[Protruding omentum with umbilical fluid leakage in a patient with liver cirrhosis]

A 57 year old woman with a history of liver cirrhosis and ascites presented with serous exudate spontaneously leaking from a ruptured umbilical hernia, also known as Flood syndrome. This syndrome is a rare complication of decompensated liver cirrhosis and is associated with high mortality. In this specific case, there was also omentum protruding through the umbilical hernia which limited the outflow of ascites. Patient was successfully treated with antibiotics and consecutive open primary hernia repair without mesh implantation.

Evaluation of the effect of umbilical hernias on play behaviors in growing pigs

Umbilical hernias (UH) are common in pigs and are an animal welfare concern. This study used an assessment of play behavior to evaluate the welfare of pigs with UH. Twenty-one grower pigs with UH and 17 without hernias (WUH) were assigned to 16 playing groups (PG) of 2 or 3 pigs (with at least 1 UH pig per PG). The time each animal was engaged in any of the defined playing behaviors for locomotor/social or toy play behaviors was recorded. Mixed Poisson or negative binomial and linear models were used to determine the effect of UH and day of session, accounting for the cluster of pigs within groups, on the frequency of each play behavior, and playing times. Pigs with UH had the same frequency of most play behaviors and playing times as pigs without hernias. There was no indication that the presence of UH-affected play behavior or performance in pigs.

Gastroesophageal reflux and congenital gastrointestinal malformations

Although the outcome of newborns with surgical congenital diseases (e.g., diaphragmatic hernia; esophageal atresia; omphalocele; gastroschisis) has improved rapidly with recent advances in perinatal intensive care and surgery, infant survivors often require intensive treatment after birth, have prolonged hospitalizations, and, after discharge, may have long-term sequelae including gastro-intestinal comorbidities, above all, gastroesophageal reflux (GER). This condition involves the involuntary retrograde passage of gastric contents into the esophagus, with or without regurgitation or vomiting. It is a well-recognized condition, typical of infants, with an incidence of 85%, which usually resolves after physiological maturation of the lower esophageal sphincter and lengthening of the intra-abdominal esophagus, in the first few months after birth. Although the exact cause of abnormal esophageal function in congenital defects is not clearly understood, it has been hypothesized that common (increased intra-abdominal pressure after closure of the abdominal defect) and/or specific (e.g., motility disturbance of the upper gastrointestinal tract, damage of esophageal peristaltic pump) pathological mechanisms may play a role in the etiology of GER in patients with birth defects. Improvement of knowledge could positively impact the long-term prognosis of patients with surgical congenital diseases. The present manuscript provides a literature review focused on pathological and clinical characteristics of GER in patients who have undergone surgical treatment for congenital abdominal malformations.

Disruption of noncanonical Wnt/CA2+ pathway in the cadmium-induced omphalocele in the chick model

PURPOSE

Cadmium (Cd) has been found to cause ventral body wall defects (VBWDs) in the chick embryo similar to human omphalocele. The earliest detectable histologic changes in Cd-induced VBWD chick model have been observed 4 hours posttreatment. The exact mechanism by which Cd acts in the early embryogenesis remains unclear. Wnt proteins play a key role during embryogenesis, and altered Wnt signaling has been linked to developmental defects. Noncanonical Wnt/Ca(2+) pathway has been implicated in regulating embryogenesis by controlling cell movement and adhesion. Wnt11 can activate protein kinase C (PKC) and calcium/calmodulin-dependent kinase II (CaMKII) in the Wnt/Ca(2+) pathway. We hypothesized that the Wnt11, PKCalpha, and CaMKII gene expression is downregulated in the Cd-induced VBWD during early embryogenesis.

METHODS

After 60 hours of incubation, chick embryos were harvested 1 hour (1H), 4H, and 8H after treatment of saline or cadmium and divided into 2 groups: control and Cd (n = 8 at each time-point, respectively). Real-time polymerase chain reaction was performed to evaluate the messenger RNA (mRNA) expression of Wnt11, PKCalpha, and CaMKII in the Cd-induced VBWD chick model.

