Use of pledgets in the repair of abdominal wall defects.
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Abdominal Muscles↗
Biomedical subjects
R T Soper
Publications and source records attributed to R T Soper.
The isolated bowel segment (Iowa model II): motility across the anastomosis with or without mesenteric division.
In previous reports, anastomosis has been shown to disrupt the myoelectric activity of the bowel. However, these studies have failed to delineate the role of the extrinsic nerves. Using an isolated bowel segment (IBS) and an amesenteric bowel segment (ABS), motility was evaluated by myoelectric recording across a bowel anastomosis. Ten rats were divided equally into the experimental group with the IBS and the control group with the ABS. In the IBS group, an 8-cm segment of jejunum was divided, reanastomosed, and coapted to the liver margin (Iowa model II). In the ABS group, an 8-cm segment of jejunum was coapted to the liver margin without disruption of bowel continuity (Iowa model II variant). Two weeks later, bipolar electrodes were implanted in the IBS and ABS, and normal jejunum in both groups. Mesenteric division (MD) was performed 4 weeks later to eliminate extrinsic innervation. Myoelectrical recordings were taken 2 weeks before and after MD. In the control group with IBS, incoordination in the propagation of the migrating motor complex (MMC) and reduction in the frequency of slow waves (FSW) were observed across the anastomosis and were unchanged by MD. In the control group with the ABS, the MMC and FSW were identical to that in the normal jejunum and were unaffected by MD. In both groups postprandial inhibition of the MMC was the same as in the normal jejunum and was unaffected by MD. This study confirms that incoordination in propagation of the MMC and reduction in FSW occur across a bowel anastomosis, and elimination of extrinsic innervation does not affect the autonomy of these changes.(ABSTRACT TRUNCATED AT 250 WORDS)
Anastomosis, Surgical↗
The isolated bowel segment (Iowa model II) created in functioning bowel.
In experimental rats (n = 15), an isolated bowel segment (IBS) was created by (1) initial enteropexy between an 8-cm-long jejunal segment and the liver margin (hepatoenteropexy; Iowa model II) with its proximal and distal ends divided and immediately reanastomosed in an end-to-end fashion to reconstruct the bowel; and (2) secondary division of the IBS mesentery 5 weeks later. The IBS is then completely free of its mesentric and intramural nervous and vascular communications. The viability of the IBS is preserved by vascular collaterals developed at the hepatoenteropexy. Twelve rats proceeded to the second procedure, having tolerated regular rat chow with satisfactory weight gain. The Iowa model II created in functioning bowel was evaluated by contrast studies and myoelectrical activities. Contrast studies demonstrated peristalsis in the IBS. In the myoelectrical recordings, the frequency of slow wave was 32.5 +/- 1.0 in the IBS and 36.3 +/- 0.8 in the normal bowel (P less than .05). During fasting, the migrating motor complex (MMC) was observed to propagate aborally in the IBS in a coordinated fashion. The cyclic period of the MMC was 17.2 +/- 1.1 minutes in the IBS and 15.8 +/- 0.8 minutes in the normal bowel (P = .30). We conclude from this study that (1) the IBS (Iowa model II) retains motor function as demonstrated by successful feeding, as well as contrast studies and myoelectrical recordings that were essentially identical to those in the normal bowel; and (2) the IBS (Iowa model II) has significant research potential for studies of bowel physiology.
Anastomosis, Surgical↗
The isolated bowel segment (Iowa Model II): absorption studies for glucose and leucine.
