Accessory scrotum and anorectal malformation associated with "pseudo" prune belly in a neonate

We report a patient with high anorectal anomaly and accessory scrotum. To the best of our knowledge only four other similar cases have been described. The patient also had renal dysplasia, partial prune-belly syndrome, and dismal outcome because of urinary septicemia. To our knowledge, accessory scrotum, high anorectal anomaly, and prune-belly syndrome in the same patient has never been reported.

Preserved viability of the isolated bowel segment, created by omentoenteropexy: a histological observation

Creation of the isolated bowel segment (IBS) by omentoenteropexy in rats and dogs consists of a two-step procedure: initial omentoenteropexy to the antimesenteric border of a jejunal segment, and division of its mesentery 6 weeks later. Viability of this IBS is maintained by the angiogenic process, which occurs at the level of the myoenteropexy. Histological studies were performed by light microscopy on the bowel wall structures of the IBS before and after the mesenteric division, as well as after a lengthening procedure performed on the IBS in one dog. The authors conclude that (1) in rats and dogs the intestinal wall structures of all IBS variants created by omentoenteropexy appear close to normal, and (2) neovascularization can be clearly detected at the level of the omentoenteropexy.

Barrett's epithelium with complete stricture of the esophagus: hypothesis of its etiology

A 4-year-old very debilitated boy, who suffered from recurrent vomiting (regurgitation) since birth, is described. At the age of 18 months, partial obstruction of the esophagus was apparent, and only semisolid food could be swallowed. The signs of obstruction progressed, and the child was admitted urgently, at the age of 4 years, to the authors' department because of severe dehydration. After resuscitation, a barium swallow and esophagoscopy showed a complete obstruction of the esophagus between its middle and lower third. Through a left thoracotomy incision, 4 cm of the diseased esophagus were resected and continually established by end-to-end esophagoesophageal anastomosis. Pathological examination showed complete obstruction of the esophagus with Barrett's epithelium above and below the stricture. Severe periesophagitis was also present because of sealed perforation of the esophagus. One week after the operation the child was on a normal diet. On follow-up, 6 months later, he has no signs of obstruction and is gaining weight. It is postulated that the presence of Barrett's epithelium in the esophagus in congenital, but the complications, such as stricture formation, are usually caused by chronic irritation, such as gastroesophageal reflux. Barrett's epithelium alone infrequently will cause

Outcome of partial splenectomy for type I Gaucher disease

Partial splenectomy was introduced to achieve the benefits of splenectomy and to avoid the risk of overwhelming infection in patients with symptomatic Gaucher disease. We observed regrowth of the splenic remnant, reemergence of preoperative symptoms, and new bone involvement among most of our patients who had undergone partial splenectomy. Enzyme replacement therapy has markedly limited indications for splenectomy, partial or total, for Gaucher disease.

Jejunal mucosal function of the isolated bowel segment created by omentoenteropexy in dogs: a study by in situ luminal perfusion

An isolated bowel segment (IBS) was created in dogs by omentoenteropexy, using staged procedures. (1) Omentoenteropexy was performed at the antimesenteric border of a 15-cm jejunal segment, which was exteriorized at both ends (IBSB). (2) After 6 weeks, once dual vascularization to the IBS had been established, its mesentery was divided (IBSA) or longitudinally split, thus achieving its elongation (IBSE). A control dog underwent a Thiry-Vella (T-V) loop procedure of an identical jejunal segment. Viability of the IBSB and IBSA was previously proven by the authors, through angiographic studies. In the present study, the absorption capability of IBS variants was assessed using in situ luminal perfusion, with a bicarbonate buffer containing glucose and labeled glycine. Jejunal transport rates of these solutes were calculated from the differences in their concentrations in the perfusion solution and in the effluent. Comparisons were made among the IBS variants and between them and the T-V loop. No significant difference in the absorption capability of glucose and glycine was noted between the various IBS variants. There was a marked reduction of glucose absorption and a moderate reduction of glycine absorption in all IBS variants. when compared with the fresh T-V loop, most probably because of disuse atrophy of the mucosa. In conclusion, absorption of glucose and glycine is preserved in the IBS, created by omentoenteropexy, both after its mesenteric division and following the IBS elongating procedure.

