Biomedical subjects
Publications and source records attributed to J Waldschmidt.
The technique is described, and the experience gained with 7 laparoscopic sigmoid resections is reported. The approach resembles Swenson's technique with only the preparatory part performed laparoscopically. With the most recent procedures, the anaesthesia time of the laparoscopic procedure did not exceed that of the open technique. There were no serious complications or blood losses.
We report on 4 children where Meckel's diverticula (MD) were excised laparoscopically. In two of the children the finding of an MD was incidental and in two it was suspected preoperatively. In three of the patients the MD was ligated by means of an "endoloop" and could be removed in a similar manner to an appendix. In one patient the MD was resected by means of a stapler. No complications occurred. Subsequent histology confirmed the complete excision of the MD. Allowing for the size and shape of an MD, we prefer to excise it by means of an endoloop. An endoloop has the advantage that it can be used through a 5 mm trocar while a stapler has the disadvantage that it requires a larger 12 mm trocar and it leaves a foreign body, i.e. metal clips behind.
Complete correction of malformations in the first hour or days of life has always been the target of pediatric surgeons. The possible halt of palliative operations involving the application of stomata in the trachea, esophagus, stomach, bowels and at the diverting urinary tract is to lighten the situation for parents and neonatologists. Requirements for a definitive primary surgical correction are an accurate diagnosis and careful selection of the child. Criteria include not only age and bodyweight, but also the presence of co-existing malformations, diseases and complications. Thus it is also possible to correct complex malformations primarily in one operation and to withdraw the use of stomata.
Ultrasound-guided, laser-induced thermocoagulation with Nd:YAG laser (1064 nm) was performed in a child with metastatic gastrinoma disease. The emitted laser energy to coagulate a radius of 15-20 mm of metastatic liver tissue was 4 W with a duration time of 300 s. Marked reduction of gastrin was observed after interstitial laser hyperthermia.
In neonates a new fixation of the trocars must be found since the umbilical ring is large and distensible and the abdominal wall is very thin. The pressure-controlled pneumoperitoneum is maintained by using a special "surgiflator" system which prevents high pressure peaks in the small abdominal cavity of neonates. By using a Nd:YAG laser for transection during coagulation an additional trocar can be dispensed with.
In the last three years an interdisciplinary ECMO (extracorporeal membrane oxygenation) team has been set up at the Free University of Berlin in the Steglitz clinic. With this form of management, newborns only a few hours or days old who present with pulmonary failure can temporarily be managed with extracorporeal oxygenation until normal lung function is restored. The set up of this ECMO team, starting with experimental training in animal models, to the bedside clinical use is discussed. The following presentation of the first four cases managed here with ECMO aims to clarify the problems which may be encountered as well as amplifying its use as a life-saving measure.
Duodenal duplications are rare. Modern imaging procedures demonstrate the relation of the duplication to the duodenum and the adjacent organs. Thus the surgical procedure can be selected preoperatively. Endoscopic ultrasound is an excellent technique for visualizing a duodenal duplication. A cystic duodenal duplication measuring 6 cm in diameter was resected in a 13-year-old boy.
Before the entry criteria for extracorporeal membrane oxygenation (ECMO) are met, newborns may require aggressive mechanical ventilation which may result in lung injury. The question arises whether the presence of a pneumothorax in these infants plays a role in the prognosis. Of the 21 newborns transferred to our hospital for ECMO, 8 were treated with ECMO. 9 of the 21 newborns developed a pneumothorax with conventional ventilation and 6 of these 9 newborns subsequently required ECMO. Infants who developed a pneumothorax but did not meet ECMO criteria and remained in the oxygenation index (OI) range between 25 and 40 for more than 2 days had a poorer prognosis. If adequate oxygenation cannot be attained with acceptable mechanical ventilation and a more aggressive ventilation results in a pneumothorax, ECMO should be considered even if the oxygenation index is below 40.
The experience gained with 225 laparoscopies in newborns and older children is reported. Most laparoscopies started as diagnostic procedures and, once a diagnosis was established, were carried on as surgical interventions. The procedures were appendectomies, lyses of adhesions, cyst resections, interventions on the internal genitalia, resections of Meckel's diverticula, and herniotomies. The children ranged from newborns weighing 1,850 g to 15-year-olds, the average age being 8 years. The majority of children were girls (60%) with recurrent ill-defined lower abdominal pain. Laparoscopy provides excellent exposure. Though the complication rate does exceed that of similar conventional procedures, with practice a comparable operating time may be achieved. The cosmetic result is better. The expenses for installation and manpower are high, but in-hospital time is decreased.