RESULTS

The mRNA expression levels of Wnt11, PKCalpha, and CaMKII were significantly decreased at 1H in Cd group compared to controls (P < .05). However, there were no significant differences in the other time-points.

CONCLUSION

Downregulation of Wnt11, PKCalpha, and CaMKII gene expression during the narrow window of early embryogenesis may cause VBWD, interfering with cell movement and adhesion, disrupting Wnt/Ca(2+) pathway.

Umbilical CSF fistula: a rare complication of ventriculoperitoneal shunt

An umbilical CSF fistula following a ventriculoperitoneal shunt is an extremely rare complication. We report a 28-year-old man who presented with leak of clear fluid from the umbilicus, one month after a ventriculo-peritoneal shunt revision. Shuntogram revealed communication between umbilicus and abdominal end of the catheter. He was managed successfully with shunt exteriorization, antimeningitic treatment, and later shunt re-insertion.

Walking with continuous positive airway pressure

A ventilator-dependent child had been in the paediatric intensive care unit (PICU) ever since birth. As a result, she had fallen behind considerably in her development. After 18 months, continuous positive airway pressure was successfully administered via a tracheostomy tube with a novel lightweight device. This enabled her to walk in the PICU. With this device, the child was discharged home where she could walk with an action range of 10 m. Subsequently, her psychomotor development improved remarkably. To the authors' knowledge, this is the first case report of a patient, adult or paediatric, who could actually walk with a sufficient radius of action while receiving long-term respiratory support.

Omphalocele, advanced maternal age, and fetal morbidity outcomes

In this study we wanted to determine if the risk for adverse neonatal outcome among omphalocele-affected fetuses is increased among older gravidas. This was a retrospective cohort study on live-born infants with omphalocele delivered in New York State from 1983 through 1999. We compared infants of older (>or=35 years) with those of younger (<35 years) mothers with respect to the following fetal morbidity indices: low birth weight and very low birth weight, preterm and very preterm, and small for gestational age. We used adjusted odds ratios to approximate relative risks. Data on a total of 1,010 infants with omphalocele were analyzed. Mean gestational age and birth weight were similar in both maternal age categories: mean+/-standard deviation (SD) for infants with omphalocele born to older mothers=37.4 weeks+/-3.9 versus 38.0 weeks+/-5.1 for those of younger mothers (P=0.2); mean birth weights+/-SD for infants with omphalocele born to older mothers=2,813+/-871.1 versus 2,958+/-809.9 for those of younger mothers (P=0.08). Also, the two maternal age sub-groups did not differ with respect to the fetal morbidity outcome: low birth weight (OR=0.95; 95% CI=0.60-1.51), very low birth weight (OR=0.78; 95% CI=0.36-1.69), preterm (OR=0.95; 95% CI=0.58-1.57), very preterm (OR=0.73; 95% CI=0.34-1.58), and SGA (OR=1.00; 95% CI=0.44-2.27). Thus, advanced maternal age does not appear to be a risk factor for fetal morbidity outcomes among omphalocele-affected fetuses. This information is potentially useful in counseling affected parents.

Umbilical and bilateral inguinal hernias in a veteran powerlifter: is it a pressure-overload syndrome?

Umbilical, inguinal and hiatal hernias are all thought to occur from basically the same etiology, a malformation in the tissue leading to herniation. The mechanisms for these malformations range from congenital to degenerative. Earlier studies proposed that hiatal hernias result from age-related degenerative changes in the phrenoesophageal ligament leading to subsequent herniation. We found that hiatal hernias occur in young power athletes secondary to intra-abdominal pressure overload of the phrenoesophageal ligament. We present a case of umbilical and bilateral inguinal hernias occurring in a veteran powerlifter. The pathogenesis of multiple hernias and the physiological pressure systems involved in the development of multiple hernias in a power athlete are discussed.

