Biomedical subjects
Publications and source records attributed to H Rode.
This is the report of a newborn girl who was treated by "trial of life" before surgical repair of her left-sided diaphragmatic hernia. Surgery was performed 60 hours after birth, at which time she was found to have an organo-axial volvulus of the stomach. Her postoperative course was complicated by a jejunal perforation on the fourth postoperative day, necessitating another laparotomy.
Respiratory distress secondary to scalds in children is rare. We report 13 children (six girls and seven boys) with a mean age of 19 months who sustained this injury, who were admitted to a major referral hospital during a 5.5-year period. Associated scalds usually to the face were always present and the mean total burn surface area (TBSA) was 14.4 per cent (range 3-30 per cent). Stridor was the most common presenting symptom with a variable time of onset. Bronchoscopy was performed in 11 children and in nine the injury was confined to the supraglottic area. Five children were treated with epinephrine nebulization and the symptoms resolved in 3-4 days, one child had a prophylactic tracheostomy. Seven children required intubation and ventilation. Three children died, two of whom sustained burns to both the upper and lower respiratory tract. Respiratory distress secondary to scalds may not be recognized or the progressive nature of the injury not appreciated. In three-quarters of our patients the injury was confined mainly to above the glottis. Children with inspiratory stridor can be managed with epinephrine nebulization but more marked respiratory distress requires intubation and ventilation. Mortality was due to direct thermal injury to the respiratory tract and secondary bronchopneumonia.
The management and outcome was evaluated in 33 patients during an 18-month period, who sustained burns as a result of working with a primus stove. There were 17 females and 16 males with an average age of 32.5 years. Twenty-nine patients were black skinned and four were coloured skinned. The average burn surface area was 16.8 per cent and the burns were deep dermal in all; 48 per cent of patients also had areas of full thickness skin loss. Twenty-seven patients were burned in more than one anatomical area. Patients spent an average of 24 days in the burns unit and all patients required tangential excision and skin grafting at least once. The average number of units of blood required was four. Only one patient died. Primus stove burns occurred in people of poor social circumstances. Primus stove burns place a heavy burden on the economic resources available. Prevention is the key to management.
Primary palmar hyperhidrosis can be a most unpleasant and distressing affliction. When normal daily activities, viz. writing, schoolwork, are interfered with and other treatments have failed, surgery is indicated. Between 1983-1987 9 children (6 F, 3 M), mean age 10.2 years (range 5-14 years) underwent bilateral transaxillary sympathectomy, 4 simultaneous and 5 1-4 weeks apart. On 14 sides a standard excision of dorsal ganglia (DG) 2, 3, and 4 was performed. The technique of lateral displacement of the sympathetic chain after transection distal to DG 4 and division of preganglionic fibres of DG 4, 3 and 2 was used on 5 sides. In addition to clinical evaluation a pilocarpine stimulation test was performed on the palms of the hands before and at follow-up 3-7 years after surgery. 17/18 hands appeared sympathectomised at early follow-up. One inadequate result required reoperation. Other complications included 2 Horner's syndromes--1 transient and 1 mild but permanent; 3 temporary intercostobrachial paraesthesias, 2 mild late recurrences of sweating and 2 compensatory increases in sweating. In 14 palms where sweat volume was measured before and 3-7 years after surgery there was a mean decrease in sweat of 84% (mg), those sweating the most prior to surgery having the best response. In 2 further palms insufficient sweat was obtained for testing. All but 1 considered the procedure worthwhile. Transaxillary transpleural sympathectomy is a safe, effective, and cosmetically acceptable operation to control symptoms of excessive palmar sweating.(ABSTRACT TRUNCATED AT 250 WORDS)
In the present study, allergens of Cladosporium herbarum were analysed by SDS-PAGE, two-dimensional gel electrophoresis and immunoblot. The SDS-PAGE under reduced conditions followed by western blotting analysis revealed 10 human IgE-binding components with molecular masses ranging from 15 to 143 kDa. Within the same molecular mass range, five components were detected under non-reduced conditions. Examination of the specificities of 10 individual sera revealed that two patients were sensitive to almost all the allergens, whereas the majority reacted with only some components. Two-dimensional immunoblot was employed to further analyse the allergens in the extract. A silver-stain of the two-dimensional gel revealed that there were more than 30 different protein components visible in the extract. Immunoblot of the proteins separated under denatured conditions disclosed that 17 spots were reactive with human atopic sera.