Traumatic rupture of the choledochus treated temporarily by Roux-en-Y entero-hepato-duodenal ligamentostomy

The authors report on a 3-year-old boy who had traumatic rupture of the choledochus. Temporary internal drainage was achieved by Roux-en-Y end-to-side entero-hepato-duodenal ligamentostomy. Two months later, a standard Roux-en-Y end-to-side choledocho-jejunostomy was performed. Five years after the injury, the child is well and has no jaundice.

Creation of the isolated bowel segment in animals by omentoenteropexy

An isolated bowel segment (IBS) was created in rats and dogs by a two-stage procedure. Initial coaptation of the bowel segment to the omentum ("omentoenteropexy") is followed by division of its mesentery several weeks later. The viability of the segment is maintained by angiogenesis at the coaptation site. Neoformed blood vessels were shown by angiographic studies, and in a dog the IBS was used for esophageal interposition.

A simple technique for anchoring tubes to the skin

The author describes a simple technique for anchoring various tubes used in the treatment of trauma patients (gastrostomy tubes, jejunostomy tubes, intercostal drains, etc.) to the skin with sutures. In this technique the tube is stretched while the suture is tied around it, thus producing a tight fit.

Mesenteric fibromatosis

The authors present the case of a 13-year-old boy in whom, after irradiation for Hodgkin's disease and exploratory laparotomy, mesenteric fibromatosis developed. The "tumor" was resected, and 1 year postoperatively the patient is well.

Partial splenectomy in Gaucher's disease: follow-up report

This is a follow-up report of three children who had partial splenectomy and are suffering from Gaucher's disease. A few years following partial splenectomy in every patient, the remaining spleen enlarged and hypersplenism reappeared; partial splenectomy did not prevent bone destruction if it already existed before partial splenectomy. Treatment with Ceredase parallel with partial splenectomy may have theoretical and practical advantages.

Pneumatic perforation of the esophagus in children

The excessive pressure in a carbonated beverage-containing plastic bottle, released by the teeth of an 11-year old boy, caused perforation of his lower pharynx. The possible mechanism is discussed.

Late presentation of Bochdalek hernia: our experience and review of the literature

During the last 18 years, 81 patients were diagnosed in the Department of Pediatric Surgery, Rambam Medical Center, as having congenital diaphragmatic hernia, 11 of whom (13.5%) presented after the first 24 h of life. In this retrospective study we describe our experience with late presentation (beyond 8 weeks after birth) of Bochdalek hernia in 5 of the 11 patients, and we review the literature.

The use of endotracheal tubes to assist in manipulation of esophageal strictures, in elongation of the esophagus in esophageal atresia, and in gastrojejunal feeding tube placement

Because of the special qualities of a PVC endotracheal tube (smooth, soft, pliable but still with a patent lumen), it serves very well for the intubation of the esophagus or the duodenum through an established gastrostomy. In this article the use of endotracheal tubes in different manipulations of the esophagus and gastroduodenum is described.

Insertion of a soft silastic nasogastric tube at operation for esophageal atresia: a new technical method

A new and simple technical method for insertion of a soft silastic nasogastric tube into the stomach in neonates born with esophageal atresia is described. The technique is simple, easy to perform, and enables feeding the baby through this tube a day after the operation. Our method is based on the principle used in insertion of Broviac-Hickman catheters, namely the use of a "peel-away sheath" through which the silastic feeding tube is threaded. We have used this technique in five patients with esophageal atresia without any complication.

[Recurrent esophago-respiratory tract fistula after repair of esophageal atresia with tracheo-esophageal fistula]

Esophageal atresia is a congenital malformation present in 1 in 4500 live births. 85% of such newborns also have a fistula connecting the distal esophagus with the trachea. Operative management includes closing the fistula by disconnecting the distal esophagus from the trachea and performing end-to-end esophago-esophageal anastomosis. A late complication is a recurrence of the fistula between esophagus and respiratory tract. The recurrent fistula is usually between the esophagus and the trachea, but it may involve the bronchi or lung tissue. This complication causes significant respiratory morbidity, mainly recurrent pneumonia, and sometimes death. The diagnosis of recurrent fistula is usually by barium swallow and/or esphagobronchoscopy. Repair is a surgical challenge. We report 5 infants with recurrent esophago-respiratory tract fistulas out of a total of 68 cases of esophageal atresia with tracheo-bronchial fistula.

