Biomedical subjects
Publications and source records attributed to S Kleinhaus.
Since its introduction, the anterior cricoid split has proven to be a safe and effective procedure for the management of infants with acquired subglottic stenosis. In this article we report an unusual complication--an aerocele, which occurred on the 14th day following an anterior cricoid split on a 9-month-old child. The possible etiology and successful management of the aerocele are reviewed.
The positive experience with laparoscopic cholecystectomy (LC) in the adult surgical community encouraged us to perform LC in our last nine adolescent patients requiring cholecystectomy. There were no operative or postoperative complications, and the average hospital stay was less than 3 days. All the teenagers resumed their normal activities 1 week after surgery and were pleased with the small operative scars. Once the technique has been mastered and adequate experience gained with the new instrumentation, laparoscopic cholecystectomy would seem to offer many advantages in the teenage patient.
The most common gastrointestinal emergency in the newborn is necrotizing enterocolitis. Premature babies are the most likely victims, but it also occurs in full-term infants. Although great strides have been made in elucidating some of the factors responsible for necrotizing enterocolitis, such as intestinal ischemia, bacterial overgrowth, and feeding dysfunction, the exact etiology is as yet unclear. The timing and indications for surgery differ from institution to institution, but the long-term outcome is similar in most large series. The overall mortality rate remains about 20% to 40%, and of the survivors, about one half seem to have no sequelae, the remaining infants having neurologic and gastrointestinal deficits of various degrees of significance.
Congenital absence of hypoplasia of the uterus is a cause of primary amenorrhea in approximately 15% of cases. Ultrasound is often employed as an early imaging modality in the evaluation of patients with primary amenorrhea. Demonstration of total absence or marked hypoplasia of the uterus in the presence of normal ovaries during pelvic ultrasound examination, suggests the diagnosis of congenital uterine aplasia or hypoplasia. Sonography may obviate the need for laparoscopy and for other imaging modalities. A case report of uterovaginal hypoplasia in association with anal atresia and recto-vaginal fistula is presented, and the value of ultrasound in the diagnosis of this entity is discussed. The embryology and clinical features of this anomaly are also reviewed.
The management of a child with an irreducible ovary remains inconsistent in pediatric surgical centers. An informal survey of senior pediatric surgeons and an extensive review of the literature showed a prevailing view that the trapped ovary is not at significant risk of vascular compromise. Two recent cases prompted a review of our experience from 1984 to 1989, during which 1,699 children with inguinal hernias underwent operation, 386 (23%) of whom were girls. Fifteen girls (4%) had irreducible ovaries present at the time of operation and in 4 of the 15 (27%) the ovary was twisted and infarcted. Two of the 4 girls were known to have an irreducible ovary prior to the day of operation--1 was noted 2 months earlier and 1 was noted 1 month earlier. At the time of the initial diagnosis, neither patient had physical findings of vascular compromise of the ovary. In the other two girls, evidence of an infarcted ovary was present when the hernia was first diagnosed and an emergency operation was performed. A 27% incidence of torsion and strangulation of irreducible ovaries appears to be high, but reports of strangulated ovaries have been reported in 2% to 33% of other series. The normal anatomy is altered when an ovary is trapped in a hernia sac, and these changes make torsion more likely. Although an irreducible ovary is not at great risk of compression of its blood supply, this report identifies a significant risk of torsion. This risk warrants treating the asymptomatic irreducible ovary as any other incarcerated hernia--as a true emergency.
Between 1982 and 1987 seven neonates ranging in age from 24 hours to 1 week were treated for idiopathic intestinal perforations at the Montefiore Medical Center, Albert Einstein College of Medicine. Four of the infants were born prematurely; three were full term. Five were being treated in an intensive care nursery when the perforation was diagnosed. All infants whose perforations were due to necrotizing enterocolitis, appendicitis, Hirschsprung's disease, meconium ileus, intestinal atresias, or drug therapy are excluded from the series. None of the infants had associated anomalies. The sites of the perforations were as follows: two in the jejunum, two in the ileum, one in the cecum, and two in the transverse colon. Six of the perforations were on the antimesenteric aspect of the bowel; one was on the mesenteric aspect. The sizes of the perforations ranged from pinhole to 1 cm in diameter. All the infants did well. Pathologic examination of the resected specimens failed to reveal an etiology for the perforations. There were no cases of duplication or muscular hypoplasia. We believe the etiology of this condition may be ischemic necrosis, secondary to a localized vascular accident in the wall of the affected viscus, but we do not have a good explanation for the upsurge in cases we are seeing.
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The increased intraperitoneal pressures that accompany laparoscopic examinations produce significant hemodynamic alterations. Studies of the effects of such pressures on mesenteric blood flow in laboratory animals with normal and compromised superior mesenteric artery blood flow lead us to conclude that laparoscopy in patients with suspected compromised intestinal blood flow should be undertaken with great caution. Since major alterations in blood flow did not occur at intraperitoneal pressures less than 20 mm Hg, intraperitoneal pressures during laparoscopy should be maintained below this level and for as brief a period of time as possible when this procedure is used in patients with suspected intestinal ischemia.
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Between 1973 and 1976, laparoscopy was performed on 50 girls aged 12 to 18 years old for evaluation of abdominal pain severe enough to warrant hospitalization. In nine patients, a pelvic mass was suspected on physical examination or ultrasonography. Twenty-three patients had histories of previous episodes of salpingitis, but negative cultures at time of admission. Eighteen patients had no significant past medical history and normal physical findings. Laparoscopy established a diagnosis in 28 of the 50 patients, and in the 32 patients in whom a specific preoperative diagnosis was entertained, laparoscopy proved it to be incorrect in 15. In all cases where laparoscopy resulted in specific treatment, the symptoms were relieved. There was no morbidity or mortality.
Three reliable diagnostic signs were identified on angiograms from 25 patients with ectasias of the right colon: (a) a slowly emptying dilated, tortuous, intramural vein; (b) a vascular tuft; and (c) an early filling vein. The frequency of these signs and the order of their occurrence reflect the different stages in the evolution of ectasias. The earliest and most frequent sign, the slowly emptying vein, reflects ectatic changes in a submocosal vein resulting from chronic intermittent partial obstruction. The vascular tuft represents more advanced lesions and corresponds to extension of the degenerative process to the venules in the mucosa. An early filling vein reflects an arteriovenous communication through a dilated arteriolar-capillary-venular unit-a mucosal ectasia.
Vascular lesions of the right colon are being diagnosed increasingly as a cause of lower intestinal bleeding, but their nature and occurrence, primarily in the elderly, remains unexplained. Colons from patients with clinical and angiographic diagnoses of cecal vascular lesions were studied by injection and clearing, and by histological sections. In all injected specimens one or more mucosal vascular ectasias were identified. The mucosal lesions appeared to be secondary to dilated tortuous submucosal veins which were the more prominent feature and were often present without the mucosal ectasia. This suggests that ectasias are caused by chronic, intermittent, low grade obstruction to submucosal veins with dilation and tortuosity initially of submucosal veins, then of venules, capillaries, and arteries of the mucosal vascular unit. Ultimately, precapillary sphincters lose their competency, producing small arteriovenous communications. The concept that ectasias are degenerative lesions was evaluated by studying 15 right colons resected for carcinoma with no history of bleeding. Mucosal ectasias were identified in four colons and submucosal ectasias in eight. These investigations suggested that these lesions: (1) are vascular ectasias developing as a degenerative process of aging, (2) are present with or without bleeding in a significant portion of the population over 60 years of age, (3) are multiple more often than single, and (4) may represent the commonest cause of major lower intestinal bleeding in the elderly.