Bladder shrinkage as a complication of long-term supravesical urinary diversion in children with solitary kidneys

Failures in the treatment of terminal ureteral stenosis are not seldom burdened by considerable bladder shrinkage, particularly in infants. Congenital anomalies of the urinary tract such as bilaterally ectopic ureteral ostia can also lead to bladder shrinkage, even in newborns. Using examples from our patient series, we discuss problems of contracted bladder in children and describe a method of continuous bladder distention by means of catheters with different balloon volumes and a simultaneous, intermittent, hydrostatic bladder dilatation. This method enables reintegration of a bladder which has been excluded from the urinary drainage system for a long period of time into the urinary tract, even in complicated cases, thus avoiding a permanent supravesical urinary diversion.

[Surgery of the endocrine pancreas]

After classification of the endocrine tumours of the pancreas our group of patients during the last 17 years is demonstrated including patients with nesidioblastosis in every case except one with islet cell carcinoma. Beside typical anamnesis and symptoms, diagnosis was confirmed mainly by the glucose/insulin-ratio, the extremely low fasting blood glucose and the increased need of glucose supply for normalisation. Medical therapy with somatostatin and/or diazoxide was not successful in any case for a longer time, although in persistent cases nesidioblastosis became treatable postoperatively with diazoxide. Usually, a so-called 7/8-resection was performed. Typical complications from surgical management of pancreatectomy did not occur none of the children died. As for long-term results, no patient suffered from insulin dependency or insufficiency of the exocrine pancreas; reoperation was also never necessary. The established neurological damage of children who had been operated on late, could not be repaired. Despite the heterogeneous forms of the samples, histochemical investigation established nesidioblastosis in every pancreas specimen. An explanation of the histological findings would be a failure of the B-cell-function as pathogenetic cause of nesidioblastosis.

[Clinical aspects, classification and prognosis of 7 cases of pediatric fibromatosis]

Seven cases of fibromatoses in infancy and childhood serve as examples to demonstrate this group of rare tumours, taking especially the aggressive forms of juvenile fibromatoses into account. There is a tendency to locally invasive destructive growth without metastasising at any time and a markedly high relapse rate after surgery--a tendency that showed up clearly in our patients, too. Only one child out of four having infantile (desmoid-type) fibromatosis of different localisation did not show any recurrence. The article reports, among other cases, on a desmoid of the stomach and oesophagus in a 15-year-old girl, not described in the literature so far, and on a congenital fibromatosis of the pancreas. Several classifications had to be performed to properly grade the individual cases (1, 6), since no generally valid systematic description of these tumours exists.

Imaging of uretero-pelvic junction obstruction with stimulated diuresis. With consideration of the reliability of ultrasonography

Eighty-nine kidneys of 81 infants and children with uretero-pelvic junction obstruction were investigated using ultrasonography (US), diuretic urography (DUR) and diuretic renography (DREN). Results of the US were false-negative in 14%. This can be avoided by ensuring that the patients get an amount of fluid appropriate to their age before the examination or by performing diuretic ultrasonography with frusemide. False-positive results were found with US in 15%, but obstruction was excluded by using the DUR and/or the DREN. During post-operative follow up the DUS is useful and after 6 months the clearance with 123-iodine hippurate combined with the DREN should be performed. The performance of the Whitaker-test is unnecessary.

[Cecil-Duplay/Cecil-Leveuf urethral reconstruction in severe hypospadias]

A total of 199 boys with severe hypospadias were subjected to surgery during 1981 to 1984 at the Department of Surgery of the Red Cross Paediatric Hospital in Siegen and from 1971 to 1984 at the Department of Surgery of the Municipal Paediatric Hospital in Cologne. Plastic reconstruction of the urethra was performed according to a multiple-stage technique after Cecil-Duplay/Cecil-Leveuf. It is evident that good results can be obtained in such severe forms of hypospadias by means of differentiated multistep surgery. A fistula rate of 14% is an essential improvement over the results previously obtained by the urethral reconstruction method after Denis-Browne.

