reporting the first child with both congenital hypothyroidism and primary hyperparathyroidism. Because the normal anatomic relationship of the parathyroid glands to the thyroid gland was absent, preoperative localization studies were necessary. Ultrasonography, radionuclide scanning, and magnetic resonance imaging all indicated a right paratracheal mass in the region where the right lobe of the thyroid gland should be located. At operation, a single, enlarged parathyroid gland that measured 1.5 X 1.2 X 0.5 cm and weighed 500 mg was removed. The discharge serum calcium level was 9.3 mg/dl and has remained normal 2 years later.

Adenoma↗
PubMed1989

Iatrogenic perforation of the bronchus intermedius in a 1,100-g neonate.

A 1,100-g infant was found to have a right tension pneumothorax following multiple attempts at endotracheal intubation. Despite the use of high-frequency ventilation, adequate oxygenation was not possible. Bronchoscopy was hazardous, and bronchography of the right lung using propyliodone oil suspension confirmed perforation of the bronchus intermedius. At thoracotomy, while on high-frequency ventilation, the size of the perforation precluded suture repair, and right middle and lower lobectomies were performed. Follow-up at 1 year showed a small, though healthy infant. Review of the surgical literature has not documented successful operative management of bronchial perforation in a neonate. Selective bronchography was precise in identifying the site of perforation and was well tolerated.

Bronchi↗
PubMed1989

Postpneumonic empyema in childhood: selecting appropriate therapy.

In order to identify appropriate treatment options for postpneumonic empyema, we reviewed the medical records and, when possible, obtained long-term follow-up chest radiographs and pulmonary function tests on children treated for empyema during the past 11 years. Fifty-one patients were treated in various ways, with antibiotics alone (N = 10), or in combination with tube thoracostomy (N = 23) or decortication (N = 18). Despite administration of appropriate antibiotics and establishment of pleural drainage, many children required prolonged hospitalization and eventual decortication. Based on this review, a scoring system was developed allowing early classification by severity of pleural disease. Factors found to be predictors of severe pleural disease include (1) low pleural fluid pH or (2) glucose; (3) presence of moderate or severe scoliosis or (4) pleural peel or parenchymal entrapment by chest radiography; and (5) infection due to anaerobes, gram-negative organisms, or mycoplasma. Complete opacification of a hemithorax on chest radiography and a pleural peel to thoracic ratio greater than 40% were also associated with severe pleural disease. In patients with mild disease (N = 7), response to antibiotics alone, rapid resolution of fever, and shorter hospital stays were observed. In patients with more severe infections (moderate = 22, severe = 22), decortication accomplished earlier defervescence, radiographic improvement, and hospital discharge than simple tube thoracostomy. No deaths or morbidity were associated with decortication, which could often be accomplished through a minithoracotomy. Follow-up chest radiographs and pulmonary fuction tests showed a prompt return to normal after decortication. This experience indicates utility of a pleural disease severity scoring system in selection of treatment options for children with postpneumonic empyema.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1989

Partial splenectomy: the preferred alternative for the treatment of splenic cysts.

We report six pediatric patients who had a partial splenectomy for splenic cysts and a seventh patient who had a total splenectomy. There were six epidermoid cysts and one traumatic cyst. All patients had benign postoperative courses. All patients who underwent partial splenectomy had a significant postoperative rise in platelet count that subsequently returned toward baseline. This rise implies a loss of splenic function, although the exact meaning of this is unclear. All patients had late postoperative liver-spleen scans that showed mean spleen size and function to be normal. We have described several methods of partial splenectomy used at Children's Hospital of Philadelphia. Recommendations for patients undergoing partial splenectomy include preoperative pneumococcus and Hemophilus influenzae vaccinations and prophylactic antibiotics postoperatively. The antibiotics are terminated if a liver-spleen scan and platelet count at the end of 3 months' time are normal.

Adolescent↗
PubMed1989

Continent urinary reconstruction in ischiopagus tripus conjoined twins.

The principle of the continent urinary reservoir involves use of a variety of intestinal segments providing continence, a mechanism of antireflux and a catheterizable stoma in either an abdominal or pelvic location. This concept was used to create a continent urinary reservoir in a 3-year-old former ischiopagus tripus conjoined twin. The solitary renal unit had been drained into a hydrocolpos with an antirefluxing ureteral reimplantation at separation. The patient remained incontinent through the urogenital sinus. At subsequent reconstruction the posterior aspect of the hydrocolpos was tubularized as a vagina, while the remainder of the hydrocolpos was augmented with ileum to create a urinary reservoir. The conduit was constructed with imbricated ileum, in which myectomy had been performed to allow for easier imbrication and tubularization for a narrow neourethra. A second set of conjoined twins have been separated similarly. Of these twins 1 will undergo creation of a continent urinary reservoir in an identical fashion. This represents the first report of the use of hydrocolpos in the creation of a urinary reservoir.

Child, Preschool↗
PubMed1989

Surgical management of alimentary tract duplications.

Alimentary tract duplications are unusual anomalies that may require surgical intervention in the neonate, infant, and occasionally in the older child. The clinical presentation of patients with alimentary tract duplications includes bleeding, abdominal pain, intussusception, and respiratory distress, or it may be an incidental finding on either abdominal examination or chest x-ray. A review of 96 patients with 101 duplications seen over the last 37 years is reported herein. Twenty-one duplications were confined to the thorax; three were thoracoabdominal, and 77 were abdominal. Seventy-four patients presented as infants less than 2 years of age, and 22 patients were older. Ectopic gastric mucosa was found in 21 duplications, and pancreatic tissue was found in five. Seventy-five duplications were cystic and 26 were tubular. Ultrasonography, computed tomography (CT), and myelography are helpful diagnostic tools. Ninety-four of the 96 patients underwent surgical management for their duplications. One duplication was found at necropsy, and one patient was asymptomatic and did not undergo operation. A single death occurred in a 2-day-old infant who had intrauterine volvulus and meconium peritonitis. Management was based on the age and condition of the patient, the location of the lesion, whether it was cystic or tubular and communicating with the true intestinal lumen, and whether it involved one or more anatomic locations. Generally, total excision was preferred, but staged approaches were sometimes necessary.

Adolescent↗
PubMed1989

Prophylactic closed suction drainage of femoral wounds in patients undergoing vascular reconstruction.

Prophylactic closed suction drainage has been advocated in a variety of surgical wounds, but its use in wounds involving vascular anastomoses has not been studied. Fifty patients undergoing lower extremity revascularization that required bilateral groin incisions were randomly assigned to have either the right or left side of the groin drained with a closed suction catheter. The contralateral wound was closed without drainage. Statistically there was no difference between wound closed with drains and undrained wounds in the occurrence of hematomas, seromas, lymphoceles, superficial infections, subcutaneous infections, or graft infections; although serious complications were more frequent in the drained wounds. Prophylactic closed suction drainage appears to offer no advantage over closure without drainage in wounds of the groin resulting from elective vascular operations.

Anastomosis, Surgical↗