Biomedical subjects
Publications and source records attributed to P C Guzzetta.
Colon interposition is an accepted method of esophageal replacement in children. Severe symptomatic reflux has occurred in only two of our patients with colonic esophageal substitution. Formation of an antireflux submucosal gastric tunnel eliminated gastrocolic reflux in both patients without impeding normal passage of food into the stomach.
A child with a superior lumbar hernia and a posterior meningomyelocele is described in this report. Although congenital lumbar hernia may be associated with lumbocostal vertebral deficiency syndromes, we believe this patient's condition became obvious due to the repair of the meningomyelocele. This is the first case report of this combination of defects.
A case of coexistent cystic and tubular duplications of the small intestine is presented. Staged resection resulted in maximal preservation of small intestinal length. Intraoperative radionuclide scanning is suggested as a technique to assure complete removal of ectopic gastric mucosa. The literature regarding multiple duplications is reviewed and the management of duplications involving long segments of the small intestine is discussed.
Cholelithiasis in infancy is believed to be a rare finding. It is also held that all cholelithiasis in infancy has a predisposing factor such as hemolysis, prolonged fasting, congenital abnormality of the biliary tree, or the administration of TPN and is associated with severe morbidity and mortality. In the last three years, four infants at our hospital have been found on real-time ultrasonography to have gallstones. Their ages ranged from 3 weeks to 6 months. One patient had a hemolytic disease but the finding of cholelithiasis in the other three patients was incidental. A repeat sonogram in the infant with hemolysis three months after initial recognition and one day before scheduled cholecystectomy revealed spontaneous resolution of the gallstones. This led us to a conservative approach in the other three patients. Two more infants had spontaneous resolution of their gallstones and one child, now aged 16 months, is thriving with a persistent asymptomatic gallstone visible on sonogram.
Polytetrafluoroethylene (PTFE) grafts have been a useful addition to the pediatric hemodialysis vascular access armamentarium. In this study, 17 pediatric patients underwent 331 total months of hemodialysis via PTFE grafts. There was a statistically significant (P less than .025) decrease in the incidence of graft infections in 12 patients (235 patient-months) while receiving prophylactic parenteral vancomycin compared with 9 patients (96 patient-months) while receiving no vancomycin (0% v 44%). Vancomycin side effects were uncommon and mild. Vancomycin is a safe and effective agent for the prevention of PTFE graft infections in pediatric patients receiving chronic hemodialysis.
The use of percutaneous transluminal angioplasty as the primary treatment of renovascular stenosis in adults has recently been described. Previously, only three children have been reported to have undergone transluminal angioplasty for stenosis of the renal artery and hypertension. At our hospital, transluminal angioplasty was attempted in four children with renal artery stenosis; one attempt was successful and three were unsuccessful. The three patients who required surgical repair of the renal artery after unsuccessful transluminal angioplasty have been described in detail. The histopathology of the stenotic vessels is also discussed. Based on the analysis of the three children, certain criteria have been derived to select pediatric patients with renovascular hypertension either for attempted transluminal angioplasty or for primary surgical revascularization.
Two children with congenital microgastria and associated anomalies requiring surgery as infants, developed severe dumping syndrome which necessitated a remedial operation. A Roux-en-Y jejunal pouch (Hunt-Lawrence) was formed at 22 months and 10 months respectively. Weight gain was immediate in both patients and has been sustained for 6 months and 8 years respectively. Symptoms of the dumping syndrome were relieved and the pouch delays filling of the jejunum.
Patients with end-stage renal disease who develop hypersplenism, patients with mild neutropenia, and those patients whose WBC fails to increase in response to cortisol administration will develop significant neutropenia following transplantation with routine doses of azathioprine. This "intolerance" of azathioprine mandates a reduction in the dose of azathioprine often resulting in allograft rejection. Splenectomy will prevent azathioprine-induced neutropenia, but the hazards of splenectomy in these immunosuppressed patients have led to attempts to salvage at least part of the spleen. Partial splenic ablation by embolization has been utilized in adults prior to transplantation to prevent azathioprine-induced neutropenia while preserving the spleen's protective mechanisms against infection. Eight children in our series of transplant candidates required a reduction of splenic function to prevent azathioprine induced neutropenia. One child had a functioning renal allograft but had recurrent neutropenia limiting the azathioprine dose. Partial splenic embolization was attempted in four children and was initially successful in two. Both patients later developed recurrent neutropenia and needed partial splenectomy. The two patients in whom partial splenic embolization was unsuccessful and five further patients in whom embolization was not attempted also underwent partial splenectomy. Approximately 75% to 80% of the spleen was resected. Six children have since undergone renal transplantation and one child had a transplant with chronic rejection at the time of partial splenectomy. Routine doses of azathioprine have been used in these children with no episodes of neutropenia or sepsis observed. We recommend partial splenectomy in those children requiring renal transplantation who are at risk for development of azathioprine induced neutropenia.
Diagnosis of right lower quadrant pain in a woman is frequently confusing. The course of 53 patients who had operation with a normal appendix and no other intra-abdominal pathology is compared with a group of 50 patients with a normal appendix and acute salpingitis. Appendectomies were performed in all cases and there was a lower mortality and morbidity rate in the group of patients with salpingitis. It is, therefore, concluded that appendectomy is a safe procedure in patients with acute salpingitis.
To assess the long term effects of arteriovenous (AV) fistulas placed in children for hemodialysis, we retrospectively evaluated 26 patients, ages 4 to 20 years, for: limb growth, evidence of excessive flow through the fistula, limb function and patient acceptance of the limb's appearance. The fistulas were created an average of 31 months prior to the study. Fourteen patients had wrist fistulas. Twelve patients had PTFE grafts; 5 in the upper thigh and 7 in the upper arm. Of the 5 patients with thigh PTFE fistulas, 3 developed ipsilateral limb hypertrophy, another developed cardiac failure and the other had excessive flow through the fistula without cardiac failure. One of the 7 children with an upper arm PTFE graft developed arm edema without hypertrophy. Two of the 14 children with wrist fistulas developed evidence of excessive flow through the fistula. Six of 26 patients (23%) required fistula ligation because of a complication.