A model of the isolated bowel segment (IBS, Iowa Model II) was successfully created in experimental animals using a new surgical technique we developed. The IBS is completely free of its mesenteric attachment, yet its viability is preserved. The technique consists of two staged procedures: (1) initial enteropexy between the anterior margin of the liver and the antimesenteric border of the IBS with its ends forming cutaneous stomas; and (2) division of the IBS mesentery 5 weeks later. The IBS is nourished by vascular collaterals that form at the hepatoenteropexy during the interval between these two procedures. Our previous studies demonstrated preserved viability and motility in the IBS. This study was undertaken to test absorption in the IBS. In 25 rats (experimental group), the IBS (Iowa Model II) was created using an 8-cm-long isolated segment of jejunum. In 15 rats (control group), an 8-cm-long segment of jejunum was arranged to form a Thiry-Vella loop. Five weeks later, the IBS mesentery was divided in the experimental group, and sham laparotomy was performed in the control group animals. Absorption of glucose and leucine was studied in 13 rats of the experimental group and 6 of the control group using a constant single perfusion technique at 3, 8, and 11 weeks after the initial operation. The results were compared between the two groups. There was a 25% to 35% reduction in absorption of glucose and leucine in both groups with the advance of time, but no significant difference was observed between the groups except in leucine absorption at 11 weeks after the initial operation. This study concludes that absorption of glucose and leucine is preserved in the IBS after its mesentery is divided, suggesting that the IBS can be used as a functioning bowel for bowel reconstruction.
Animals↗
Isolated bowel segment (Iowa Model 1): technique and histological studies.
An isolated bowel segment (IBS) is a viable loop of bowel that is completely free of its mesenteric attachments. We created an IBS by staged procedures: (1) myoenteropexy between the undersurface of the abdominal wall muscle and a jejunal loop that is exteriorized at both ends as mucous fistulae; and (2) division of the IBS mesentery several weeks later. Viability of the IBS is preserved by vascular collaterals that develop at the myoenteropexy during the interval between these two procedures. In this study, histological observation of the IBS was performed to retrospectively determine the optimal interval required for adequate collateral circulation to develop. Twenty-eight rats were subdivided into seven groups of four rats each; each group underwent mesenteric division of the IBS at successive 1-week intervals after myoenteropexy (1 to 7 weeks). The bowel wall structures were histologically examined under light microscopy for each group after mesenteric division. Ischemic changes were observed in the groups in which the intervals were shorter than 6 weeks. With the time interval longer than 6 weeks, no ischemic changes were observed in the intramural ganglia and muscle layers and minimal changes were noted in the mucosa. This study concluded that an IBS can be safely created in the rat that preserve normal bowel structures when its mesentery is divided 7 weeks after myoenteropexy.
Abdominal Muscles↗
Solitary intrahepatic biliary cyst: diagnostic and therapeutic strategy.
This paper describes a newborn infant in whom an intrahepatic biliary cyst was successfully demonstrated by antenatal ultrasound. Postnatally, percutaneous cyst aspiration and computed tomography enhanced with intravenous cholangiographic contrast proved extremely helpful in the selection of surgical procedure. The lesion was completely removed at 12 weeks of age without complications.
Bile Duct Diseases↗
Isolated bowel segment (model 1): creation by myoenteropexy.
A surgical technique to create an isolated bowel segment (IBS) that is completely free of its mesenteric attachment, and yet preserves the viability of IBS is described. The procedure consists of (1) initial myoenteropexy between the abdominal wall muscle and the IBS, and (2) secondary division of the mesentery of the IBS 6 weeks later when the vascular collaterals have formed at the myoenteropexy. The IBS created by this technique is useful for the studies of bowel physiology and possible elongation of the bowel in the management of the short-bowel syndrome.
Abdominal Muscles↗
Aortosternopexy for tracheomalacia following repair of esophageal atresia: evaluation by cine-CT and technical refinement.
During the period of 1 year (1988 to 1989), five infants, aged 3 weeks to 10 months, presented with recurrent respiratory distress following repair of esophageal atresia with tracheoesphageal fistula (EA/TEF). These patients had associated congenital anomalies, including right aortic arch (1), biliary atresia (1), and a long gap that required esophageal elongation by spiral myotomy (1). The patients were evaluated for tracheomalacia using cinecomputed tomography (cine-CT; C-100 Scanner, Imatron, San Francisco, CA), which provides images of eight levels (8-mm interval) simultaneously with 0.7 second time intervals of cine-CT. Dynamic studies of the trachea by cine-CT showed tracheal collapse that was most significant during expiration in the segment immediately above and at the aortic arch. These patients underwent aortosternopexy. Via a right second intercostal approach, the ascending aorta and aortic arch were lifted anteriorly using two to four sutures of 5-0 Tevdek on pledgets placed between the tunica media and adventitia of the side walls of the aorta and the adjacent sternum. Respiratory distress was significantly improved postoperatively. Preliminary experience with these patients allows us to conclude that (1) cine-CT is a useful technique for diagnosing tracheomalacia; (2) it provides objective indication for its correction by aortosternopexy; and (3) the refined technique in placing sutures on the aorta may reduce the surgical risks of aortosternopexy.
