Biomedical subjects

T Z Polley

Publications and source records attributed to T Z Polley.

At least 19 recordsLinked to original sources

PubMed1999

Prenatal diagnosis of congenital cystic adenomatoid malformation and its postnatal presentation, surgical indications, and natural history.

BACKGROUND/PURPOSE: Regression of a cystic adenomatoid malformation (CAM) in a fetus is well described. Little, however, is known about the postnatal course of these infants. This study attempts to correlate the prenatal course of CAMs with postnatal symptoms, radiological manifestations, and need for surgery. METHODS: The clinical course of patients with a CAM diagnosed prenatally were retrospectively reviewed. Inclusion in the study required a prenatal ultrasound scan documenting a CAM. RESULTS: Over 10 years, 14 patients with a CAM were diagnosed prenatally. Six (43%) showed a partial in utero regression. Four patients were symptomatic at birth and underwent a resection as newborns. Ten patients were asymptomatic at birth, and eight of these had normal chest x-rays. Elective resection has been performed in 3 of these 10, and two additional children are scheduled to undergo an excision near 1 year of age. The remaining five patients have undergone follow-up nonoperatively for a mean of 36 +/- 15 months. Of the seven asymptomatic patients not undergoing immediate surgery, only one has shown a slight postnatal regression, despite five of these showing regression in utero. None have become symptomatic. CONCLUSIONS: The results suggest that regression of a CAM on prenatal ultrasound scan is common, but this process does not continue after birth. A normal chest x-ray does not indicate complete regression of a CAM; a computed tomography (CT) scan is required to evaluate such patients, and will generally demonstrate a CAM. Asymptomatic patients with a CAM may be followed up nonoperatively with no apparent adverse effects. The decision and timing of an excision in an asymptomatic patient remains controversial among pediatric surgeons.

Cystic Adenomatoid Malformation of Lung, Congenita↗

PubMed1999

Specialty networking in pediatric surgery: a paradigm for the future of academic surgery.

OBJECTIVE: To review retrospectively a 4-year experience with pediatric surgical networking at a major academic medical center in the Midwest. BACKGROUND: The growth of managed care in the United States during the past decade has had a major impact on the practice of medicine in general, but especially on academic medicine. In some academic medical centers, the loss of market share has not only affected clinical activity but has also compromised the educational and research missions of these institutions. METHODS: At the authors' institution, a networking strategy in pediatric surgery was established in 1993 and implemented on July 1, 1994. In 1994, one new satellite practice was established; over the next 4 years, four additional practices were added, including one in another state. To assess the impact on financial status, clinical activity, education, and academic productivity, the following parameters were analyzed: gross and net revenue, surgical cases, clinic visits, ranking of the pediatric surgery residency, publications, grant support, and development and endowment funds. RESULTS: Gross and net revenue increased from $3,273,000 and $302,000 in 1993 to $10,087,000 and $2,826,000, respectively, in 1998. Surgical cases and clinic visits increased from 1240 and 3751 in 1993 to 5872 and 11,604, respectively, in 1998. At the medical center's children's hospital, surgical cases and clinic visits increased from 1240 and 3751 to 2592 and 4729 during the same time period. During this 4-year period, the faculty increased from 4 to 11. Since 1997, the National Resident Matching Program has provided data on how pediatric surgery residency candidates ranked a training program. In 1997, this program received the second-most one to five rankings; in 1998, it tied for first. This exceeds the faculty's perception of previous years' rankings. Publications increased from 26 in 1993 to a peak number of 62 in 1996; in 1997 and 1998 the publications were 48 and 37, respectively. External grant support increased from $139,882 in 1993 to a total of $6,109,971 in 1998. Development and endowment funds increased from $103,559 in 1993 to $2,702,2777 in 1998. CONCLUSIONS: Pediatric surgical networking at the authors' institution has had a markedly positive impact on finances, clinical activity, education, and academic productivity during a 4-year period. The residency training program appears to have improved in popularity among candidates, probably because of the increased referral of complex cases to the medical center from the various networking satellites. External grant support and basic laboratory research significantly increased, most likely because of the greater number of faculty with protected time for research recruited. Development and endowment funds dramatically grew because of the excellent fiscal health of the pediatric surgical program. This experience may serve as a model for other academic surgical specialties.

