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Biomedical subjects

G W Holcomb

Publications and source records attributed to G W Holcomb.

At least 91 records · Page 5Linked to original sources
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↗
PubMed1988

Penetrating popliteal artery injuries in children.

Two children, aged 8 and 12, were seen recently at the Vanderbilt University Medical Center and Metropolitan Nashville General Hospital with gunshot injury to the popliteal artery. Both patients presented with late complications following missed penetrating injury to the popliteal artery. At presentation, distal pulses were palpable despite significant proximal arterial injury. Arteriography detailed traumatic popliteal artery aneurysms in both children, and an arteriovenous fistula in one child. These two children represent the youngest patients recorded in the surgical literature with gunshot trauma to the popliteal artery, subsequent formation of traumatic aneurysms, and an arteriovenous fistula. The increasing availability of guns and rifles in the household will likely increase the incidence of such injuries to children. As evidenced by these children, palpable pulses distal to an injury do not obviate the need for arteriography when arterial injury is suspected. Autogenous repair of the injured artery or reconstruction with autogenous vein graft is preferable for repair of vascular injuries in children.

Aneurysm↗
PubMed1988

Experience with hepatic hemangioendothelioma in infancy and childhood.

This report describes our experience with 16 infants and children with a mean age of 7 months and a median age of 6 weeks with hepatic hemangioendothelioma. Fifteen patients presented with hepatomegaly. Seven had congestive heart failure and four had associated cutaneous lesions. Although diagnosis was clinically evident in 15 of the 16 patients, arteriography and computerized tomography (CT) were diagnostic. A variety of treatment approaches were used including radiation, resection, systemic steroids, hepatic artery ligation, angiographic embolization, and various combinations of these modalities. The following information was gained from this experience. CT with enhancement is as specific a diagnostic tool as hepatic arteriography. Angiographic and CT appearances do not correlate with prognosis. Most patients can be treated successfully with steroids; those who do not respond should have other approaches tried such as embolization or ligation. The angiographic appearance determines whether embolization therapy is worthwhile, as we found that hemangioendotheliomatosis with portal as well as hepatic arterial supply will not respond to embolization. The survival rate in this series was 80%.

Adolescent↗
PubMed1988

Acute abdominal conditions in children and adolescents.

Evaluation and management of the acute abdomen in childhood require a thorough familiarity with the numerous disorders that may cause abdominal emergencies. Many of these entities are rarely seen in adults or have clinical features that are very different from those observed in adults. Diagnosis is often confounded by difficulties in obtaining an accurate history and physical examination. In infants and young children, complications of various congenital abnormalities are more common causes of abdominal pain, whereas acquired disorders are observed more frequently in older children and adolescents.

Abdomen, Acute↗
PubMed1988

Surgical experience with thirteen conjoined twins.

Conjoined twins occur in approximately one in 50,000 or so births, and most do not survive. The authors report herein their experience with 13 conjoined twins over the last 30 years, involving those of the following forms: thoracopagus (4 cases), omphalopagus (1 case), ischiopagus (4 cases), pygopagus (1 case), craniopagus (1 case), and incomplete or parasitic varieties (2 cases). The various diagnostic and imaging studies used are described in detail for each form of twinning. Separation is best delayed until such infants are relatively mature (i.e., 6-12 months of age). Operative survival was 50% in those operated on in the neonatal period, but 90% in those over 4 months of age. Ten separations were attempted in 13 sets of twins, with 16 operative survivors. Significantly, up to 10 years after surgery, there were six late deaths due to serious associated congenital anomalies, predominantly cardiac. Improved recent survival is probably the result of the availability of more accurate imaging studies and better anesthetic and operative techniques, with great emphasis on performing immediate reconstruction whenever possible. Use of skin expanders and prosthetic mesh has facilitated wound closure. In the future, ex vivo cardiac reconstruction and autotransplantation may permit separation of twins with complicated conjoined hearts.

Female↗
PubMed1986

Spectrum of biliary disease in childhood.

Obstructive biliary disease in childhood is not common, but should be considered in the differential diagnosis of a child with jaundice, abdominal pain, or an abdominal mass. We have reviewed the experience at Vanderbilt Children's Hospital from 1970 to 1985, during which 87 children 18 years of age or younger with biliary tract disease were seen. Twelve patients (14%) had congenital disorders including choledochal stenosis, Caroli's disease, choledochal cyst, teratoma of the common hepatic duct and common bile duct, congenital septate biliary tree, and isolated atresia of the distal common bile duct. Thirty patients had neonatal cholestatic syndromes, and 37 had calculous disease of the gallbladder or extrahepatic bile ducts. Three patients had obstruction of the common bile duct caused by fibrosing pancreatitis. Two had sclerosing cholangitis. Obstruction of the common bile duct was caused by metastatic neoplasm in three patients. We discuss principles of diagnosis and management.

Adolescent↗
PubMed1984

Renal artery dissection.