Anastomosis, Surgical↗
Pediatric first rib fractures.
First rib fractures are associated with a high incidence of thoracic, vascular, abdominal, and central nervous system injuries. Usually reported in the adult population, first rib fractures are infrequently described in the pediatric population. We take this opportunity to describe six pediatric patients who sustained traumatic first rib fractures. Overall, five patients required operative intervention. Two patients sustained major vascular injuries which were detected on physical examination and confirmed by arch aortography. In view of the high percentage of patients with vascular injury, first rib fracture in a pediatric patient should prompt a search for major vascular injury.
Adolescent↗
Ultrafast CT of laryngeal and tracheobronchial obstruction in symptomatic postoperative infants with esophageal atresia and tracheoesophageal fistula.
We evaluated the role of ultrafast CT in the diagnosis and follow-up of nine consecutive, symptomatic infants with suspected laryngeal and tracheobronchial obstruction after surgery for esophageal atresia. With 80% or more area collapse as a criterion for the diagnosis of laryngomalacia and 50% or more for tracheomalacia, six patients had tracheomalacia, one had laryngomalacia, and two had both. Tracheomalacia was focal in four patients and diffuse, involving the thoracic trachea, in the other four. Associated bronchomalacia was present in two patients. The site and degree of abnormality were verified by endoscopy in five of nine patients. The degree of tracheal collapse did not always correlate with the size of the esophageal pouch or with the site of the tracheo-esophageal fistula. These findings support the concept that the larynx and/or tracheal walls are often abnormal in symptomatic infants with esophageal atresia, tracheoesophageal fistula, and airway obstruction. Ultrafast CT was a reliable technique for detecting and assessing the site, extent, severity, and dynamics of airway collapse in five of seven symptomatic infants with congenital tracheoesophageal anomalies when the imaging findings were compared with endoscopic findings and previously published normal standards.
Airway Obstruction↗
Case study: conjoined twins and anencephaly.
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Anencephaly↗
Acute appendicitis in children: sonographic findings.
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Acute Disease↗
Overview of neonatal surgery.
Neonatal surgery emerged as a fledgling in the 1930s and 1940s in restricted regional centers of the world where the pioneer pediatric surgeons were located. It galvanized into a bona fide pediatric surgical subspecialty during the 1950s, lead by those children's hospitals that developed neonatal surgical units and training centers. These institutions produced increasing numbers of highly trained young pediatric surgeons who fanned out to bring their expertise to other academic surgical centers. The 1960s saw both neonatologists and pediatric surgeons enriching the care of newborns in community and private hospitals in developed countries. Pediatric anesthesiologists, pediatric radiologists, and perinatologists joined ranks in the 1970s, extending care to the fetus as well as the newborn. Technologic developments such as ultrasound, computer tomography (CT), sophisticated ventilators, and advances in parenteral nutrition revolutionized both diagnosis and treatment. Magnetic resonance imaging, ECMO, cine CT, and sophisticated improvements in other areas have increased the scope and expanded the horizons of neonatal care in the 1980s, improving treatment yield and reducing morbidity and mortality of newborns who suffer from major medical and surgical diseases. Singapore, Hong Kong, Korea, and Taiwan recently have built neonatal surgical centers where high-quality care and training is offered. Almost every developing country now has surgeons who are partially or completely trained in pediatric surgery and who are on the faculty of their major medical teaching centers. There is every reason to believe that the next pediatric surgical issue of Clinics in Perinatology will describe further revolutionary advances in the care of the newborn patient, in areas now sacrosanct to perinatologists, neonatologists, and pediatric surgeons of this generation.
General Surgery↗
Sodium deficit causing decreased weight gain and metabolic acidosis in infants with ileostomy.
