[Ovarian pseudocysts in female newborn infants: prenatal ultrasonic diagnosis and surgical consequences]

During the last year we diagnosed within the scope of preventive medical care of pregnant women in about the 30th pregnancy week, seven foetuses with abdominal cystic tumours by ultrasound examination. Postpartal ultrasound controls of the mature newborn confirmed the findings. After laparotomy we found ovarian pseudocysts with a volume up to 90 ccm. Histologically we could not identify ovarian tissue. In 66% of the cases we found small cysts on the contralateral ovary. Differential diagnosis and the possible complications must be considered. A laparotomy should be performed and only by high steroid serum level a conservative therapy with MPA should be considered. This is the case in premature newborn with an immature endocrine regulation mechanism.

[Effect of dithranol therapy on membrane, basement membrane and nuclear markers in psoriasis lesions]

We investigated the effects of anti-psoriatic therapy with dithranol (1/20-1%) in salicylic acid (0.5%) in white petrolatum on lesional skin. FITC-labeled lectins and pemphigus vulgaris antibodies (PV) served as analytical means to study the glycocalyx. Antibodies of bullous pemphigoid (BP) were used as basal membrane markers. Nuclear antigens were recorded according to the binding of speckled, anti-nuclear antibodies (ANA) as well as antibodies to dsDNA. With some lectins, dithranol therapy resulted in pronounced fluorescence of the lower parts of the basal cells. ConA was fixed by the basal cell layer. To a lesser degree, ANA were fixed by nuclei of keratinocytes. PV antibodies were not fixed at all.

Tumour-induced intraluminal stenoses of the cervical trachea--tumour excision and tracheoplasty

Three children with stenoses of the cervical trachea caused by tumours are reported on. The first was a 13-year-old girl with a sarcoma of the tracheal wall 20 cm down. We performed partial resection of the trachea and turned a skin flap according to Denecke into the defect. In the second case a capillary haemangioma had caused severe stenosis, requiring resection of the tumour together with the tracheal mucosa. A haemangioma had caused tracheal stenosis in the third case, too; in this child partial tracheal resection and skin flap plasty were performed. The postoperative course was uneventful in all three children. So far, there is no recurrence of the sarcoma 4 1/2 years after operation.

[Implantation technic of a peritoneal dialysis catheter in infancy and childhood]

Since 1979 the continuous ambulatory peritoneal dialysis (CAPD) is used even in childhood. Practical management and tolerance of this method over a longer period are dependent on the compatibility of the chosen catheter material, the implantation technique and the exact introduction in catheter care with sac changing. The used variant of the classical Tenckhoff-catheter with spiral end and individually fitted cuffs has proved to be reliable. The left-sided paramedian incision is the preferred operative access. The transrectal position of the catheter guarantees its cranio-caudal course and placement of the spiral in the minor pelvis. The standardisation of surgical procedure in all details is an essential assumption for the improvement of long-term catheter function.

[Peculiarities of juvenile vertebral fractures and dislocations of the cervical vertebrae]

In addition to diagnostic and therapeutic problems of the bony spine injuries in childhood, questions of the participation of the growth plate arise and indicate the following treatment. In the last decade we treated 23 spine injuries, resulting after fall from height. Most of the cases showed single to multiple compression fractures of the anterior spine followed in a descending frequence by the lateral compression fractures, the disconnection ot the epiphyseal plate of the axis and the actual luxation fractures with injury of the stratum germinativum. In contrast to the prognostic favourable impression fractures with a spontaneous correction, luxation fractures with or without paraplegia must be repositionned and stabilized.

[Fractures and cartilage injuries of the knee joint in children]

In the last decade we treated and followed up 48 children in the Department of Paediatric Surgery in Heidelberg with fractures and cartilaginous injuries of the knee joint. In 13 cases we could see severe osseous injuries localised at the epiphyseal plate. With decreasing frequency, the following conditions occurred: avulsion fractures of the intercondylar eminence, fracture of the tibia head in children, fractures of the patella and avulsions of the tuberositas tibiae. Furthermore, we report about the special problems of foreign bodies incorporated in the knee joints of children, particularly if sewing needles are involved.