Serial lung volume measurements during the perinatal period in infants with abdominal wall defects

METHODS

Daily measurements of lung volume (functional residual capacity, FRC) were made during the perinatal period in eight infants (median gestational age, 37 weeks; range, 34 to 38 weeks) with abdominal wall defects.

RESULTS

On the first day of life and before surgical intervention, four infants had FRCs below the reference range; the occurrence of low lung volumes was not significantly related to gestational age or diagnosis. Lung volume was further, but only temporarily, impaired by surgical closure of the abdominal wall defect, with a reduction in the median FRC from 25 mL/kg (range, 18 to 36) preoperatively to 12 mL/kg (range, 5 to 19) on the first postoperative day (P < .02).

CONCLUSION

These data are consistent with abnormal antenatal lung growth in certain infants with abdominal wall defects.

Direct measurement of intra-abdominal pressure in various conditions

OBJECTIVE

To standardise a direct method for measuring intra-abdominal pressure (IAP), to correlate the results with intrarectal pressure, and to compare the results in various conditions.

DESIGN

Prospective open study.

SETTING

Teaching hospital, Egypt.

SUBJECTS

34 Subjects in 4 groups: control (n = 11), hernia (n = 8; 6 umbilical and 2 incisional), mass (n = 7; 6 enlarged spleen and 1 carcinoma of sigmoid), and obese (n = 8; a mean of 40% above expected weight).

INTERVENTIONS

Measurement of IAP with a Verres needle connected to a pressure transducer with the patient at rest, straining, supine, erect, and before and after anaesthesia. Intrarectal pressure was measured simultaneously.

MAIN OUTCOME MEASURES

Reproducibility and correlation between the two measurements.

RESULTS

The hernia group had significantly lower IAP than controls both at rest and on straining (mean (SD) 2.7 (1.5) cm H2O compared with 7.0 (5.09) and 6.1 (2.7) compared with 20.5 (7.9), p < 0.01 in each case). Neither the mass nor the obese group differed from the controls at rest, but the pressure was higher on straining (31.2 (1.4) and 33.5 (2.07) cm H2O, respectively, compared with 21.9 (7.3), p < 0.05 in each case). There was a significant drop in IAP after anaesthesia in all groups, and no significant difference between intrarectal pressure and IAP in any group.

CONCLUSION

The method of measuring IAP is reproducible. Intrarectal pressure is similar to IAP and can therefore be used instead of it.

The effect of calfhood diseases on growth of female dairy calves during the first 3 months of life in New York State

Our objective was to study the effects of pneumonia (cumulative incidence, 25%), diarrhea (29%), umbilical infection (14%), and umbilical hernia (15%) on BW and height gains during the first 3 mo of life. Female dairy calves (n = 410) born from January to December 1990 in 18 commercial herds in New York state were used. Average daily gains during the 1st, 2nd, and 3rd mo were 374, 596, and 719 g, respectively; average gain was 565 g during the 3-mo period. Average monthly height gains during the 1st, 2nd, and 3rd mo were 4.4, 5.6, and 5.7 cm, respectively. Use of multiple linear regression, with farms treated as random effects, indicated that treated, verified pneumonia was associated with a reduction in average daily gain of 66 g and that failure of passive transfer reduced average daily gain by 48 g during the 1st mo. During the 2nd mo, neither disease nor failure of passive transfer affected average daily gain. During the 3rd mo, each additional week of pneumonia reduced average daily gain by 14 g, and umbilical infection reduced average daily gain by 96 g. Each additional week of diagnosed pneumonia reduced total BW gain during the first 3 mo by 0.8 kg. Similarly, each week of pneumonia reduced total height gain by 0.2 cm and failure of passive transfer by 0.9 cm. Prevention of chronic pneumonia and umbilical infection may improve average daily gain of calves.