The records of 11 infants, 25 to 38 weeks' gestation, with metabolic abnormalities induced by ileostomy fluid losses were reviewed. At operation for necrotizing enterocolitis (NEC) (9) or meconium ileus (MI) (2), they weighed between 1,100 and 3,100 g and were from one to 41 days old. All developed total body sodium depletion and metabolic acidosis from ileostomy bicarbonate loss. In seven, sodium depletion was severe enough to require supplementation; six initially lost or failed to gain weight despite being fed adequate diet and calories. However, after receiving sodium supplementation (three with NaCl and three with NaHCO3), these six patients gained weight and improved their metabolic acidosis. The other five subjects did not initially receive sodium supplementation. Four gained weight; one of these later received supplemental NaHCO3 for a metabolic acidosis. The fifth patient failed to thrive until his ileostomy was closed. All infants initially had urine Na less than 10 mEq/L and normal serum Na. All infants whose urine Na rose above 10 mEq/L and had serum HCO3- greater than or equal to 20 mEq/L grew adequately. A direct relationship existed between ileostomy output and sodium intake required for growth. This expressed mathematically (Na intake = 1.2 + [0.13 x ileostomy output] shows a basal sodium need (with no ileostomy output) of 1.2 mEq/kg/d and an additional requirement of 0.13 mEq/kg/d of sodium for each mL/kg/d of ileostomy output. We conclude that infants with ileostomies are at extreme risk of total body sodium depletion with resultant metabolic acidosis and inadequate weight gain. These infants require sodium supplementation with a combination of NaCl and NaHCO3.(ABSTRACT TRUNCATED AT 250 WORDS)
Acid-Base Equilibrium↗
Congenital angiomatoid malignant fibrous histiocytoma. A light-microscopic, immunopathologic, and electron-microscopic study.
We present a case of a congenital angiomatoid malignant fibrous histiocytoma. This rapidly growing lesion, which was located in the subcutis of the left upper arm, was excised at the age of 8 1/2 months. The patient, a girl, was well and free of disease 10 months after surgical removal of the tumor. The tumor appeared grossly encapsulated. The gray-tan tissue contained cystic spaces filled with recent and organizing hemorrhages. Microscopically, the tumor was composed of solid masses of histiocyte- and fibroblast-like cells, inflammatory infiltrate, and multifocal irregular blood-filled spaces, which were predominantly devoid of endothelial cells. The tumor was studied immunohistochemically with antibodies specific for FVIII-related antigen, S-100 protein, epithelial membrane antigen, vimentin, desmin, alpha-1-antitrypsin, muramidase, laminin, and collagen type IV. Ulex europaeus lectin-I was also utilized. These studies, along with our ultrastructural findings, suggest that: (a) the tumor is composed of a mixture of mesenchymal cells; (b) an imperfect angiogenesis may be taking place, resulting in a wide spectrum of vascular structures; and (c) the cell of origin may be a pluripotent mesenchymal cell.
Blood Vessels↗
Obstructive jaundice due to congenital stenosis of the ampulla of Vater.
Two infants who had obstructive jaundice due to congenital stenosis of the ampulla of Vater improved dramatically with sphincteroplasty. In one, the jaundice was complicated by hepatocellular dysfunction and mild biliary cirrhosis. Only a few cases of such an anomaly have been reported, mostly with different modes of clinical presentation.
Ampulla of Vater↗
Chronic diarrhea of infancy: nonbeta islet cell hyperplasia.
The case of an infant who developed refractory watery diarrhea at the age of 2 weeks is described. Diarrhea was secretory in type, stool weight on no oral intake was 400 to 600 gm daily. A vasoactive intestinal peptide (VIP)-producing tumor was suspected. At the age of 7 1/2 months an exploratory laparotomy revealed nonbeta islet cell hyperplasia of the pancreas. VIP levels were elevated in plasma and pancreatic tissue. After 95% pancreatectomy, plasma VIP level dropped to normal. Hypokalemia, described in adult patients with VIP-producing pancreatic tumors and refractory watery diarrhea, was not a significant problem in this infant. This is the first report on the association of refractory watery diarrhea with elevated levels of plasma VIP and pancreatic islet nonbeta cell hyperplasia in the pediatric age group.
Adenoma, Islet Cell↗
Pneumatosis intestinalis after cardiac catheterization.
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Cardiac Catheterization↗