[Delivery planning and interdisciplinary management of large coccygeal teratomas]

Prenatal sonographic screening and a growing experience of examiners with regard to possible congenital malformations such as large coccygeal teratomas have induced the request for an early interdisciplinary consultation between obstetrician, human geneticist, paediatric surgeon, neonatologist and psychologist. It should aim at a careful information and counselling of the parents with regard to the mode of delivery and possibilities of operative management. The prerequisites for far sighted planning and performance of delivery are demonstrated by the example of large coccygeal teratomas. The availability of equipment, facilities and manpower at the time of delivery guarantees a course of delivery at reduced risk and is, together with the psychological guidance of the parents, a basic element of optimal care for the newborn.

Programmed electrical stimulation to determine the need for antiarrhythmic therapy in patients with complex ventricular ectopic activity

Patients with complex ventricular ectopy (greater than or equal to Lown grade III) and organic heart disease (OHD) are at increased risk for sudden cardiac death. Despite this fact, many such patients will remain free of symptomatic ventricular arrhythmia and thus are unnecessarily exposed to antiarrhythmic drug toxicity and arrhythmic potentiation. Programmed stimulation (PS) was used to direct therapy in 88 patients with asymptomatic ventricular ectopy complicating OHD. Thirty-three had inducible ventricular tachycardia (VT) and underwent treatment. The 55 patients without inducible VT (less than or equal to 6 repetitive ventricular responses) are the focus of this study. Three patients required treatment for persistent cardiac awareness. The remaining 52 have been followed for 22 months off antiarrhythmic drugs and all have remained free of subsequent major arrhythmic events. Therefore, in patients with complex ventricular ectopy, OHD, and absence of prior symptomatic ventricular arrhythmia, PS identifies patients at low risk for future disabling or life-threatening arrhythmic episodes and patients with absence of inducible VT can usually be managed without antiarrhythmic drugs.

[Delayed diagnosis in right sided congenital diaphragmatic hernia]

Report on two cases with delayed diagnosis of congenital diaphragmatic hernia. The cause of partial and total opacity of the right chest was recognised only after thoracotomy which followed misdirected diagnostic procedures such as tomography, bronchoscopy and repeated punctures of the pleural cavity. In both cases a transdiaphragmatic liver prolapse with signs of transthoracic liver punctures was found. The diagnostic importance of sonography and if necessary, computed tomography and liver scintigraphy in infancy and childhood, is emphasised.

[Cystic duplications of the cervical esophagus]

Cystic duplications in the cervical region are very rare. In most cases compression of the trachea leads to severe symptoms of respiration. Two cases of cystic duplication are described - a nine months old child and a newborn baby. In the first case the cyst was localized on the right side of the thyroid. Extirpation could be done without any complications. The operation on the second case was difficult. The tumor was localized between oesophagus and trachea rotating the larynx.

[Problem of fracture of the radius head in the child]

Guidelines for the choice of conservative or operative treatment of fractures of the proximal radius are derived from a study comprising 21 children. Postoperative complications and long-term failures are specifically stressed. True intraarticular fractures of the radial head are rarely observed in children. Major problems arise in the treatment of comminuted fractures of the radial head associated with dislocation of the elbow, since these show the worst prognosis. Displaced marginal fractures below 3 mm are suited for early functional treatment using conservative procedures. 18 patients suffered a fracture of the radial neck type III and IV (Judet). Despite low failure rates of the operative therapy, we have recently been refraining from the operation.

Cytotoxicity of lectins on rat intestinal mucosa enhanced by neuraminidase

The lectins wheat germ agglutinin (WGA) and Concanavalin A (ConA) were perfused into an isolated small intestinal segment alone or after prior perfusion with neuraminidase for a 10 day period in the rat. Intestinal morphometry, intraepithelial Lymphocyte (IEL) and round cell content as well as digestive capacity was measured in the loop and in the adjacent segments. Both lectins induce a mucosal transformation in all segments but ConA is more effective than WGA. Pre-incubation with neuraminidase enhances the action of ConA throughout, whereas only a partial enhancement of the effect of WGA is observed. The mucosal transformation after long term perfusion with the lectins resembles the hyperregenerative adaptation of the mucosa due to gluten in coeliac disease and may thus serve as an animal model for this disease.