Academic Medical Centers↗

PubMed1998

The lateral approach for open splenectomy.

BACKGROUND: Laparoscopic splenectomy (LS) has been used increasingly to treat children with hematologic disorders and has been reported to have advantages over open splenectomy performed through a standard vertical or subcostal incision. The authors perform open splenectomy (OS) through a lateral, muscle-splitting approach, and believe their approach is more reasonable in comparison with LS. METHODS: Thirty-nine consecutive open splenectomies performed between 1991 and 1995 were reviewed retrospectively and compared with recent reports of LS. The series included 24 boys and 15 girls with an average age of 9 years and average weight of 37.5 kg. Indications included immune thrombocytopenic purpura (n = 20), hereditary spherocytosis (n = 18), and sickle cell anemia (n = 1). The operation was performed with the child in the lateral decubitus position through a left upper abdominal muscle-splitting incision (off the 11th rib), sparing the rectus muscle. RESULTS: All 39 cases were completed without intraoperative complications with an average surgical time of 98.0 minutes (range, 30 to 302). The average surgical blood loss was 89 mL (range, 10 to 300). The children started feeding an average of 1.2 days (range, 0 to 4) postoperatively, were on a regular diet at an average of 2.0 days (range, 1 to 6) postoperatively, and had an average length of stay of 2.7 days (range, 1 to 6). There was no mortality or morbidity. CONCLUSIONS: Open lateral splenectomy is performed with shorter surgical times, less blood loss, an excellent cosmetic result, no complications, and a length of stay comparable to any of the published series on laparoscopic splenectomy in children. This approach provides a reasonable basis for comparison with laparoscopic splenectomy.

Adolescent↗

PubMed1997

Use of abdominal ultrasonography to assess pediatric splenic trauma. Potential pitfalls in the diagnosis.

OBJECTIVE: The purpose of this study was to evaluate the accuracy of abdominal ultrasonography (US) for screening and grading pediatric splenic injury. SUMMARY BACKGROUND DATA: The use of abdominal US has increased rapidly as a method of evaluating organ damage after blunt abdominal trauma. Despite US's increasing use, little is known about its accuracy in children with splenic injury. METHODS: Children (N = 32) suffering blunt abdominal trauma who were diagnosed with splenic injury by computerized tomography (CT) scan prospectively were enlisted in this study. Degree of splenic injury was evaluated by both CT and US. The ultrasounds were evaluated by an initial reading as well as by a radiologist who was blinded as to the results of the CT. RESULTS: Twelve (38%) of the 32 splenic injuries found on CT were missed completely on the initial reading of the US. When the ultrasounds were graded in a blinded fashion, 10 (31%) of the splenic lacerations were missed and 17 (53%) were downgraded. Seven (22%) of the 32 splenic fractures were not associated with any free intraperitoneal fluid on the CT scan. CONCLUSIONS: This study has shown that US has a low level of sensitivity (62% to 78%) in detecting splenic injury and downgrades the degree of injury in the majority of cases. Reliance on free intraperitoneal fluid may be inaccurate because not all patients with splenic injury have free intra-abdominal fluid. Based on these findings, US may be of limited use in the initial assessment, management, and follow-up of pediatric splenic trauma.

Abdomen↗

PubMed1996

Effect of very delayed repair of congenital diaphragmatic hernia on survival and extracorporeal life support use.