[Esophageal replacement by right colon in children]

In 10 children operated on during 1977-86 the esophagus was replaced by the right colon which was brought up into the neck retrosternally. In 6 of them esophageal atresia, and in 4 severe stricture of the esophagus after ingestion of caustic liquids were the indications for operation. There was no mortality; 2-9 years after colonic transplant the patients have normal physical and mental development.

Wide gap esophageal atresia: a new method to elongate the upper pouch

A new surgical method is presented for overbridging wide gap esophageal atresia. The method is based on the fact that the atretic upper pouch has an excellent longitudinal blood supply, and is two to three times wider than the lower pouch. Muco-muscular flap is created, which is anastomosed to the lower esophagus.

Protection of the pediatric surgeon from heat stress caused by the overhead radiant heater during surgery

To protect the pediatric surgeon from heat stress while operating on premature infants under an overhead radiant heater, we propose covering the surgeon's head with an ordinary straw hat wrapped with heavy-duty kitchen aluminum foil. The temperature under such a straw hat is approximately 37 degrees C, versus 52 degrees C under a surgical cotton cap.

Absorption of medium chain triglycerides in the stomach of the human infant

Following previous observations that medium chain triglycerides (MCT) are absorbed from the stomach of suckling rats, this study was devoted to studying absorption of MCTs in human infants. Four groups of patients were studied: (a) infants suffering from pyloric stenosis, (b) premature infants, (c) children suffering from cystic fibrosis, (d) infants with miscellaneous conditions. Infant formulae with known amounts of MCT were introduced by gastric tube and samples were removed at 0, 20, 40, and 60 min. In patients with pyloric stenosis there was an 18.1% decrease in MCT during the first 20 min. No significant changes in MCT took place during the subsequent 40 min. A similar response was observed in the group of premature infants. Older infants with miscellaneous diagnoses and children with cystic fibrosis showed an even rate of disappearance of MCT during the 60-min test period, and approximately 30% of the original MCTs present disappeared during this period. We conclude that MCTs are absorbed in the stomach of infants and children. Absorption appears to improve with age. Because MCT are an important constituent of formulae for premature infants and children with defects of small intestinal digestion and absorption of fat, these observations have practical implications.

Does the spleen regenerate after partial splenectomy in the dog?

Four dogs underwent two thirds partial splenectomy and the remaining spleens were followed up to 6 months by radioisotope studies and finally measured at the time of sacrifice. In this study we showed that the remaining spleens after partial splenectomy did not show any signs of regeneration.

Effective peritoneal dialysis in an infant with extensive resection of the small intestine

Acute renal failure and pulmonary edema developed in a 1-month-old baby with necrotizing enterocolitis and hypovolemic shock. Following resection of 93% of her small intestine and mesentery, peritoneal dialysis was started; it was terminated 96 h later with complete recovery of renal and pulmonary functions. Two weeks later, while on total parenteral nutrition, the infant developed fulminant septicemia and died. Postmortem examination showed normal kidneys. Surface measurement of the abdominal wall and viscera revealed that the actual peritoneal surface area of the patient was 671 cm2, only 44% of her calculated normal peritoneal surface area. We conclude that effective peritoneal dialysis is feasible in infants with acute renal failure even after marked reduction of the peritoneal surface area.

Determination of the normal position of the anus (with reference to idiopathic constipation)

The position of the normal anus was numerically defined by the ano-genital index, which is the distance from the anus to the vagina or scrotum divided by the distance between the vagina or scrotum and the coccyx. In idiopathic constipation, one must look for an anterior displacement of the anus, which might be the cause of the constipation.

Congenital stenosis of the esophagus due to tracheobronchial remnants: a missed diagnosis

Lower esophageal strictures in infants in more than 90% of cases are related to reflux esophagitis, while the remainder are congenital or induced by injuries such as penetrating trauma or corrosion by caustic agents. Among congenital disorders cartilaginous remnants in the esophagus are very rare, but it is a possibility that should always be considered, especially if signs of esophagitis are not seen on esophagoscopy. The first aim, when evaluating the vomiting or regurgitating infant, is to establish whether this is due to an organic disorder. When stricture of the esophagus becomes evident following prolonged vomiting, clinicians tend to attribute this to reflux with peptic injury, and in most of the cases that will be correct (1). Carefully performed investigation will bring forth those rare etiologic factors that can be easily overlooked (2). The investigation has to include radiographic studies, esophagoscopy, pH monitoring, and in selected cases, manometry. Recognition of the correct etiologic factor that caused the stricture will pave the way for adequate management. We report on two patients with congenital stenosis of the lower esophagus due to cartilaginous rings, one of which was diagnosed preoperatively.