[Fractures in the elbow joint area in childhood and adolescence]

73 cases of elbow joint fractures were treated in our Dep. of Paediatric surgery over a period of 10 years. Most of the fractures in the region of the distal humerus are localized at the ulnar epicondyle and the radial condyle. At the proximal forearm the radial head and the radial collum fractures are dominant in respect to olecranon fractures. Only two cases involved a comminuted fracture of the distal humerus. Due to the fact that only a small number of cases involving a fracture of the radial epicondyle after a luxation of the elbow were registered, it is possible that we paid no attention to this kind of fractures. An early functional therapy in the case of segmental fracture of the radial head must be emphasized among the 11 cases with a conservative treatment. Another 3 cases with a radial head fracture, type Judet III, should be mentioned, because they were treated without reposition but were spontaneously redressed. The operation procedure and the late results by 62 patients are discussed with the results of other examiners. As expected the comminuted fractures of the distal humerus and the radial head had a bad prognosis. Functional relevant dislocations were rare. Only in one case after a conservative treatment of a lateral condyle fracture a development of a valgus position with a pseudarthrosis after a secondary dislocation was observed. In more than 90% of our cases we could achieve a complete anatomical reposition with good to very good functional results.

[Influence of the volume of peridural morphine bolus injections on morphine concentration in the cisterna magna of the dog]

14 dogs received randomly a bolus injection of either 2 mg morphine in 10 ml isotonic saline solution or 2 mg morphine in 1 ml isotonic saline solution epidurally at T6. An epidural infusion of 0.16 mg morphine/0.06 ml/h was applied immediately following the 1 ml bolus injection of morphine. Cisternal cerebellomedullary CSF samples were taken at varying intervals to determine free morphine immunoreactivity by radioimmunoassay. Within 20 min after the 10 ml bolus injection the peak CSF morphine concentration of 3594 +/- 910 ng/ml was reached. Following this, CSF morphine levels decreased exponentially and after 48 h 8 +/- 3 ng/ml were measured. The peak CSF morphine concentration of 139 +/- 51 ng/ml was, however, reached only after 2 h following the 1 ml bolus injection plus the infusion treatment. Despite the additional infused amount of 7.68 mg over 48 h the CSF morphine concentrations decreased also exponentially and after 48 h 16 +/- 4 ng/ml were measured. One may conclude, therefore, that the risk of respiratory depression is negligible under epidural infusion treatment following an initial "Low-Volume"-bolus injection of 2 mg morphine, a recommendable method for treating post-operative pain. High-volume bolus injections of morphine should generally be abandoned in epidural treatment of pain.

[Ventral abdominal wall defects--antenatal diagnosis, course of pregnancy and post partum therapy]

The article reports on antepartal sonographic diagnosis and the course and completion of 27 cases with ventral abdominal wall defects. There were 17 cases of omphalocele, 4 cases of gastroschisis and 6 cases of complex ventral abdominal wall defects with associated malformations. In 23 of the 26 women examined prenatally via sonography (89%), the diagnosis was ventral abdominal wall defect. In the 3 cases not diagnosed via sonography, there was one case of intrauterine foetal death. In another case, Potter's syndrome with anhydramnion was found besides a foetal abdominal wall defect, whereas the last unrecognised case had been subjected to sonographic examination outside the hospital only. In 13 out of 17 cases (77%) with omphalocele there were additional malformations. On the other hand, no further associated malformations were seen in the 4 patients with gastroschisis. Complex abdominal wall defects (in the sense of total abdominal wall aplasias or thoracoabdominal gastroschisis, etc.) with multiple associated malformations occurred in the remaining 6 cases. The most frequently seen associated malformations in children with omphalocele were neural tube defects and skeletal malformations (35% each), followed by cardiac and vascular malformations and malformations of the digestive tract. In those women examined in our clinic via sonography who had foetal abdominal wall defects, amniotic anomalies were seen (hydramnion 44%, oligohydramnion 13%). Chromosomal anomalies occurred in omphalocele with 35% incidence. The results obtained point to the necessity of conducting detailed and accurate sonographic examination if a foetal abdominal wall defect is discovered, in order to exclude or confirm further associated malformations.(ABSTRACT TRUNCATED AT 250 WORDS)

[Spleen autotransplantation--comparative animal experiment study of implantation sites]

Iatrogenically induced local splenosis seems to be a method for the partial preservation of splenic functions with appealing surgical simplicity. Pathophysiological aspects, such as flow direction of splenic venous blood, the ectopic occurrence of potential splenic affections, and the formation of pseudoabscesses as well as the preconditions for nidation of the autografts have not been sufficiently investigated so far. Sixty Wistar-rats, divided into four groups according to the surgical procedure performed (sites of implantation: omentum majus, liver, retroperitoneal space, pedicular omental flap), were subjected to macroscopical and histological studies with regard to the nidation of splenic autografts. Based on the results obtained and considering the above mentioned criteria, a pedicular omental wrap technique with or without retroperitoneal shifting and autograft fixation with fibrin glueing are suggested as the most preferable procedure.