BACKGROUND: Since November 1992, operative repair in neonates with congenital diaphragmatic hernia (CDH) at this institution was delayed until respiratory insufficiency had resolved. METHODS: A retrospective analysis was performed (n = 33) comparing delayed repair with our previously reported institutional experience with immediate repair from January 1988 to October 1992 (n = 66). Infants with severe genetic defects or moribund conditions or who were premature were not considered candidates for repair or extracorporeal life support (ECLS), but they were included in the survival analysis. Survival was defined as hospital discharge. Data were compared with an independent t test or Pearson chi-squared test. RESULTS: Mean age at repair was 8.9 +/- 4.5 days (range, 3 to 20 days). Eleven infants in the study group were placed on ECLS (33% versus 68% in the comparison group; p = 0.001). Six of these infants survived (55% versus 58% in the comparison group; p = 0.846). Of these survivors, one patient was repaired while on ECLS, and the remainder underwent repair after decannulation from ECLS. All 20 of the remaining candidates for repair survived without need for ECLS. Overall survival was 79% versus 56% in the comparison group (p = 0.027). CONCLUSIONS: Our current data suggest that very delayed repair of newborns with CDHs is associated with an increase in the overall survival and a decrease in the use of ECLS when compared with previous experience at this institution.

Extracorporeal Membrane Oxygenation↗

PubMed1995

Prehospital classification combined with an in-hospital trauma radio system response reduces cost and duration of evaluation of the injured patient.

BACKGROUND: This study was undertaken to determine whether a prehospital trauma classification system (PHTCS) in combination with an in-hospital trauma radio system response (IHTRSR) impacts emergency care of the injured patient. METHODS: In 1991 our trauma center used no prehospital trauma classification system. A PHTCS was implemented in 1992, and in 1993 the PHTCS was integrated with an IHTRSR: RESULTS: Implementation of the PHTCS and IHTRSR resulted in a significant reduction in the time required for initial evaluation of the trauma patient with an associated reduction in cost. Reduction in time of the initial trauma evaluation was noted in both adult and pediatric populations, in patients with a blunt mechanism of injury, and in the injured patients posing the greatest strain to health care resources. CONCLUSIONS: Integration of a PHTCS with an IHTRSR has a significant impact on the cost and time of emergency treatment of the trauma victim with no adverse effect on patient outcome. Use of an integrated trauma response provides cost-effective and expeditious care of the injured patient and should be considered in trauma system development.

Adolescent↗

PubMed1994

Malrotation in patients with duodenal atresia: a true association or an expected finding on postoperative upper gastrointestinal barium study?

We retrospectively reviewed the imaging and surgical findings in 17 patients with duodenal atresia to determine (a) the frequency of coexistent malrotation in patients with duodenal atresia and (b) the reliability of the upper gastrointestinal barium study (UGI) in differentiating malrotation from postoperative deformity of the duodenal sweep after repair of duodenal atresia. Postoperatively, 9 (53%) of the 17 patients had UGI findings consistent with malrotation. Of these nine, only two had malrotation coexistent with duodenal atresia, while the other seven had normal midgut rotation demonstrated intraoperatively. The radiographic appearance of malrotation was simulated in two patients in whom the ligament of Treitz had been surgically divided, in three in whom the ligament had not been taken down, and in two in whom the status of the ligament was not specified in the surgical report. Although there is an association between duodenal atresia and malrotation, this cannot be accurately documented on postoperative UGI examination. Malrotation cannot be detected preoperatively because contrast material cannot pass beyond the level of the atresia. Postoperatively, surgical deformity of the duodenal sweep cannot be reliably distinguished from malrotation.

Barium Sulfate↗

PubMed1994

Laparoscopic diagnosis and excision of Meckel's diverticulum.

Meckel's diverticulum is one of the primary concerns in the differential diagnosis of the pediatric patient with massive, acute gastrointestinal bleeding, intussusception, or abdominal pain of uncertain cause. The hospital course of two children with Meckel's diverticulum, successfully treated by laparoscopic excision, is presented, along with details of the operative procedure. Both patients recovered from the procedure without incident and were discharged at 24 and 48 hours after surgery. The authors believe a laparoscopic approach is safe and effective in the diagnosis and treatment of Meckel's diverticulum.

