Biomedical subjects
Publications and source records attributed to M J Asch.
Glass shrapnel from explosions of "dry ice bombs," created by thrusting dry ice into glass soft-drink bottles and occluding the opening of the bottles, has produced serious and multiple lacerating injuries in three children, which required major operative intervention. We found no previous reports of this grave hazard.
Bilateral nephrectomy was performed in 4 patients with bilateral Wilms tumor. The current philosophy regarding the need to preserve maximum renal parenchyma is discussed. New guidelines suggested by the National Wilms Tumor Study group discourage unilateral nephrectomy and partial nephrectomy at initial exploration for bilateral Wilms tumor. Alternatively, it is recommended that continued treatment with chemotherapy and/or radiation therapy followed by second and third-look operations to maximize preservation of renal parenchyma be done with bilateral nephrectomy as a last resort option.
Twenty-one patients with bilateral Wilms' tumor are reviewed and the details of diagnosis, therapy, and survival presented. All patients had an abdominal mass at the time of diagnosis. Associated findings included hypertension, aniridia, and genitourinary anomalies. Favorable histologic features were found in all simultaneously occurring tumors and in the initial tumor in nonsimultaneous tumors. Eleven of the 18 patients with simultaneously occurring tumors survived for at least 2 years, for an overall 2-year survival rate of 61%, which was similar to the 2-year survival rate of 60% found in a review of 61 other simultaneously occurring bilateral Wilms' tumors reported in the literature since 1971. Two "front-end" factors that affected prognosis were the patient's age and the stage of the most advanced tumor at the time of diagnosis. A significantly better survival was found in children whose tumor was diagnosed before the age of 2 years and in patients who had Stage I or II disease in the most advanced tumor, as compared with those who had Stage III or IV disease. The overall survival rate in this series and in the literature review is much poorer than that reported for bilateral Wilms' tumor in the National Wilm's Tumor Study; some possible reasons for this are given. The authors' current approach to diagnosis and therapy is reviewed.
Although the etiologies of Hirschsprung's disease and infantile hypertrophic pyloric stenosis remain unclear, it is certain that in Hirschsprung's disease, there is an absence of myenteric ganglia. In pyloric stenosis, there is a decreased number of ganglia, but this may be secondary phenomenon. The occurrence of both Hirschsprung's disease and pyloric stenosis in any single patient is uncommon, disputing a common etiology on statistical grounds. The authors have recently seen two infants with both diseases, and have reviewed the histology and pathophysiology analyzing the possibility of a single cause.
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Transanal suction injuries were sustained in 1981 by five children when they sat upon uncovered swimming area drain sites. Tears of the rectosigmoid areas occurred in each with associated evisceration and loss of substantial amounts of small intestine because of mesenteric separation. These cases are reviewed.
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Splenectomy has been the standard treatment during this century for traumatic splenic injuries. Because of the association between asplenia and overwhelming sepsis, recent attempts have been made to repair injured spleens. Details of splenic anatomy and blood supply allow prediction of the usual type of splenic injury that can be repaired. By utilizing a topical hemostatic agent, capsular sutures, and arterial ligation, severely traumatized spleens have been repaired. Postoperative splenic scanning is available in assessing remaining splenic tissue. The present and future ramifications of reparative splenic surgery are presented.
Splenectomy for traumatic injury of the spleen has recently been questioned, due to the occurrence of postsplenectomy sepsis. During the past year we have operated on six children with splenic injuries and, by utilizing different surgical manuevers, have successfully reserved all or part of the spleen. The following report describes the management of these children and the operative techniques that allow the injured spleen to be salvaged.
A home program of total parenteral nutrition (HTPN) has been developed for managing patients with severe chronic small bowel disease who would otherwise be unable to leave the hospital. Six such children were treated by this program using a Broviac catheter to shorten hospitalization, to decrease the cost of care, and to normalize their lives as much as possible. They ranged in age from 2 1/4-17 yr and received HTPN for periods of from 1-11 mo. Criteria for instituting this therapy were the inability to maintain fluid and nutritional balance on therapeutic diet or oral formula, or a need for 30 or more days of conventional TPN. The 6 patients had a total of 1139 days on HTPN with 1 episode of catheter sepsis and 1 localized infection at the catheter site. None of the catheters clotted but 1 was accidentally dislodged. Small bowel adaptation occurred in 4 of the 6 patients. This allowed gradual discontinuous of HTPN and reinstitution of total oral alimentation.
Two cases of gastric volvulus in children are reported, one acute and one chronic. The diagnosis should be suspected as an unusual cause of chronic recurring upper abdominal pain or in acute gastric obstruction. The radiographic appearances of these patients are presented. Anterior gastropexy has produced good results in both the patients described.
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Metabolic and hormonal studies were performed in 6 infants during the first 3 months of life while receiving 3 different types of parenteral nutrition: 1) 20% glucose and a nitrogen source (Dudrick's method) 2) 12% glucose, a nitrogen source and soybean fat emulsion (Intralipid method) and 3) 12% glucose, a nitrogen source and 1% alcohol (Babson's method). All three regimens provided positive nitrogen balance of similar magnitude. The substrate-hormone relationships were appropriate. After parenteral fat free nutrition (primary caloric source glucose) the plasma glucagon levels were significantly lower and the growth hormone levels significantly higher than after the fat emulsion therapy period. The Dudrick and Intralipid methods resulted in a higher caloric intake and weight gain than the Babson method. The former two regimens cannot be completely endorsed, however, since septic and central vein complications are unavoidable with the Dudrick method particularly in the small infant; and the long term effects of intralipid, particularly on the liver are still unknown.
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A total of 107 children and adolescents underwent laparotomies for penetrating trauma. There were 64 patients with stab wounds and 43 with gunshot wounds. Only 8 per cent of the patients were under 12 years of age. Three patients died--two from gunshot wounds of major vessels and one from a gunshot wound of the colon. Most of the injuries were related to crimes of violence or were self-inflicted. Multiple organ injuries and postoperative complications were significantly more common among patients with gunshot wounds than in those with stab wounds. Associated extra-abdominal injuries appeared to be more common among patients with gunshot wounds but the difference was not statistically significant. Unnecessary laparotomies were twice as frequent in victims of stab wounds.
Obstructive jaundice due to benign neoplasms of the extrahepatic bile ducts is rare in all age groups. A case is reported which represents the first obstructing papilloma of the ampulla of Vater found in the pediatric age group and the literature pertaining to benign obstructing neoplasms is reviewed briefly. Differential diagnosis of persistent jaundice past the immediate neonatal period is discussed and the need for operative cholangiogram and open liver biopsy in difficult cases is stressed. Obstructing papillomas and other neoplasms of the extrahepatic bile ducts should be added to the differential diagnosis of jaundice in the pediatric age group.