Ambulatory surgery has become an important component in the provision of surgical care. In 1987 a day-case surgical unit was established at Red Cross War Memorial Children's Hospital, Cape Town. Experience over a 6-year period (1987-1992) is reviewed in relation to the nature and total number of surgical procedures, pre-operative preparation, daily utilisation of the facility, postoperative care and complications. During this period 16,538 patients (mean age 3 years) were operated on in the unit. Nine surgical disciplines participated. Pre-operative assessment and preparation reduced the rate of cancellations on the day of surgery to less than 6%, with a 90% effective use of schedules operating time. Scarce nursing resources were also maximally utilised. Most procedures took less than 30 minutes and only 0.8% exceeded 1 hour. The average ward stay was 6 hours. No major complications were encountered and acceptance by patients and parents was excellent. Only 16 children who were not scheduled to do so needed to stay in hospital overnight. Recommendations to establish and improve day-stay surgical services are presented. It is concluded that a practical, efficient service can be established and that the authorities should be encouraged to expand appropriate facilities.
The aim of this study was to clarify the role of the oligosaccharide side chains of MHC Class II antigens in allostimulation. The approach was to cleave the oligosaccharides from protein by subjecting plasma membranes (PM) of the Daudi cell line to chemical deglycosylation yielding deglycosylated (dgl) proteins and a supernatant fraction containing plasma membrane oligosaccharides (dgl sup). MHC Class II antigens affinity purified from the native and the dgl PM were inserted into the plasma membrane of peripheral blood leukocytes (PBL) used as stimulators in a mixed leukocyte reaction (MLR). Cells used as stimulators and as responders were from the same donor. Both native and to a lesser extent the dgl antigen could elicit a proliferative as well as a cytolytic (CML) response. A comparable reduction in the CML reaction was also obtained when native antigen was used to elicit effector cells, but the target was stripped of N-linked oligosaccharides by pretreatment with tunicamycin (TM). Five clones of responding cells raised against the native antigen were studied. Two gave proliferative reactions of equal magnitude to native and to dgl antigen alike, while three responded only to the native form. These three clones did not lyse TM-treated target cells. Inhibition experiments of CML were performed with either the dgl sup containing Daudi PM oligosaccharides or with an anti MHC-Class II MoAb. CML reactivity of the three clones which responded to native antigen was blocked by the dgl sup but not by the anti-MHC antibody. Conversely, the reaction of the two clones reactive to both forms of antigen was only inhibited by the anti-MHC antibody using intact or TM-treated targets. Accordingly, in terms of the latter set of clones oligosaccharide side chains of MHC may not be required for allostimulation. Data obtained with the set of three clones suggest that oligosaccharides could act as target of cytotoxic T cells.
A 5-year audit of the formation, management and closure of small-bowel stomas and colostomies at Red Cross War Memorial Children's Hospital, Cape Town, is described. Of the 203 patients, 128 (63%) required the stroma in the neonatal period. Anorectal malformations (80), Hirschsprung's disease (65), necrotising enterocolitis (33), trauma (11) and neoplasm (5) comprised most of the indications. One hundred and thirty large-bowel stomas were sited in the proximal sigmoid and 37 in the transverse colon, all but 11 being divided with each end brought out through a short muscle cutting incision or through the laparotomy wound. Thirty-six ileostomies were performed and in 30 of these the stoma was sited in the wound. Complications, which included necrosis, bleeding, prolapse and wound sepsis, occurred in 31%. The colostomies sited in the transverse colon had the highest incidence of prolapse (38%). Neonatal stomas brought out in the wound had an acceptably low incidence of complications. Most stomas were temporary in nature. One hundred and eighty-eight were closed, all with excision and end-to-end intraperitoneal anastomosis. There was a 4% incidence of complications (5 would sepsis, 2 leaks, 1 stenosis). The formation, management and closure of bowel stomas represents a considerable section of the work of the paediatric surgeon. Correct meticulous technique is essential in keeping complications to a minimum.