Adolescent↗

PubMed1994

Resolution of splenic injury after nonoperative management.

Numerous studies have demonstrated success with nonoperative management of splenic injuries in pediatric patients. However, the resolution of the splenic injury has not been previously evaluated. The records of 50 pediatric patients with splenic injuries from blunt trauma treated nonoperatively between 1984 to 1992 were reviewed retrospectively. Abdominal computed tomography (CT) was performed at the time of injury and 6 weeks postinjury in 25 patients. These scans were reviewed and categorized by a modification of a previously reported grading system for parenchymal injury. All patients had healing of the splenic injuries, with complete resolution of the healing process observed at 6 weeks postinjury in 44%. Even those with shattered spleens (n = 6) had consistent improvement in splenic architecture, with resolution of fractures and/or contusions and return of splenic perfusion. Ten (77%) of 13 grade 1 and 2 injuries were completely resolved by the 6-week follow-up examination, whereas only one (8%) of 12 grade 3 to 5 injuries showed radiological resolution of splenic injuries. None of the 25 follow-up CT scans affected clinical decision-making or led to a deviation from the established protocol, which included a 3-month period of reduced activity. All 50 patients did well, without evidence of morbidity, mortality, or complications after return to full activity 3 months postinjury.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1993

Trauma scores, accident deformity codes, and car restraints in children.

The importance and effectiveness of the appropriate use of automobile restraints by young children has been emphasized in several studies. Once the child has entered the emergency care system, however, restraint use may not be the best predictor of injury severity. This study was undertaken to investigate the relationship of restraint status to morbidity and mortality in children examined in a hospital emergency facility following involvement in a motor vehicle crash (MVC). The emergency room charts of 101 children under 18 years of age, who were victims of MVCs, were reviewed and the following trauma scores were calculated: Glascow Coma Scale, Pediatric Trauma Score, Revised Trauma Score, Injury Severity Score, and Maximum Abbreviated Injury Score. In addition, the Traffic Accident Damage (TAD) score, an estimate of crash severity determined by the police at the accident scene, was recorded. The patients were age stratified as follows: 0 to 4 years (n = 24), 5 to 11 years (n = 29), and 12 to 17 years (n = 48). Fifty patients were appropriately restrained at the time of the crash. There was a significant correlation between mean trauma scores and mean TAD codes (P < .05). There were no significant differences in mean trauma scores between improperly restrained (n = 11) and unrestrained (n = 40) children (P > .05) across all age groups, and these children were grouped together as "unrestrained" in further analyses.(ABSTRACT TRUNCATED AT 250 WORDS)

Accidents, Traffic↗

PubMed1991

Surgical management of ambiguous genitalia in the infant and child.

Proper gender assignment to a neonate born with ambiguous genitalia is a social emergency of the newborn period. Once an appropriate sex assignment has been made, the next critical step is performance, if needed, of a reconstructive procedure in a timely fashion. In an attempt to evaluate our experience with this unique group of patients, we have retrospectively reviewed the course of 69 children with ambiguous genitalia managed surgically at this institution between 1974 and 1989. This series consists of 32 genotypic females with congenital adrenal hyperplasia (CAH), 10 children with mixed gonadal dysgenesis (MGD), 10 male pseudohermaphrodites, 3 true hermaphrodites, 8 genotypic females with urogenital sinus anomalies (UGS), and 6 genotypic males with bilateral undescended testes and penoscrotal hypospadius. All newborns initially seen at this institution received proper sex assignment within the first week of life. Prior to 1980, 17 of the children with CAH underwent clitorectomy and vaginoplasty and three underwent clitoral recession and vaginoplasty. After 1980, 10 patients with CAH were managed with clitoral recession and vaginoplasty and 2 with vaginoplasty alone. Eight of 10 cases of MGD were given a female sex assignment and all 8 underwent gonadectomy due to the high risk of gonadoblastoma; the other 2 children were raised as males. There were 3 true hermaphrodites of which 2 were assigned female gender roles and were managed with a clitoral recession and vaginoplasty. All 10 male pseudohermaphrodites were raised as females and all underwent bilateral orchidectomy. The 8 children with UGS were raised as females and underwent vaginal reconstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1990

Hirschsprung's disease in adolescents and adults.