Problems in spleen autotransplantation: comparative study of types of implantation in animal experiments

Iatrogenic localized splenosis presents a seemingly simple surgical possibility for preserving partial function of the spleen. Until now, pathophysiological aspects, such as the drainage direction of venous blood from the spleen, possible splenic diseases in ectopic tissue, and the formation of pseudoabscesses as well as conditions for implantation have been given insufficient attention. In 45 Wistar rats, divided into three groups according to the surgical procedure (implantation in the greater omentum, liver, retroperitoneum), the taking of the grafts were examined macroscopically and histologically. Because of the results, and bearing in mind the mentioned criteria, a new method for spleen autotransplantation is suggested: the implantation into a pediculated flap of omentum and retroperitoneal displacement behind the splenic bed.

[Tumors of the adrenal gland in childhood. Report of 38 patients]

During the past 17 years at the Department für Pediatric Surgery, University of Heidelberg, 38 children aged 1.6 to 14 years were adrenalectomized (unilateral 3.3, bilateral 5). Individual diagnoses were: neuroblastoma 23; pheochromocytoma 5; adrenocortical carcinoma 8; adrenocortical adenoma 4; bilateral nodular hyperplasia 2 cases. Patients with histologically benign lesions are alive and without recurrence more than 5 years after surgery, except one patient who developed Nelson's tumor after bilateral adrenalectomy for Cushing's disease. Of the patients with malignant adrenal tumors 21 died within 18 months after therapy was started, a 7 years old girl with an adrenal carcinoma died after a period of 3.6 years of combined treatment. In most cases of adrenocortical tumors virilization was the prominent feature.

[Disturbance of micturition, a harmless side effect of subdural regional anesthesia?]

The authors report on a disturbance of micturition following spinal anaesthesia which due to improper treatment took two months to resolve. The neurological status showed failures which were due both to the anaesthesia (irritation of root in the S 4 and S 5 regions by the spinal needle and action of the local anaesthetic agent) and to the surgery of a relapsing inguinal hernia (irritation existed, we could not exclude the possibility that the primary disturbance of bladder emptying was due to the anaesthesia and not to the surgical procedure of a possible mental component. In any case, the long-term atony resulting from the basically harmless handicap - even requiring placement of a suprapubic bladder fistula - could have been avoided if the postsurgical treatment had been conducted properly and in accordance with good medical practice.

[Technical aspects of splenectomy]

A detailed report is given on a modified surgical technique of the resection of the spleen. A successive division is performed within the area of the demarcation line after careful study of the vessels. The wound surface is sealed by fibrin and collagen fleece soaked with fibrin and therefore flexible.

Compliance with disulfiram treatment of alcoholism

One hundred twenty-four men were randomly assigned to receive disulfiram with a riboflavin marker or riboflavin alone. During a one year follow-up urine specimens were collected at each visit and analyzed for riboflavin. There was a strong relationship between excellent attendance and infrequent drinking. For subjects taking disulfiram there was a high correlation between a subject submitting 15 or more positive urines during follow-up and infrequent drinking. For the disulfiram patients there was also a strong relationship between continuous usage of disulfiram and infrequent drinking. However, the correlation between percentage of urine specimens positive for the riboflavin marker and infrequent drinking was slight. This occurred because a person who was drinking tended to return for follow-up only when he was not drinking and thus submitted only a few specimens of which the majority were positive. We conclude that (1) excellent attendance, (2) submission of a large number of positive urines and (3) a period of continuous compliance to the disulfiram regimen were highly associated with infrequent drinking.

