Esophageal atresia. A 41-year experience

Since the first attempted repair in 1935, a total of 365 infants have undergone treatment for esophageal atresia with or without tracheoesophageal fistula. To evaluate the improvement in our results, we have divided our patients into four, approximately equal, time periods. The overall late survival has indeed improved during each of the four decades from between 36% and 53% to 68% in the last ten years. During this past decade, the group A risk infants (35 patients) had a 3% mortality, the group B (20 patients) had a 5% mortality, but the group C babies (22 patients) had a 41% mortality due to associated anomalies or severe prematurity. Anastomotic leaks and recurrent fistulas were each encountered in approximately 5% of the cases in all decades. Postoperative stricture has been encountered in 20% of the entire series and no esophageal replacements have been required.

Total body water changes during high volume peripheral hyperalimentation

A premature baby with gastroschisis, ileal atresia and secondary short gut syndrome was sustained with the use of peripheral hyperalimentation consisting of 2 per cent Amigen, 12 per cent glucose and 10 per cent Intralipid at an average rate of 140 to 160 milliliters per kilogram per day or 100 to 111 kilocalories per kilogram per day. The weight of the child increased during the first four months to approximately 14 grams per day, with body length increasing by about 6 millimeters per week. Six reliable measurements of the total body water of the child during the four month period were obtained using deuterium oxide dilution followed by double vacuum distillation and falling drop analysis in a constant temperature chamber. Measurements obtained showed a gradual decrease of total body water from 77.13 per cent of body weight to 60.50 per cent during the study period, with values consistently on the lower end of the spectrum of known normal controls, even during periods of increased growth rates of as much as 35 grams per day. These data on total body water, coupled with the observed gains in body weight and length, support tissue accretion rather than fluid retention as the mechanism of weight gain in long term, high volume peripheral hyperalimentation.

Pseudomembranous colitis associated with antibiotic therapy in a child: report of a case and review of the literature

A case of pseudomembranous colitis is presented in a child with multiple medical problems who received intraoperative antibiotics. Despite aggressive medical management and operative intervention, the patient died. All patients who develop diarrhea after receiving antibiotics should be suspected of having pseudomembranous colitis. Sigmoidoscopy and hyaque enema should be performed to confirm the diagnosis and all antibiotics should be discontinued. Aggressive medical management consisting of intravenous fluids, albumin, lactinex granules, fecal enemas, and cholestyramine should be instituted. Surgery should be considered only in the face of perforation, toxic megacolon, peritonitis, and failure of medical management with disease limited to the colon.

Actinomycotic bowel and ureteral obstruction in a patient with Hodgkin's disease

This is a case report of a patient who presented with colonic and ureteral obstruction 4 yr following diagnosis and abdominal-pelvic radiation therapy of stage IIA Hodgkin's disease. Biopsy of a pelvic mass revealed actinomycosis.

The effect of various resuscitative regimens on hemorrhagic shock in puppies

Since shock secondary to hemorrhage is not infrequently encountered in the pediatric patient, a puppy model was devised to help measure and monitor cardiovascular and metabolic changes that occur before and after resuscitation from hypovolemic shock (mean arterial pressure of 50 mm Hg for 1 hr). Three resuscitation protocols were compared: whole blood (replacement:shed) 1:1, 5% albumin in Ringer's lactate 1:1; and Ringer's lactate 3:1. All dogs survived the experiment and responded similarly during the shock period. Thermal dilution cardiac output rose in all groups after resuscitation; however, in the Ringer's lactate and 5% albumin groups, cardiac output was statistically greater than that observed in the blood group. In all groups, pH and blood pressure approached but did not return completely to baseline levels after resuscitation. In addition, early resuscitation demonstrated a further decrease pH ("hidden acidosis") before it began to return toward normal as resuscitation progressed. This study suggests that the infusion of large volumes of Ringer's lactate or 5% albumin in Ringer's lactate are equally efficacious in the treatment of hemorrhage. However, 5% albumin seems to be preferable because it allows infusion of a smaller quantity of electrolyte solution with equivalent physiologic benefits.

A simplified approach to diagnostic rectal biopsy in infants and children

Ninety-four patients underwent rectal biopsy with a suction capsule during a two year period. This painless procedure was performed in seventy-one patients for diagnosis of aganglionosis (Hirschsprung's disease). In nine patients, no ganglion cells were encountered, and subsequent surgery confirmed the diagnosis of Hirschsprung's disease in each of these patients. In twenty-three patients, biopsies were taken to search for neuronal storage disease. Six specimens contained abnormal material in the cytoplasm of the ganglion cells.

Fiberoptic transillumination: a new tool for the pediatric surgeon

Transillumination (TI) is a safe and reliable technique for evaluating masses or the presence of free air in the thorax or abdomen. TI can also be of help in the accurate placement of catheters or needles in the chest, abdomen, bladder, or vessels. Its use in several hundred cases has been documented by this report.