Hirschsprung's disease in the adolescent and adult is a rare and often misdiagnosed cause of lifelong refractory constipation. Two adolescent and three adult patients with Hirschsprung's disease treated between 1973 and 1987 at the University of Michigan Medical Center are reported. Each patient presented with chronic constipation requiring enemas, cathartics, and multiple hospital admissions for management. Diagnosis in each case was made with barium enema and full-thickness rectal biopsy. Four patients underwent endorectal pull-through procedures, all with good long-term results. The fifth patient, initially treated with a Duhamel retrorectal pull-through procedure, required reoperation for constipation secondary to a retained rectal septum. Review of 199 cases of adult Hirschsprung's disease enables comparison of the various operative procedures for this disorder with respect to postoperative complications and functional outcomes. Anorectal myectomy with low anterior resection, the Duhamel-Martin procedure, and the Soave endorectal pull-through procedure are the most acceptable methods for surgical management.

Adolescent↗

PubMed1990

Congenital biliary dilatation: a spectrum of disease detailed by ultrasound.

Recently we have examined six children with the diagnosis of choledochal cyst who demonstrate a greater spectrum of biliary involvement than expected. Classically choledochal cysts have been divided into types and subtypes based on the configuration of common bile duct dilatation; however, this simplified information is misleading since surgical management is dependent on the exact extent of intrahepatic and extrahepatic biliary abnormalities. The pre-operative ultrasound examination must be meticulous to provide enough pertinent anatomic details. Much of the intrahepatic anatomy is not visualized at surgery nor on the operative cholangiograms where reflux of contrast into the intrahepatic ducts may not be consistently achieved.

Adolescent↗

PubMed1989

Independent measurement of oxygen consumption and oxygen delivery.

This experiment investigated the relationship between oxygen consumption and oxygen delivery (cardiac output X arterial oxygen content) in an acute canine model. Previous studies investigating this relationship have largely utilized methods in which oxygen consumption and oxygen delivery were each calculated using the same measured variables resulting in mathematical coupling of variables. In this study, oxygen consumption was measured directly by closed-circuit spirometry. Oxygen delivery was independently controlled using right atrial bypass. These techniques assured that the values for oxygen consumption and oxygen delivery were derived entirely independently. In our study using 11 dogs, we found that oxygen consumption was constant and independent of oxygen delivery at oxygen delivery levels greater than 8.0 cc/kg/min (normal canine oxygen delivery 20-25 cc/kg/min). Oxygen consumption was linearly related to oxygen delivery at oxygen delivery levels less than or equal to 8.0 cc/kg/min. Below this critical level of oxygen delivery, animals were more acidotic and hypotensive than at higher delivery levels.

Animals↗

PubMed1989

Reversal of mortality for congenital diaphragmatic hernia with ECMO.

Extracorporeal Membrane Oxygenation (ECMO) has been available to neonates with respiratory failure at the University of Michigan School of Medicine since June 1981. In order to evaluate the impact of this type of pulmonary support, a retrospective analysis of 50 neonates with posterolateral congenital diaphragmatic hernia (CDH) who were symptomatic during the first hour of life and were treated between June 1974 and December 1987 was carried out. The patients were divided into two groups, those treated before June 1981 (16 patients) and those treated after June 1981 (34 patients). Overall survival improved from 50% (eight of 16 patients) during the pre-ECMO era to 76% (26 of 34 patients) during the post-ECMO period (p = 0.06). During the period after June 1981, 21 neonates were unresponsive to conventional therapy and were therefore considered for ECMO. Failure of conventional therapy was defined as acute clinical deterioration with an expected mortality of greater than 80% based on an objective formula previously reported. Six patients were excluded on the basis of specific contraindications to ECMO. Thirteen of 15 infants (87%) supported with ECMO survived. Three patients treated before 1981 met criteria for ECMO; all three died while receiving treatment using conventional therapy. These survival differences are significant (p less than 0.01). In addition, the survival of 87% for the infants treated with ECMO versus the expected mortality of greater than 80% for these same patients when treated with conventional therapy is highly significant (p less than 0.005). Based on this data, ECMO appears to be a successful, reliable, and safe method of respiratory support for selected, critically ill infants with CDH.

