Biomedical subjects
Publications and source records attributed to H H Nixon.
The intestinal obstruction of duodenal atresia needs urgent differential diagnosis from malrotation with its risk of midgut volvulus and gangrene. There is an uncommon variant with a high incidence of familial recurrence, and a significant association with Down's syndrome, although the majority of the babies are otherwise normal. Oblique end-to-end anastomosis around the atresia is the preferred treatment and has a high success rate.
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The mortality occurring in a series of 310 patients with Hirschsprung's disease is analysed. Forty-one (13%) died, 13 (4.5%) soon after a pullthrough operation. Anastomotic leaks were the largest cause of death in this latter group, but enterocolitis remains the most important cause of overall mortality.
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In a controlled trial in children aged 2 days to 16 years undergoing large bowel surgery a group of 15 patients had preoperative mechanical bowel preparation and oral neomycin while a second group of 15 patients was similarly prepared but also had preoperative and postoperative metronidazole medication. Five of the 9 postoperative infections in the first group involved Bacteroides spp. but no anaerobe was found in the 3 wound infections in the metronidazole group.
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Suction rectal biopsy specimens, from a series of 168 infants and children with constipation and other gastrointestinal problems, were stained with a sensitive acetylcholinesterase method, and the results were compared with routine histology, radiology, anorectal manometry, and the final diagnosis. In all cases of Hirschsprung's disease, there was an increase in numbers and sizes of cholinergic nerves in the lamina propria and muscularis mucosae. No false-positive or false-negative results were found. The test was found to be more reliable and consistent than other methods available.
A group of 43 adults who as children had been diagnosed as having bilateral retractile testes were traced. Seventy-four per cent of the married patients had children. The testicular volume was normal in all the 19 patients examined.
The long-term results of low anomalies are excellent, as expected, whether primarily treated by cutback or transplantation. Those of the high anomalies are perhaps better than expected but only achieved after an unacceptably long period of incontinence. Better techniques are still needed for these supralevator deformities. Permanent colostomy also had its problems.
A case of neuronal colonic dysplasia in association with Hirschsprung's disease is described. It is suggested that this condition be borne in mind when investigating operated Hirschsprung's cases having residual symptoms.
A case of adynamic bowel syndrome is described. Full thickness biopsies of the large bowel showed the presence of ganglion cells, no acetylcholinesterase positive nerves in the lamina propria, submucosa or among the smooth muscle cells of the circular and longitudinal muscle coats, and absence of the argyrophil plexus. Electron microscopic examination showed replacement of the normal axon bundle by vacuolated tracts with small round bodies in one area--probably viral. Neuronal cytoplasm also showed similar vacuolation. It is suggested that the damage to the cholinergic innervation may be caused by a neurotoxic agent.
84 of 89 cases were traced 18 to 27 years after Swenson's operation. Seven had long segments. All were alive and in good general health except one who had renal transplant for hypertension due to pyelonephritis in a residual solitary kidney. 61 are married of whom 34 have children. None of the children have Hirshsprung's disease. 48 were fully normal within one year of operation. 29 had constipation enough to require treatment. Seven had diarrhoea which in three required hospitalisation for electrolyte disturbances and dehydration. 39 had some degree of soiling, but in only nine was this troublesome. Recovery of normal bowel control was more rapid in those with a good social background. Eight had postoperative strictures, but treatment has remained successful in the long-term in seven of these. Five patients had inadequate resections and are well after further surgery. Nine had urinary incontinence of which seven had only nocturnal enuresis. All are fully recovered. Two male patients have absence of ejaculation and two females are infertile with scarred Fallopian tubes. 83 of the 84 now have normal bowel control and good health. One has a permanent ileostomy.
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A procedure is described which combines the posterior liberation of the levator with the levator plication. This operation was performed in 15 children, born with anorectal agenesis, all of whom were incontinent of feces after primary operation. Four of the 15 children became fully continent following levatorplasty, seven patients now have only occasional soiling, and four patients continue to soil persistently. In all the cases, a good correlation was found between bowel control after levatorplasty and anal canal pressures. Normal resting anal canal pressure was as significant as the voluntary squeeze pressure in relation to continence.