[Various aspects of pediatric surgery in surgery of the spleen]

The method of partial splenectomy by applying fibrin glueing has become a safe surgical procedure thus opening new aspects of pediatric surgery of the spleen. Indications for partial splenectomy are discussed with special regard to Hodgkin's disease. The autotransplantation of splenic tissue--a localized form of iatrogenically induced splenosis--is considered as secondary to partial splenectomy since the arterial perfusion and the filter function of the spleen are not maintained. In cases, where partial splenectomy cannot be performed, splenic tissue should be placed in a retroperitoneal pouch of the splenic bed. The vulnerable infant omentum is rejected as a possible site of implantation since there is danger of spreading splenic tissue into the whole abdominal cavity inducing further complications by infections or neoplasma with splenic participation.

[Comparative therapeutic activity of pirprofen and acetylsalicylic acid in rheumatoid arthritis. A 12-month controlled multicenter study]

This double-blind cooperative study comparing pirprofen and acetylsalicylic acid (ASA) in the treatment of rheumatoid arthritis was conducted in 12 centres and involved 342 patients distributed throughout the United States. The patients were randomized to either pirprofen 200 mg four times a day or ASA 900 mg four times a day. The drugs were administered for 52 weeks. Nine standard clinical criteria were used for assessment of the therapeutic results by the investigators and by the patients themselves. Fifty-five % of the total patient population reported that they were highly satisfied with pirprofen, as against 47% with ASA. The investigators preferred pirprofen in 51% of the cases and ASA in 38% (p less than 0.05). Side effects (tinnitus, gastrointestinal disorders) were more frequent in the ASA group than in the pirprofen group. During the 52-week treatment-period, biological alterations were only observed in two patients (1 on pirprofen, 1 on ASA).

[Problems of intramural haematomas in childhood. A report of 5 cases]

5 cases of intramural haematomas are discussed. The haematomas were of different origin, were localized at different sites and treated differently. In one case an obstructive duodenal haematoma developed after a liver and spleen rupture. This hematoma was treated by gastro-enterostomy. In the second case the cause could not be determined. The third haematoma was induced by an intestinal clamp. In the last two cases there was a tendency to haemorrhages (Morbus Schönlein-Henoch and haemophilia A).

[The transpectoral blockade of the brachial plexus (author's transl)]

The brachial plexus can be located and blocked by a needle inserted perpendicularly to the frontal plane 3 cm medial to the coracoid process and 3 cm caudad to the clavicula. The method is easy to master, complications are of little consequence and the success rate with some experience high.

[The problem of congenital duodenal obstruction - A report of 123 cases (author's transl)]

The authors report on a consecutive series of 123 children (46 males, 54 females) with congenital duodenal obstruction who were operated on between 1962 and 1980 at the Department of Paediatric Surgery, University of Heidelberg, Surgical Centre. 78 patients (64%) had an extrinsic obstruction; in 36% of the children a membraneous stenosis or complete atresia was observed. 74 children (60%) were mature at birth and had no additional malformations. Out of the remaining 49 children, 25 were mature but had additional malformations. 13 prematurely born children without and 11 prematurely born children with additional malformations were seen. 17 (14%) out of 123 children died. In 74 cases with uncomplicated duodenal obstruction only 5 children (5%) died, as compared to 13 children (27%) out of 49 cases with complicated obstruction. A division of our patients into two time spans (1962 to 1971, 1972 to 1980) shows a total lethality of 25% for the first series, which included 39% cases with complications. In a consecutive series of 54 children operated between 1972 and 1980 no child died.

[Segmental resection of the spleen and glueing with human fibrinogen - an alternative to splenectomy and autotransplantation (author's transl)]

Basing on exemplary case histories - trauma, benign tumour and staging of lymphogranulomatosis - the possibility of maintaining the function of splenic tissue by means of partial splenic resection is discussed. Indication, surgical approach including fibrin glueing and postoperative follow-up are described, taking recent literature into account, and are discussed as an alternative to splenectomy and autotransplantation.

[Soft tissue sarcomas in childhood (author's transl)]

477 patients with soft tissue sarcomas, including 87 children (18.2%) were treated at the Surgical Center of the University of Heidelberg between 1950 and 1980. 22.8% of the patients with solid tumors (excluding brain tumors) in childhood were soft tissue sarcomas. In the pediatric age group there were 30% rhabdomyosarcoma and 20% angioblastic sarcoma. Since introduction of combined tumor therapy (surgery, radiation, and chemotherapy) the survival rate increased impressively from (29% to 58%).