From 1971 to 1990, 18 children were surgically managed for choledochal cysts at two Berlin pediatric surgical units. Eight patients underwent an internal drainage procedure, eight a Roux-en-Y hepaticojejunostomy and one a choledochoplasty. The children were followed-up 2 to 20 years later (median: 8.4 years). Three children died in the early postoperative period, but the immediate postoperative course was uneventful in all other cases. Later, five patients suffered from recurrent gastrointestinal disease, cholangitis and pancreatitis and, in two cases, from progressive liver fibrosis. Four of the five patients with symptoms had undergone internal drainage procedures; one developed cholangitis after a hepaticojejunostomy. In one case of internal drainage, the anastomosis was transformed into a hepaticojejunostomy. No patient had cancer.
A case of laparoscopic fundoplication is described in a child weighing 25 kg. The patient had severe skeletal deformities. Five trocars were used. The view was excellent. A complete posterior wrap was achieved without transsecting the short gastric vessels. Operating time and expenses were greater than with the conventional technique. No complications occurred. The cosmetic result was good.
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During a period of time between 1984 and 1986, 79 boys with 91 cryptorchid testes were treated with a therapy which combined a LH-RH nasal spray followed by HCG. Kryptocur (LH-RH) was administered as a nasal spray at a dosage of 1.2 micrograms daily for a period of 14 days. HCG was injected intramuscularly, 5 times at 2-day intervals. The dosage was one-half the amount recommended by the WHF. This particular therapeutic strategy was more efficacious than those used previously. During the follow-up seven years later, 50.5% of the testes were in a scrotal position. The results during a five year follow-up of a second study were similar to those observed in the earlier study: 67% of the cryptorchid testes were in the scrotum.
A case of foetal non-immune hydrops fetalis is presented. A second gravida was referred to our department at 31 weeks' gestation after normal pregnancy course. Sonography revealed marked foetal ascites as well as a polyhydramnion. Prenatal examinations did not yield a safe diagnosis. The foetal ascites was punctured via a pigtail-catheter that was left in the foetal abdomen. This procedure was supposed to facilitate the development of foetal lungs. At 33 weeks' gestation, after spontaneous rupture of membranes, a boy was spontaneously delivered. Postpartal radiography pointed to bowel perforation. Surgery on the first day of life showed a severe meconium peritonitis following a perforation of the ileum. 22 months after this operation, the boy is physically and mentally well developed. Until now, there is no sign of mucoviscidosis. We believe that early diagnosis, the possibility of prenatal therapy and the close collaboration of disciplines made the survival of this child possible.
In a cell culture model of bile duct epithelial cells, the effect of prostaglandin E2, lithocholic acid and deoxycholic acid was studied. Bile acids and prostaglandin are administered postoperatively in biliary atresia empirically as choleretics. Prostaglandin E2 and the bile acids all had inhibitory effects on bile duct epithelial cells in culture. There is no clinical study proving the efficacy of either bile acids or prostaglandin E2 in biliary atresia. The negative results with these substances in cell cultures warrants reserve in their routine clinical use in biliary atresia.
Vascular tumours of the liver present variously in the paediatric age group. Their clinical course depends on tumour size, its growth characteristics, localization and complications. The most feared complications are cardiac failure and the Kasabach-Merritt syndrome which may occur in up to 50% of affected children. In haemangioendotheliomata and capillary haemangiomata spontaneous regression can be expected. Regression may be stimulated by x-ray radiation therapy, corticosteroids, Endoxane or alpha Interferon. Emergency percutaneous catheter embolization or operation must be carried out in the event of such complications. The Nd:YAG laser is particularly well suited for these cases. In all events, careful interdisciplinary cooperation among paediatricians, radiologists, cardiologists, oncologists and paediatric surgeons is required owing to threatening complications which mostly occur in neonates and infants.
In a 2-year-old girl a blue rubber-bleb-nevus syndrome is described. Apart from cutaneous hemangiomas, pronounced hemangiomas of the urinary bladder were diagnosed and treated by laser surgery. The features of the disorder are discussed as a special clinical condition within the framework of this syndrome.
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