Renal artery dissections are stenotic or occlusive lesions most often observed in hypertensive patients with underlying atherosclerosis or fibromuscular disease. Acute dissections may present spontaneously, as a complication of diagnostic or therapeutic angiography or as an agonal event associated with overwhelming systemic illness. Chronic dissections may produce renovascular hypertension or be entirely asymptomatic. Fourteen renal artery dissections have been encountered in nine patients treated at Vanderbilt University Medical Center during the past decade. Eleven dissections have been found in seven patients with renovascular hypertension. Seven of these dissections were chronic (six functional, one silent) and four acute (two spontaneous, two secondary to angiography). Three agonal dissections were found in two additional patients postmortem: one at autopsy and bilateral dissections found at the time of cadaveric donor nephrectomy. Ten bypass procedures, including five complex branch reconstructions of which three were performed ex vivo, have been performed with 100% immediate patency and maintenance or improvement of renal function. Long-term follow-up of these patients has shown sustained patency of the reconstructed renal arteries, excellent blood pressure control, and normal renal function in all. Nephrectomy has not been required and there have been no associated deaths. Seventy-seven additional renal artery dissections in 72 patients collected from previous reports have been analyzed. Patient survival (55/72, 76.4%) and preservation of the involved kidney in surviving patients (26/55, 47.3%) were low in these earlier series. In addition, renal failure was associated with 59% of the deaths. The lethality of renal artery dissections and the ease and success of revascularization, which preserves renal function and ameliorates associated renovascular hypertension, emphasize the need for an aggressive approach to the recognition and treatment of this entity. Therapy should be directed toward arterial reconstructions and the preservation of functioning renal tissue.

Adult↗
PubMed1982

Recent experience with esophageal atresia.

A nine-year experience with esophageal atresia of all types is described with current diagnostic and therapeutic approaches and long-term results. During this time, 53 neonates with esophageal atresia and tracheoesophageal fistula had a 93% survival, with four deaths in risk group C. Temporary postoperative morbidity related to the anastomosis occurred in ten patients. All patients had some disturbance in esophageal motility. While all have been studied for gastroesophageal reflux, only five had significant reflux, and four required fundoplication. Five patients with isolated esophageal atresia survived staged repair, and an additional five patients with H-type fistulae survived primary repair, including one with a long tracheoesophageal cleft. Despite the fact that 45% of the 63 patients had significant associated anomalies, initial survival was 93.5% and late survival 91%. Long-term functional results were generally satisfactory.

Esophageal Atresia↗
PubMed1980

Cholecystitis, cholelithiasis and common duct stenosis in children and adolescents.

A study of 100 patients from 14 months through 18 years of age with extrahepatic biliary tract conditions who have been treated from 1950 through 1979 is reported. For discussion, these have been classified into four groups including acalculous cholecystitis, nonhemolytic cholelithiasis, hemolytic cholelithiasis and stenosis of the common duct. Ninety-nine patients were operated on and there were no deaths. Except for unusual contraindications, cholecystectomy is preferred for acute noncalculous cholecystitis. The largest number having gallstones were those patients (87%) without hemolytic disease. Only 13% had an associated hemolytic disorder. Cholecystectomy is the preferred treatment and common duct exploration is utilized when indicated. Six children with chronic relapsing pancreatitis secondary to stenosis of the ampulla of Vater and two with common duct stenosis are analyzed. Although extrahepatic biliary disorders are usually not considered in the differential diagnosis of children and adolescents with vague abdominal pain, it is evident by this large number of patients that there should be greater emphasis placed on earlier diagnosis in the future.

Acute Disease↗
PubMed1979

Surgical experience with neonatal necrotizing enterocolitis (NNE).

Neonatal necrotizing enterocolitis, a highly lethal disorder of premature infants, is a common occurrence in newborn care units. This report details operative experience with 33 infants over the past seven years. During this time many more infants with NNE have recovered with supportive therapy. All patients are treated on a standard protocol of therapy and monitoring designed to select those with signs of continuing clinical deterioration. Therefore, those coming to operation had additional complications, such as perforation, intestinal gangrene or stenosis. This protocol is described. The 33 infants, averaging less than 4 lbs., developed NNE within five days of birth. Perforation and signs of continued clinical deterioration were the indications for operation; severe sepsis and clotting abnormalities were the rule. The overall mortality was 40% but included six infants with total bowel necrosis who had laparotomy alone. Five patients had intestinal or colonic resection with primary anastomosis, with two leaks leading to death. Twenty-one patients had staged resection with delayed anastomosis and only four deaths. Thus 27 determinative cases had a 26% mortality, and the recent group with staged resection had a 19% mortality. The essentials of pre-, intra- and postoperative management are detailed, as well as pathology and bacteriologic data. Most infants had temporary malabsorption requiring parenteral nutrition and special diets. Long-term results are gratifying.

Enterocolitis, Pseudomembranous↗