Peripheral intravenous nutrition without fat in neonatal surgery

During a 1 yr period, 19 infants less than 2 mo of age were fed intravenously with an infusate composed of glucose, amino acids, electrolytes, and vitamins. The solution was infused at a rate of 200 ml/kg/day or more for periods ranging from 5-247 days. No central venous catheters were utilized; the solutions were always administered through a needle in a peripheral vein. Weight gains similar to those seen with other techniques of intravenous nutrition were observed in all of the patients studied. No instance of fluid overload in the form of pulmonary edema, peripheral edema, or congestive heart failure was seen, and osmotic diuresis was not observed because of the lower tonicity of the infusate. Phlebitis was seen in 1/5 of the infusions, but was reversed by stopping the infusion and applying warm soaks. Three cases of skin slough were observed and two of these healed spontaneously without the need of skin grafting. The advantages of this technique over central venous nutrition are the elimination of the complications related to the central venous catheter, namely, sepsis and superior vena cava thrombosis.

Pediatric vascular trauma. Manifestations, management, and sequelae of extremity arterial injury in patients undergoing surgical treatment

Twenty pediatric patients with a mean age of 9.2 years exhibited 21 injuries to arteries of an extremity and underwent operation. Included were 12 iatrogenic injuries and nine non-iatrogenic penetrating injuries. Femoral, brachial, popliteal, radial, axillary, iliac, and tibial arteries were sites of vascular trauma. Long-term follow-up, averaging 36 months, was possible in 14 patients. Postoperative scanograms, digital impedance plethysmographic studies, and bone age roentgenograms were routinely obtained. Limb length disparities greater than 5 mm, extremity blood pressure differentials greater than 10 mm Hg, and bone age retardation were encountered. Proper treatment of pediatric patients with acute arterial injuries of an extremity requires early operative intervention and continuous postoperative follow-up during years of active growth. If chronic arterial insufficiency ensues, arteriographic studies should be obtained and arterial reconstruction undertaken.

Surgical management of aplasia cutis congenita

A child born without scalp, or dura to cover the brain (aplasia cutis congenita) was successfully treated by a multidiscipline team. A coexisting rupture omphalocele forced a change in treatment from the currently recommended regimen of mandatory early scalp closure. Homograft skin was used to protect the brain during the time the omphalocele was treated and skin flaps were delayed. Fluoroscein dye was utilized to determine flap viability and predicted ischemia until after a third delaying procedure was performed. The successful outcome suggests that the present philosophy of early surgical closure being essential for survival in infants with large cranial defects can be altered and, in fact, permanent full-thickness flaps may be designed, tested for viability, and delayed while homograft skin protects the infant's brain from infection and thrombosis.

Assessment of thermodilution cardiac output in small subjects

Thermodilution cardiac output determinations were compared with dye-dilution measurements in normovolemic and hypovolemic puppies. Good correlation was achieved with small volumes of cold and warm saline. Injectate volumes and significant caval displacement of the injectate port did not significantly affect thermodilution output measurements. This study demonstrates that thermodilution is a reliable and practical method of cardiac output determination in small subjects and suggests that this technique may be useful in the clinical management of neonates and small infants.

Modification of the endorectal procedure for Hirschsprung's disease

During the last four years, 25 patients have been operated upon using a technical modification of the endorectal procedure for the treatment of Hirschsprung's disease. There have been no major complications, and the ease with which the lower anastomosis was carried out has been quite remarkable. This opinion has been substantiated by surgeons who previously used other techniques for the lower anastomosis and have now adopted this modification.

Incidence and clinical features of patent ductus arteriosus in low-birthweight infants: a prospective analysis of 150 consecutively born infants

The incidence of persistent patency of the ductus arteriosus beyond the third day of life was prospectively determined in 100 preterm infants with birthweights of 2,000 gm or less and 50 infants with birthweights of 2,001 to 2,500 gm. The overall incidence was 21% and was inversely related to increasing gestational age and birthweight. The data suggest that immaturity is the major determinant of the persistent patency of the ductus arteriosus. Spontaneous delayed closure of the ductus occurred in 79% of patients that survived the immediate neonatal period. There was a high degree of association between the presence of a patent ductus arteriosus (PDA) and respiratory distress syndrome (RDS). Eight infants with severe RDS and PDA developed heart failure and four required surgical ligation of the ductus. None of the infants with birthweights greater than 2,000 gm who had PDA developed heart failure or required surgical ligation of the ductus arteriosus.

Total proctocolectomy without the lithotomy position

Total proctocolectomy for benign disease can be done entirely from within the abdominal incision, thus, avoiding the extra time and inconvenience of operating with the patient in the lithotomy position. This procedure is quick and simple, and the visibility is excellent even in a narrow adult male pelvis, and the lithotomy position is completely eliminated. Results in six patients have been gratifying.

Surgical closure of patent ductus arteriosus in the premature infant with respiratory distress

During the period from February, 1971 to February, 1973, 30 premature infants underwent surgical ligation of patent ductus arteriosus. The gestational ages ranged from 25 to 36 wk (mean 30), and the birth weights ranged from 760 to 2010 g (mean 1274). The patients were divided into two groups on the basis of the indications for assisted ventilation. Group I consisted of 21 patients with severe hylanine membrane disease who required assisted ventilation during the first 2 days of life and could not be weaned off the respiratory by 10 days of age. Group II was composed of nine infants who required intermittent positive-pressure breathing after a mean age of 8 days because of repeated apneic spells secondary to uncontrollable heart failure. All infants in Group II survived the operation and left the hospital well. Fourteen of the 21 patients in Group I survived; the seven deaths were all due to underlying severe pulmonary disease (bronchopulmonary dysplasia). The value of PDA ligation in premature infants with uncontrollable heart failure is demonstrated in this study; this procedure also appears to be beneficial in neonates with severe respiratory distress syndrome.