Unconjugated hyperbilirubinaemia in hypertrophic pyloric stenosis, an enigma

In a search of features that might be relevant to the understanding of the hyperbilirubinaemia of infants with hypertrophic pyloric stenosis (HPS), we examined the duodenal fluid in 11 infants with this condition. Four (36%) had an unconjugated bilirubin level above 2.5 mg/dl in the serum. Levels of electrolytes, bicarbonate, liver function tests and cholesterol were similar in the jaundiced and the non-icteric infants. Examination of duodenal fluid for pH, concentration of bilirubin, bile salts, electrolytes and beta-glucuronidase levels also did not disclose any significant differences between the HPS patients and the controls. Bacterial culture of the fluid yielded similar results in both groups. We may conclude that the unconjugated hyperbilirubinaemia observed in some patients with HPS is not associated with overgrowth of bacteria, changes in glucuronidase levels, pH, electrolytes or biliary obstruction.

Hyperchloremic metabolic acidosis as a clue to recto-urethral fistula in an infant with anal atresia

An infant with high anal atresia and transverse colostomy, in whom initial radiologic evaluation of the urinary tract had been normal, developed hyperchloremic metabolic acidosis at 24 days of age. Gastroenteritis and renal tubular acidosis as possible causes for this metabolic disturbance were excluded, which prompted a repeat investigation of the possibility of a communication between the urinary tract and the rectum. A recto-urethral fistula was demonstrated by urethrography. Analysis of the fluid obtained from the left colon as compared to urine in the bladder and voided urine demonstrated that electrolyte exchange was taking place in the colon, resulting in hyperchloremic hypokalemic acidosis. Treatment with oral sodium bicarbonate and daily lavage of the left colon resulted in normalization of the acid-base status and catch-up growth of the baby. Hyperchloremic acidosis associated with anal atresia and recto-urinary communication appears to be uncommon. However, early diagnosis and treatment of the metabolic derangement are of importance as it may determine the infant's overall prognosis.

Partial splenectomy in children with Gaucher's disease

Because of hypersplenism and mechanical problems, partial splenectomy was performed in four children with Gaucher's disease. Subsequently, one of the patients underwent a total splenectomy due to bleeding from the remnant of the spleen. At the follow-up of the other three patients, an isotope scan showed that the remaining spleen was functioning well.

Tubular duplication of the jejunum and ileum lined entirely by gastric mucosa

A 3-year-old boy who suffered from severe colicky abdominal pain is presented. Laboratory studies, including ultrasound, upper gastrointestinal films, and 99mTc-scan, were interpreted as normal. On exploration of the abdomen a tubular duplication of the small bowel was found. The duplication had a common mesentery with the normal bowel. By meticulous dissection the duplication was resected without interfering with the blood supply of the normal bowel. The entire duplication was found to be covered by gastric mucosa.

Idiopathic cricopharyngeal achalasia

Two neonates with cricopharyngeal achalasia are presented. In one of them myotomy of the cricopharyngeus relieved the obstruction. In the other baby, the symptoms disappeared without surgical treatment.

The Ale-Calo syndrome in monozygotic twins associated with bilateral cryptorchidism--case report

A case report of identical male twins with the clinical and radiological features of the rare Ale - Calo or M.E.M.R. (Multiple Exostoses - Mental Retardation) or Langer-Giedion's syndrome - is presented. The additional finding of bilateral cryptorchidism in our case is also very rare in twins, and has hitherto not been described in association with the Ale - Calo syndrome. Differential diagnosis is reviewed briefly.

Gastrografin treatment of intestinal obstruction due to Ascaris lumbricoides

Gastrografin was used to relieve subacute intestinal obstruction due to Ascaris lumbricoides in children. This hyperosmolar and wetting agent proved to be highly efficient to achieve this goal. Statistical evaluation of the hospital stay and first bowel action showed a significant difference between the treated "gastrografin group' and the untreated by gastrografin "control group,' in favor of the "gastrografin group.' Our data strongly suggest the use of Gastrografin in subacute intestinal obstruction due to Ascaris lumbricoides. This treatment should be instituted provided the patient has been adequately hydrated prior to administration.