The syndrome of degenerative leiomyopathy causing intestinal obstruction clinically manifests in young indigenous African children as massive megacolon without aganglionosis. Eighteen children have been seen over a 16 year period from a localized geographic area. There were 10 males and 8 females having a mean age of 9.5 years at presentation and a mean duration of symptoms of 4.3 years. The youngest was 6 months old. All had progressive abdominal distension and infrequent stooling but 11 had intermittent diarrhoea and 9 had colicky abdominal pain. Gross gaseous distension of the large bowel with extension into small intestine occurred in 9 and this extended into stomach and oesophagus in 4. Biopsy of the dilated, thin walled bowel showed smooth muscle degeneration and necrosis with replacement by fibrous tissue. Neuronal cells of Auerbach's plexus tend to be displaced into the circular layer of smooth muscle with mild inflammatory changes. Some small arteries show medial fibrosis with subintimal fibroblastic proliferation. Acetylcholinesterase and immunohistochemical staining with neural and muscle markers are within normal limits. One child died while 14 have been maintained on prokinetic agents, low residue diets, laxatives and enemas. Nine children have required surgical intervention of whom 4 had volvulus and 3 adhesive bowel obstruction. Degenerative leiomyopathy is a distinctive entity with classical clinical and histological features. The aetiology is still obscure.
A survey of the current practice of general paediatric surgery in South Africa and Namibia was conducted by means of a postal questionnaire. One hundred and eighty-one replies were obtained (52%). Analysis showed that although surgeons are located predominantly in the major cities, 18% practised in the larger towns or rural areas. Although paediatric surgery represents a small volume of their work, most surgeons do attend to the surgical needs of children. The majority of surgeons have received some paediatric surgical training but this was considered inadequate by nearly half of all surgeons and by 60% of those who qualified in the last 10 years. Current postgraduate training at most of our universities involves a 3-6-month rotation, but from our survey this is considered insufficient in practice and there appears to have been some deterioration in paediatric surgical training in recent years. Steps needed to maintain paediatric surgical standards are discussed.
Subarachnoid-pleural fistula is an unusual complication of spinal cord injury without radiologic abnormality (SCIWORA) and a rare cause of posttraumatic pleural effusion. The clinical presentation and surgical management of a child, the first with this complication seen at our institution, who sustained a T-6 SCIWORA and a cerebrospinal fluid-pleural effusion following a pedestrian-motor vehicle collision is discussed. Magnetic resonance imaging (MRI) proved superior to myelography in demonstrating the fistulous connection and associated cord damage. The fistula was successfully closed via a thoracotomy using a muscle and pleural plug.
Over a 14-year period 587 children under 13 years of age were admitted with blunt injury to the abdomen. Twenty-nine (4.9 per cent) of these were found to have bowel rupture. Evidence of peritonitis was present at initial evaluation in 11 children (38 per cent). Radiological evidence of perforation (pneumoperitoneum) was present in only five of 27 (19 per cent) with a further six of 27 (22 per cent) showing dilated loops of bowel or fluid levels. Thus 59 per cent of radiographs were not diagnostic. The mean time from admission to laparotomy was 17 h. Proximal bowel perforation was common and perforation at multiple sites occurred in five patients; 59 per cent had a concomitant injury which resulted in two deaths (from head injury). Initial clinical and radiological evidence of bowel perforation can be misleading and reliance on such indicators may result in significant diagnostic delay. Frequently repeated clinical examination is advocated; progression of abdominal signs should alert the clinician to proceed to laparotomy.
Two cases of delayed shunt infection attributable to the abdominal complications of Ascaris lumbricoides infestation are reported. The first child presented with a peritoneal shunt catheter protruding through the anus and the second patient was found to have two live worms around the cephalic shunt tubing. Both had enteric shunt infections which responded well to therapy. The epidemiology and treatment of ascariasis are briefly discussed.