[Comparative results of ileal conduit and colonic conduit. Analysis of 50 children with bladder exstrophy]

During the last 20 years 50 children with exstrophy of the bladder were treated in the Department of Paediatric Surgery of the Children's Hospital of Cologne employing besides other surgical methods such as primary closure, ureterosigmoideostomy, ureterocutaneostomy etc., in 15 cases an ileal conduit and in 12 cases a colonic conduit. These children could be followed up on the average 8.5 or 3 years after the operation, clinically, roentgenologically and in some cases via scintigraphy. Late complications requiring surgical correction, such as stomatostenoses, conduit elongation, stenoses of the ureterointestinal anastomosis, calculus formation in the conduit, or complications like ureteral reflux, recurring infections of the urinary passages with pyelonephritis, occurred only with ileal conduits, whereas no late complications requiring surgery were seen with the colonic conduits. Similar results in respect of late complications were found among the patients in Munich from 1955 to 1983 with 35 exstrophies of the bladder (13 ileal conduits, 1 colonic conduit) in which additionally an adeno-carcinoma was seen after ureterosigmoideostomy with fatal outcome. Hence, we are of the opinion that the method of choice is the preparation of a colonic conduit in patients with exstrophy of the bladder where primary closure is not possible because the bladder lamina is too small or already epithelialised. This approach offers the safest possible long-term protection of the primary normally positioned upper urinary tract.

[Bridging extensive esophageal atresias by a peritoneal transplant]

A method is presented that represents a modification of Rehbein's perlon filament technique for treating extensive oesophageal atresias. This new approach enables, in case of congenital oesophageal defects exceeding three vertebral bodies in length, to eventually perform end-to-end anastomosis of the patient's oesophagus. For this purpose, the distance between the mobilised oesophageal segments that are interconnected by means of a centrally positioned perlon filament, is additionally bridged over with a peritoneal cylinder in the sense of an autotransplant. The advantages of the method are the creation of a wide preformed channel for subsequent bougineages, the protective effect exercised on the mediastinum to prevent possible inflammatory conditions, and especially the continuous traction exercised on both oesophageal pouches by the shrinking of the transplant resulting in a ring-shaped stenosis that is easy to resect and can be bypassed via end-to-end anastomosis. We treated according to this method from 1982 onwards seven children with congenital oesophageal atresias extending over the length of three to seven vertebral bodies; four of these patients now present with patent oesophageal passage.

Liver abscess in Dubai. An analysis of 29 cases and an assessment of the value of CAT scan

The clinical features and management of 29 consecutive cases of liver abscess admitted to the Medical Division at the Rashid Hospital, Dubai, between February 1979 and March 1982 are reviewed and the value of CAT scan in the diagnosis and management is assessed.

[Familial adenomatosis coli--a precancerous condition]

The presented paper includes the medical records of five children with familial adenomatous polyposis coli on the one hand and the detailed description of the pathologic findings of the disease on the other hand. Particular emphasis is given to the morphologic criteria of the disorder predisposing the affected individuals to development of colorectal cancer at unusually early ages. In the current cases there was a so-called classical presentation of diffuse polyposis in the early and late childhood respectively. The diagnosis was established in supposedly unaffected siblings due to colonoscopy and radiologic procedures. Prophylactic total colectomy was performed in all proven cases. The association with extracolonic tumours has proved to be a remarkable feature of the disease. This fact is especially stressed.

[Lobar emphysema]

The lobes most commonly affected are the left upper and the right middle lobes. The classical sign of respiratory distress is mainly found within the first two months of life. In 14 infants the diagnosis was confirmed by microscopic examination, 13 were treated by surgery and 4 infants, who had associated serious malformations or complications, died. In most cases hypoplastic bronchial cartilage of the concerned bronchi was seen, in some cases a stenosis of the lobar bronchi. It is of great importance to establish the diagnosis as soon as possible. The lobectomy is recommended if the respiratory or cardial failure is worsening despite artificial ventilation.

Pituitary thyrotropic adenoma associated with congenital hypothyroidism. Report of two cases

Two patients with congenital hypothyroidism and thyroid-stimulating hormone-secreting pituitary adenomas are described. Both patients had a history of long-standing, inadequately treated hypothyroidism accompanied by markedly elevated levels of serum thyroid-stimulating hormone. Pituitary tissue, obtained at autopsy in the first patient and at surgery in the second, disclosed a thyrotropic adenoma. Immunocytochemical studies with anti-thyroid-stimulating hormone antisera showed both tumors to be strongly immunoreactive. Such thyrotropic adenomas of the pituitary gland are presumed to occur as the result of protracted pituitary stimulation secondary to long-standing thyroid deficiency.