Craniofacial microsomia in a parasite of a heteropagus conjoined twin: a clinical and histopathologic evaluation

This report evaluates a rare case of craniofacial microsomia in a partially developed, malformed heteropagus conjoined twin. In this instance, several major components of the craniofacial complex were involved: bones, cartilage, teeth, salivary glands, auditory apparatus, cerebrum, cranial nerves, and ocular neuroepithelium. In addition, cervical vertebrae and appendicular long bones were markedly affected. To date, the underlying disorder (whether genetic, metabolic, or environmental) responsible for the development of this congenital malformation is not fully understood. Our clinical and pathologic examinations tend to suggest that an apparent lack of an adequate arterial blood supply to the growing embryo could have contributed to the elaboration of this complex syndrome. The fact that the parasite's blood supply relied mainly upon a single, medium-sized artery (1.5 mm in diameter) could have brought about local ischemic milieus during the critical phases of embryogenesis; hence, impeding the preprogrammed migration of neural crest cells to their end targets in the upper branchial arches. In such a case, the normal sequence of cell differentiation is damaged, which in turn imposes a severe impact on the morphogenesis of the various tissues composing the craniofacial complex.

Leiomyosarcoma of the colon in an infant. A case report and review of the literature

A rare case of leiomyosarcoma of the sigmoid colon in a 7-week-old infant presenting with signs of intestinal obstruction followed by colonic perforation and peritonitis is reported, and the literature pertaining to childhood colorectal leiomyosarcoma is reviewed.

Heredity in anal atresia

Although anal atresia is known to occur occasionally in families and as part of genetically determined syndromes, the role of genetics in its causation is highly disputable. In this paper evidence is presented for multifactorial genetic determination as the mode of inheritance in anal atresia. This conclusion is argued as based on evidence from the literature as well as findings in an additional series of 48 cases which were collected as a family study.

Prolactin binding by testes of unilaterally cryptorchid rats: the effect of hCG, testosterone, prolactin and orchiopexy

The effect of unilateral cryptorchidism on prolactin binding to the testes was studied in the rat. Cryptorchidism was rendered surgically for 3 weeks and 3, 6 and 9 weeks later prolactin binding was measured in testicular homogenates. Prolactin binding to the cryptorchid testes decreased significantly at 3 weeks with a further decrease at 6 and 9 weeks. Binding by the contralateral testes decreased at 3 weeks and increased at 6 and 9 weeks. To examine the possible mechanism of these changes one group of rats was treated for 5 weeks with testosterone and another with hCG. Testosterone treatment resulted in a significant fall in prolactin binding to normal, cryptorchid and contralateral testes. hCG also produced a slight but significant reduction in prolactin binding. To study the effect of surgical relocation of the testes into the scrotum, orchiopexy was performed in another group of rats. Orchiopexy increased prolactin binding only if performed 3 weeks after cryptorchidism. At 6 and 9 weeks after cryptorchidism orchiopexy did not increase prolactin binding. Treatment of cryptorchid rats with prolactin for 5 weeks induced an increase in prolactin binding to control, cryptorchid and contralateral testes. It is concluded that testicular atrophy follows upon placement of a testis within the peritoneal cavity. This atrophy lowers the total amount of prolactin binding and increases binding to the contralateral testes. Intratesticular concentration of testosterone may play a major role in the decrease of prolactin binding. Orchiopexy improves prolactin binding only if performed before 6 weeks of age. Administration of prolactin augments prolactin binding to the testes, irrespective of their location.

Repeated endotracheal intubations and bronchial lavage in the postoperative treatment of tracheoesophageal fistula

Recurrent pulmonary atelectasis occurs often in neonates following primary repair of esophageal atresia, leading to massive pneumonia and respiratory failure. The atelectasis is caused by tenacious mucous plugs which are presumably formed as a result of ciliary mucosal damage secondary to reflux of gastric fluid through a tracheo-esophageal fistula. Early aggressive treatment of the atelectasis by repeated gentle tracheal intubation with bronchial lavage and suction is advocated. This treatment is well tolerated and is preferred to continuous intubation with its inherent dangers for the neonatal patient.