Biomedical subjects
Publications and source records attributed to J H Hertzler.
This is a report of a case of primary occlusion of the abdominal aorta in the first day of life that was managed operatively. Thromboembolic occlusion of the abdominal aorta is a surgical emergency. When promptly recognized and managed with arteriotomy and thromboembolectomy, morbidity and mortality should significantly decrease.
Esophageal atresia with distal tracheoesophageal fistula has been treated at one institution between 1951 and 1983 primarily by prompt transpleural repair without gastrostomy. Two hundred and seventy one patients are assigned to three time periods: (1) 1951 to 1963, prior to modern intensive care; (2) 1964 to 1973, the initial era of mechanical ventilation; and 1974 to 1983, the era of readily available ventilators and TPN. During these time periods mean birthweight decreased from 2,780 g to 2,670 g to 2,500 g, while the incidence of associated anomalies increased from 41% to 44% to 55%. Eleven patients had no operation or gastrostomy only and died. Twenty (predominantly in the early years) had staged repairs with initial gastrostomy and fistula ligation. Primary anastomosis was done in 240 patients regardless of birth weight, 229 of which were by the transpleural approach. Gastrostomy was performed primarily in 28 patients for varied indications. Operative mortality (definitive as well as staged repairs) fell over the three time periods from 44% to 15% to 7%. Anastomotic leaks occurred in 20% of patients who underwent primary repair regardless of the time period. The mortality associated with a leak, however, decreased from 88% to 47% to 0%. Anastomotic strictures requiring more than two dilatations occurred in 15% in all periods. The overall incidence of recurrent fistula was 5%. Of 200 patients surviving the initial hospitalization, follow-up longer than 2 months is available for 156 patients with a median follow-up of 30 months. There were 15 late deaths.(ABSTRACT TRUNCATED AT 250 WORDS)
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Rectal prolapse in pediatric patients has different anatomic causative and, hence, therapeutic significance from prolapse or procidentia encountered in adults. Medical management successfully relieves prolapse in a large percentage of pediatric patients. Seventy-three patients in whom the correction of rectal prolapse by medical management failed underwent linear cauterization of the anorectum. Seventy-one were treated successfully. Five children had an additional cauterization for the permanent relief of rectal prolapse. One patient required an additional extensive operation to prevent recurrence. This successful method of managing rectal prolapse has been associated with a low morbidity rate and should be considered before attempting more complex alternative surgical procedures.
Congenital diaphragmatic hernias appearing in late infancy or childhood are entities distinct from the more common newborn disorder. "Delayed" diaphragmatic hernias are associated with prior normal chest roentgenograms. Symptomatic intermittent herniation of abdominal viscera through a congenital posterolateral defect has not been previously reported in 17 cases of late-onset diaphragmatic herniation and may explain the latency period seen in older children.
Omphalocele, umbilical cord hernia, and gastroschisis are surgically correctable defects of the abdominal wall. Each of these defects has a distinct embryologic basis that results in a characteristic clinical picture. Twenty-five infants with congenital defects of the abdominal wall were treated at the University of New Mexico Hospital in the past four years. Six infants had omphalocele, one had umbilical cord hernia, and 18 had gastroschisis. Survival among infants who underwent a corrective operation was as follows: omphalocele, 50%; umbilical cord hernia, 100%; and gastroschisis, 82%. Long-term survival for the entire group was 72% (18/25). Gastroschisis, which had a lower incidence of major associated anomalies, had a better prognosis than omphalocele. The mortality of congenital abdominal wall defects was related to presence of severe associated anomalies and to poor clinical condition on admission. Prompt and informed initial care may increase the chance of survival.
Aspiration of foreign bodies into the pediatric airway is a common surgical emergency condition. Once impacted into the peripheral airway, repeated attempts at removal may push these objects into segmental bronchi, causing endobronchial bleeding, and prolonged anesthesia time. In addition to standard endoscopic techniques, the use of fluoroscopy, endobronchial contrast material, topical vasoactive medications, and diverse retrieval instruments in eight such cases has avoided the need for either bronchotomy or segmental pulmonary resection. By using such supportive intraoperative techniques, the morbidity and mortality from impacted airway foreign bodies can be greatly reduced.