Temporary impairment of lung function in infants with anterior abdominal wall defects who have undergone surgery

Compliance of the respiratory system (CRS) was measured before and after surgical intervention in 14 infants who had anterior abdominal wall defects (AWD) (7 exomphalos, 7 gastroschisis). The median gestational age was 37 weeks (range, 34 to 40) and median birth weight was 2.38 kg (range, 1.94 to 3.45). The infants had stiff lungs before surgery (median CRS, 0.58 mL/cm H2(O)/kg). During the first and second postoperative days, the median CRS decreased to 0.33 mL/cm H2(O)/kg (P < .05). In seven cases, measurements also were obtained on the third and fourth postoperative days, which showed an increase in the median CRS (day 3, 0.47 mL/cm H2(O)/kg; P < .05). These findings show that in infants with AWD, primary surgical closure is associated with deterioration of lung function, but this effect is temporary.

Prediction of outcome in omphalocele and gastroschisis by intraoperative measurement of intravesical pressure

A simple and accurate measurement of intraabdominal pressure is essential to predict a successful closure of defects in omphalocele and gastroschisis. Intravesical pressure (IVP) is a close estimation of intraabdominal pressure and can be measured safely by placing a catheter in the urinary bladder during surgery. Three neonates with gastroschisis and four with omphalocele were studied. Pressure-related complications such as ascites leakage, ventral hernia, impaired venous return of the lower extremities, and oliguria developed only in the patients with IVP > 20 mmHg after fascial closure. Prolonged hospitalization, ventilation support and intensive care were required for these patients.

Bladder pressure monitoring significantly enhances care of infants with abdominal wall defects: a prospective clinical study

Increased intraabdominal pressure (IAP) has been demonstrated to cause intestinal and renal ischemia in both animals and humans. Neonates undergoing closure of anterior abdominal wall defects are at risk for these complications from markedly increased IAP, which are putatively responsible for a 13% to 20% mortality. In an effort to decrease morbidity and mortality we performed a 4-year prospective clinical study to determine if monitoring IAP using bladder pressure (BdP) measurements would significantly improve perioperative care in infants with abdominal wall defects. Forty-two consecutive infants with gastroschisis (28) and omphalocele (14) were prospectively studied. Intraoperative and serial postoperative measurements of BdP were obtained from an indwelling bladder catheter using a standard pressure transducer. Methods of initial closure, as well as manipulations in sedation, paralysis, and silo reduction, were selected to keep BdP < 20 mm Hg. Bladder pressure monitoring significantly altered the management of 64% of our patients, particularly those with gastroschisis (74%). Thirteen patients with gastroschisis underwent staged closure; in 7 (54%) this decision was based on high BdP even though bowel reduction was mechanically possible. Elevated BdP influenced the closure method and timing of silo reductions in 5 of 14 (42%) infants with omphalocele. There were no episodes of renal failure or refractory oliguria. There were three patients in a single cluster who developed uncomplicated, nonsurgical necrotizing enterocolitis late in their respective courses. One patient whose bowel was placed in a silo had severe hypotension associated with group B streptococcal sepsis and subsequently developed necrotic bowel despite low BdP.(ABSTRACT TRUNCATED AT 250 WORDS)

Impaired respiratory function in infants with anterior abdominal wall defects

Respiratory function at follow-up was assessed in 13 infants who had undergone surgical repair of an anterior abdominal wall defect. Six infants had exomphalos and seven had gastroschisis. The infants were delivered at a median gestational age of 36 weeks (range, 32 to 38 weeks). Respiratory function was assessed by measurement of functional residual capacity (FRC) at a median postnatal age of 5 months (range, 1 to 10 months). Although there was no significant difference in the FRC of the infants with gastroschisis compared with those with exomphalos, the study group's mean FRC (25 mL/kg) was significantly lower than that of 50 healthy control infants (mean, 30 mL/kg; 95% CI, +/- 6 mL/kg). Five infants had an FRC below the 95% confidence limit of the normal range. These data suggest that infants with anterior abdominal wall defects may have impaired antenatal lung growth.