Evaluation Studies as Topic↗

PubMed1988

The development of necrotizing enterocolitis following repair of gastroschisis: a surprisingly high incidence.

We recently observed the development of necrotizing enterocolitis (NEC) in two consecutive newborn infants after gastroschisis repair. Because this association was unexpected, a retrospective review of our 11-year experience was performed using a multivariant computer analysis. The cohort consisted of 54 newborns with gastroschisis. All infants with omphalocele were excluded. Ten of 54 infants (18.5%) developed NEC as defined by classical clinical findings and pneumatosis intestinalis. Twenty-one distinct episodes of NEC occurred with up to three episodes (mean, 2.1) per patient. Twenty of the 21 episodes were successfully treated nonoperatively. Two infants developed pneumoperitoneum, one of whom underwent laparotomy upon which no perforation or intestinal infarction was found. Eight of the ten patients survived--a survival rate no different than for the remainder of the study group. Neither of the two deaths was attributable to NEC. The NEC was atypical in that no significant relationship was established with known predisposing conditions such as prematurity or low Apgar scores. Suspected risk factors such as time of feeding, type of closure, type of formula, total parenteral nutrition (TPN), and composition of TPN were not statistically related. Significant associations included concurrent TPN associated cholestatic liver disease in nine of the ten infants, antecedent intestinal surgery other than abdominal wall closure in five of the ten infants, and delay in initiation of enteral feedings (greater than 30 days) in eight of ten infants. In addition, the NEC occurred significantly later (range, 32 to 79 days; mean, 52 days) in the clinical course than usual; in fact, three of ten infants were rehospitalized with NEC following discharge. We conclude that a relationship exists between NEC and gastroschisis.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Muscles↗

PubMed1988

A randomized, controlled trial of parenteral clindamycin in neonatal necrotizing enterocolitis.

For an assessment of the efficacy of clindamycin in preventing bowel necrosis (intestinal gangrene or perforation), 42 premature infants with radiographically confirmed necrotizing enterocolitis (NEC) (pneumatosis, intraportal gas, or both) were randomly assigned to receive parenterally either ampicillin and gentamicin (control group, n = 22) or ampicillin, gentamicin, and clindamycin (n = 20), 20 mg/kg/d at 8-hour intervals for 10 to 14 days. Infants who had received antibiotics for greater than 24 hours before randomization and those developing intestinal gangrene or perforation less than 12 hours after randomization were excluded. Intestinal gangrene or perforation developed in four infants in the control group and six in the clindamycin group. Four in each group died of NEC. In the control group, one of 18 survivors developed a late stricture requiring surgical resection, whereas six of 15 survivors in the clindamycin group developed such strictures (P = 0.022). Routine inclusion of clindamycin in medical treatment of NEC does not reduce the frequency of intestinal gangrene or perforation and may be associated with an increase in late stricture formation.

Body Fluids↗

PubMed1987

Gastric perforation following cardiopulmonary resuscitation in a child: report of a case and review of the literature.

We report a case of gastric rupture complicating cardiopulmonary resuscitation in a 13 year old. The tear occurred on the lesser curvature of the stomach as in reported adult cases. A tear was not discovered until autopsy, despite extensive premortem investigation. In a comatose or paralyzed patient, laparotomy may be indicated in the evaluation of pneumoperitoneum following cardiopulmonary resuscitation.

Adolescent↗