Although the therapeutic approach to gastroesophageal reflux in children is well established, there are differences of opinion regarding the management of esophageal strictures, viz bougienage with medical therapy, fundoplication without dilatation, preoperative dilatation followed by fundoplication with intraoperative and postoperative dilatation, or resection and interposition. Sixteen consecutive children (mean age, 30.2 months) with reflux strictures were evaluated, constituting 12% of children operated on for gastroesophageal reflux. The strictures became clinically apparent 22.4 months (mean) from the onset of symptoms and were diagnosed by contrast studies and endoscopy. At first endoscopy all the patients had well-established fibrotic strictures. The strictures were mostly situated in the middle or lower esophagus and 7 were longer than 3 cm in length. All 16 were treated with antacids, H2-receptor blockers (Cimetidine), prokinetic agents, and intense nutritional resuscitation, together with preoperative stricture dilatations (average, 3.6 times). This was followed by fundoplication when nutritional parameters had been restored, esophagitis improved, and the strictures dilated to adequate size. Seven children required concomitant gastrostomies for prograde esophageal dilatations. Twelve children needed postoperative esophageal dilatations. The results were satisfactory in 14 (88%). Two required endoesophageal resection for localized unyielding strictures. One child responded only after failed reflux surgery was corrected at a second procedure. During an average follow-up of 8.2 years (range, 3 to 11) there has been no stricture recurrence and growth velocity was restored in all. We conclude that our preferred method is preoperative in-hospital management of gastroesophageal reflux with maximum nutritional support and careful evaluation of the degree and extent of esophagitis and fibrous scarring.(ABSTRACT TRUNCATED AT 250 WORDS)
An increasing incidence of colorectal carcinoma has been noted at this institution. We report seven children with colorectal carcinoma. The average delay between onset of symptoms and diagnosis was 41/2 months, and in five patients distant metastases were present at the first operation. Initial symptoms were ignored in all cases and in only one was the serious nature of the condition realized at first presentation. In five lesions the histology was mucin secreting adenocarcinoma, a poor prognostic variant. All seven died on average 11 months after diagnosis. These three factors--delay in diagnosis, advanced stage of disease, and poorly differentiated histology--contribute overall to a poor prognosis in the young.
The use of concomitant tube cecostomy remains an option for decompression after distal large-bowel surgery but has been criticised because of a reported high complication rate. Two hundred and three patients who underwent a Soave endorectal pull-through procedure for Hirschsprung's disease (1974-1990) were evaluated. Operative technique included a modified sutured Soave endorectal pull-through procedure and a Stamm tube cecostomy utilising a large-lumen catheter. One hundred and twenty patients who had a modified two-stage procedure plus concomitant tube cecostomy were compared with 83 patients who underwent a three-stage procedure with colostomy cover. Early postoperative complications occurred in 8 patients (6.6%) in whom cecostomies were performed. A distal cuff abscess developed in 1 patient (0.8%), an anastomotic leak in 1 (0.8%) and 3 patients (2.5%) had colo-anal stenosis. The cecostomy tube dislodged in 2 patients and 1 required operative closure of a faecal fistula at the cecostomy site. Colonic venting was adequate and little nursing care was required. In 2 instances colonic distension developed after cecostomy clamping. Decompression was achieved by opening the cecostomy tube; this resulted in relief of symptoms and a good subsequent recovery. In contrast, there were 11 postoperative complications in the 83 patients undergoing a three-stage procedure (13.2%). In 2 patients (2.4%) an anastomotic leak occurred and 5 distal cuff abscesses (6%), 3 (3.6%) early strictures and 1 (1.2%) neorectal retraction developed. The use of a concomitant tube cecostomy with a two-stage Soave procedure is an effective and safe means of providing proximal colonic venting and did not add to mortality or morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)
Creation of neomucosa is one of many experimental surgical techniques tried in order to improve the results of the complicated treatment of short bowel syndrome. The syndrome is associated with severe physical and mental retardation and not infrequently may be fatal. In this experimental study on pigs and rats we successfully enlarged the small bowel surface by growing new mucosa on the parietal peritoneum following enteroperitoneal anastomosis. The technique has 2 more important advantages: fluids and electrolytes are absorbed through the peritoneum and bowel transit time is slowed.