We reviewed a 22 year experience with 138 newborn infants with congenital evisceration through defects of the abdominal wall. Omphalocele is a large defect which always has a sac, in which the rectus muscles insert laterally on the costal margins and which usually has associated anomalies. Cord hernia is a small defect which always has a sac, in which the rectus muscles insert at the xiphoid and which commonly has associated anomalies. Gastroschisis is a small defect which never has a sac, in which the rectus muscles insert at the xiphoid and has few associated anomalies, though prematurity is frequent. We hypothesize that gastroschisis develops because the umbilical coelom fails to form, which forces the elongating midgut to rupture into the amniotic cavity. This differs from the embryogenesis of omphalocele, which is failure of closure of a primary body fold, and from that of cord hernia, which is failure of the midgut to return from the umbilical coelom. The number of infants in this series who survived after surgical repair of an omphalocele was 31 of 51 patients; of a cord hernia, 22 of 28 patients, and of gastroschisis, 40 of 59 patients. Factors contributing to mortality were associated anomalies, low birthweight and surgical closure under excessive tension.
Mucosal perforation during Fredet-Ramstedt pyloromyotomy is the cause of unnecessary morbidity and death if unrecognized. Previously, a variety of closure have been advocated. In 1,777 cases there has been 42 (2.3%) intraoperative perforations. One unrecognized perforation led to a postoperative death. Closure of a mucosal tear is accomplished safely by a simplified suture technique without prolonged convalescence or death.
Cystic adenomatoid dysplasia of the lung is an unusual lesion, only 142 cases having been reported in the English literature by 1979. This review describes 32 additional previously unreported patients treated at our institution. The male:female ratio was 1.4:1 and lesions were equally distributed in both lungs. The age range at presentation was 1 day-14 yr. This large experience identifies two distinct modes of presentation. Ten patients presented as newborns with acute progressive respiratory distress secondary to mediastinal displacement and pulmonary compression as a result of the expanding cystic lesion. This group of patients ranged from 1 to 28 days with a mean of 9.4 days of age. Of the remaining patients, varying from 2 mo to 14 yr, half were under 1 yr. The presentation in this group was generally different. Unresolving pulmonary infiltrate (5) or recurrent respiratory infection localized to the same portion of the lung (7) prompted the diagnosis of a pulmonary developmental abnormality. Three children in this group had failure to thrive. Progressive dyspnea was not a characteristic finding. Specific lobar or segmental resection effectively eradicated the disease process. All of the last 30 patients resected have survived without unusual sequelae. Cystic adenomatoid dysplasia should be considered in the differential diagnosis of progressive respiratory disease in the neonate or of recurrent or persistent pneumonic processes in the same segment of the lung in the older child.
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Case histories of 53 patients with surgically treated vascular rings are presented. The diagnosis was strongly suggested in all patients by symptoms of tracheosophageal obstruction and was confirmed by barium esophagogram, which showed typical bilateral and posterior indentations in the esophagus. Angiography was rarely used although it is helpful in doubtful cases. Endoscopic studies were considered unnecessary and potentially harmful. A left posterolateral thoractomy afforded ample access for division of the ring in all patients. Two patients died who were operated upon during the early experience. There were no postoperative deaths among the last 45 consecutive patients. All survivors had excellent symptomatic relief although complete resolution of symptoms took several months in some patients. All survivors had excellent symptomatic relief although complete resolution of symptoms took several months in some patients. The importance of early diagnosis and prompt surgical division is emphasized.
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In 27 years, 64 patients were operated upon for ovarian lesions, 43 for tumors, 12 for nonneoplastic cysts and nine for ovarian torsion. Of all the girls in this age group who were operated upon for appendicitis, 2 percent had ovarian lesions. Of the girls referred for isosexual precocity in the last ten years, 4.7 per cent had ovarian lesions. Of the girls in this age group operated upon for malignant abdominal lesions, excluding hepatic, in the last 15 years, 10.8 per cent had ovarian tumors. Of the 11 tumors with endocrine function, four were malignant. This association is statistically significant. There were no operative deaths. There were no postoperative deaths among six patients with Stage I and II lesions. Mortality was confined to the two patients with Stage III and IV lesions. The surgical approach was designed to conserve ovarian tissue, and adjunctive chemotherapy and radiotherapy were infrequently used.
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