[Surgical management of intersexuality in infancy and childhood--medication, procedure and operation schedule (author's transl)]

In recent years a multidisciplinary therapy contribution has brought about a remarkable change from a purely morphological to a markedly functional type of surgery in corrective operations of intersexual genitals. Methods of surgery generally in use today are described groupwise according to functional aspects. Their development is subject to cultural influences just as it depends on general medical progress and recent psychological knowledge.

Polyamine responses in a solid transplanted tumor (S180) in liver and in urine during endotoxin-induced tumor injury in the mouse

Polyamine (PA) and ATP concentrations have been measured in the S180 sarcoma damaged by endotoxin (1) 4 hours after administration, coinciding with the onset of hemorrhage, (2) at 8 hours, and (3) at 24 hours, preceeding overt necrosis. The putrescine (PU) content increased promptly, the spermidine (SPD) level dropped by 30% between 8 and 24 hours, while the spermine (SPM) concentration remained unchanged. The ATP level fell, reaching 1% of the control value at 24 hours. The parallel between increases in tumor PU content and urinary PU excretion appears to be largely fortuitous; no similar correlations existed in the cases of SPD and SPM. The development of tumor stasis and the alterations seen in PA metabolism of tumor-free controls suggest that the changes in liver PA concentrations and in urinary excretion primarily reflect responses of nonmalignant cells. Both these findings in animals without tumors and existing data from other experimental systems are consistent with the thesis that PA response patterns to a particular procedure are qualitatively similar regardless of the presence or absence of a malignant growth, and are characteristic of the procedure employed.

[Surgery of lung metastases in childhood (author's transl)]

Over the past 10 years 18 patients have been operated upon (sometimes repeatedly) because of pulmonary metastases. The primary tumour with pulmonary secondaries was usually an osteosarcoma or a Wilm's tumour. The indication for surgery and the result of treatment are discussed. The pre-operative diagnosis is helped considerably by ventilatory and perfusion isotope studies.

Abnormal chloroidal circulation: association with arteriovenous fistula in the cavernous sinus area

Abnormalities in the choroidal circulation developed in two patients with arteriovenous fistulae in the area of the cavernous sinus. Fluorescein angiography in both patients revealed delayed filling of their choroidal circulation. In the first patient, this was associated with a central serous detachment of the retina secondary to a retinal pigment epithelial defect. In the second patient, a large choroidal detachment and serous retinal detachment, which resolved spontaneously developed. High venous pressure, low mean arterial pressure, and subsequent tissue hypoxia are postulated to be the cause of the altered choroidal circulation. The possibility of occult dural arteriovenous fistulae should be considered in the differential diagnosis in patients with a choroidal detachment, proptosis, and a red eye.

[Electron microscopic observations in internal organs in morbus Fabry (author's transl)]

Electron microscopic findings are reported on the localization and fine structure of glycolipid inclusions in different organs (heart, kidney, lymph nodes, arterial blood vessels, pancreas) in Fabry's disease in a female. The intracellular and extracellular inclusions were made up of multilamellar membraneous systems in concentric, excentric, and parallel arrangement. This fine structure is characteristic of liquid-crystalline phases of phospholipid-water systems. The same type of inclusions are found in the internal organs of heterozygotic women as in homozygotic men. The relationship between the glycolipid inclusions and the lysosomes is discussed.

[Agammaglobulinemia and secretory IgA (author's transl)]

After serum IgA has been intravenously administered, it appears immediately in secretions, sputum, and urine. At about the same time, a mechanism is employed which leads to the concentration of IgA in the sputum. In urine, 7sIgA and SC were separately eliminated; a linkage with 11sIgA did not occur. Similar relationships are probably present in the sputum, but exact proof could not be provided. By administrating immunoglobulin concentrates which contain IgA in 7s-serum form, the IgA concentration in external secretions can be raised; replacing the physiological 11s-IgA however, is not possible. The extent to which 7sIgA can take over the function of 11sIgA in these secretions has not yet been clarified. In this connection, the use of local 11sIgA inhalation therapy rather than ultrasound atomazation seems to be well founded theoretically and also promising. Whether such therapy can be carried out practically and is successful remains to be seen.