Percutaneous nephroureteral drainage and stenting for postsurgical ureteral leaks

Five patients with postoperative ureteral fistulae subsequent to surgically created ureteral anastomoses were treated successfully by temporary percutaneous nephroureteral drainage and stenting. Low, constant suction applied to the drainage tubes achieved total urinary diversion, while concomitant ureteral stenting seemed to prevent subsequent stricture formation. The techniques have reduced considerably the morbidity of this particular postoperative complication.

[Pre- and retrorenal neuroblastoma without kidney displacement]

Pre- and retrorenal growing neuroblastomas did not produce any displacement of the kidney or any obstruction in the intravenous pyelogram. The diagnosis was done by ultrasound-scanning as well as biochemically before surgery. The reported cases show that sonography and determination of the catecholamine metabolites are essential in the diagnostic evaluation of abdominal tumors in childhood.

[Abnormal choledocho-pancreatico ductal junction causative of cystic-cylindric dilatation of intra- and extrahepatic bile ducts]

During the last 5 years there were 6 patients found to have abnormal ductal junction of the choledochus into the pancreas. Clinical signs were: repeating upper abdominal pain, intermittent icterus, signs of pancreatitis and/or palpable tumor. Sonography is the initial examination to show up a dilatation of the intra- and extrahepatic bile ducts. But intraoperative cholangiography alone reveals the true condition of the choledocho-pancreatico ductal junction. Only after this procedure the therapeutic step of a choledocho-jejunostomy should be done.

[Operative correction of a urogenital malformation with persistent cloaca]

A case of malformation of the urogenital system with a persistent urogenital sinus and a cloaca is reported. There was unilateral agenesis of the kidney, megaureter and a double ureter with an ureteral orifice into the vagina and the clitoris. There was a double uterus and vagina with an orifice into the terminal gut. The patient had chronic recurrent urinary tract infections which required a colostomy during childhood. The operation largely restored a normal urogenital area and a functional anus.

[Supracondylar humeral fractures in infants and small children]

The question of separation of the epiphyses in infants and small children of the type Salter-Harris affecting the distal humerus is discussed. The indications for open reduction of the distal humerus epiphyseal separation is rarely indicated and should only be utilised when there is associated injury to the nerves of vessels or a total disruption of the chondyle. Provided that accurate re-position and fixation can be performed, the prognosis of this injury is satisfactory.

On the variance of the maximum of partial sums of n-exchangeable random variables with applications

A general formula is obtained for the variance of the maximum of partial sums of n-exchangeable random variables, derived from a result of Spitzer's. The formula is applied in particular to obtain the variance of the maximum of adjusted rescaled partial sums of normal summands. This is of direct relevance to the Hurst effect.

[Stomach duplication]

The eighty-four cases of stomach duplication known to date from world literature are presented including one case of the authors' own experience. The most varied theories of pathogenesis are discussed, as well as the very different clinical course the disease may take, and the diagnostic difficulties presented by X-ray examination. Finally, attention is drawn to the current use of the scintigraphy, which has broadened the diagnostic possibilities.

[Traumatic subluxation of the head of the radius (author's transl)]

Radial-head subluxations were noted in 194 patients in the course of two years. It was more frequent in girls than boys (57.7% and 42.3%). The highest incidence was between the first and fourth year of life, with a peak in the first and second years. It no longer occurs after the seventh year. In 82.5% of cases the history was typical: a sudden longitudinal pull of the affected arm. In the remaining 17.5% no exact event could be ascertained. A questionnaire sent to the attending doctors provided replies in 82 cases (42.3%). Reposition by pull and pressure on the head of the radius, supination and acute flexing achieved repositioning in 92.7%, while in 7.3% repeat repositioning was necessary on the same or the next day. After successful repositioning complete absence of symptoms occurred in 98.8%. Incidence of recurrence was 30.5% during a follow-up period of up to a year and a half. The diagnosis had at first been had at first been missed 9.8% of cases.