Psychosocial adjustment and physical growth in children with imperforate anus or abdominal wall defects

Pediatric surgeons have the unique responsibility of performing surgical procedures that will enable their patients to function normally throughout a lifetime. Good anatomic results may not ensure that this goal will be achieved. Using a battery of psychological testing instruments, we evaluated the academic achievement and psychosocial status of 56 children (mean age, 10.6 years) with imperforate anus (IA) and abdominal wall defects (AWDs). Physical growth was assessed by measurement of standard anthropometric parameters, and a parent questionnaire was used to define clinical status. As a group, the children presented with average intellectual ability. Achievement in both reading and math was in the normal range. In 12.5% of the children a reading learning disability was noted and 10.7% had a disability in math. On the basis of parental assessments, 25% of the children demonstrated externalizing behavior disorders (eg, conduct problems) and 29% displayed internalizing symptomatology (eg. withdrawal, anxiety). Social competency deficits were described in 23% of the children. Data obtained from the teachers were consistent with the parental assessments. No major differences between the IA and AWD patients in academic achievement, psychosocial status, or physical growth were discovered. Routine screening of these children for learning disabilities and behavior problems is recommended.

[The relationship of preoperative emotional stress in children to the type of autonomic regulation of the heart rhythm]

Psychophysiological characteristics of the emotional stress reaction have been studied preoperatively in 31 patients aged 3 to 14 years. The dependence of the nature and depth of peroperative stress on the type of autonomous cardiac rhythm regulation has been established. Psychophysiological differences in the reaction of children with distinct types of autonomous regulation to standard premedication (promedol and atropine) have been observed.

Prediction of successful primary closure of congenital abdominal wall defects using intraoperative measurements

To determine whether intragastric pressure (IGP) and central venous pressure (CVP) would reliably predict successful primary closure of congenital abdominal wall defects (omphalocele/gastroschisis) in newborn infants, we developed the following prospective intraoperative management protocol. Following a temporary trial of fascial closure, infants who had an IGP less than 20 mm Hg or an increase in CVP of less than 4 mm Hg were primarily closed. If IGP was greater than 20 mm Hg or if CVP increased by more than 4 mm Hg, the temporary closure of the abdomen was reopened and a prosthetic silo was placed. Ten infants who were less than 24 hours old and averaged 2.7 kg (range, 1.4 to 4.2 kg) and 37-weeks gestation (range, 32 to 41 weeks) were studied. Eight infants met criteria for primary closure. Their IGP averaged 14 +/- 4 mm Hg (+/- SD) (range, 8 to 19 mm Hg), and their increase in CVP averaged 1 +/- 2 mm Hg (range, -2 to 3 mm Hg). In the two infants who required staged repair, IGP averaged 25 +/- 1 mm Hg (+/- SD) (range, 24 to 25 mm Hg), and the increase in CVP averaged 7 +/- 1 mm Hg (range, 6 to 8 mm Hg). All patients were anesthetized with fentanyl (12.5 micrograms/kg) and paralyzed with metocurine (0.3 mg/kg) intraoperatively. There were no postoperative complications in either group of patients related to increased intraabdominal pressure, and all patients were extubated within 48 hours of the initial surgery. We conclude that the intraoperative measurement of changes in IGP and CVP can serve as a guide to the operative management of congenital abdominal wall defects and can reliably predict successful outcome following repair.

[Immediate results of the surgical treatment of umbilical hernia in children]

Based upon an experience with treatment of 126 newborns the authors consider the main cause of unfavourable outcomes resulting from the operation proper to be inadequately elevated intraperitoneal pressure. Measures for prevention of this complication are recommended.

The accuracy of esophageal pressure measurements in convalescent and sick intubated infants

Assessment of the esophageal pressure technique for measuring dynamic lung compliance (Cdyn) showed that accurate results were obtained in only 5 of 15 studies of sick intubated infants, whereas they were obtained in 6 of 6 studies of convalescent nonintubated infants. In sick infants, inaccuracy was due to large variations in esophageal pressure change (delta Pes) at different esophageal depths and difficulties validating Pes using the occlusion test. Methods of assessing lung stiffness that depend on the measurement of esophageal pressure are unreliable and should not be used in sick intubated infants.

Umbilical Hernia in Xhosa Infants and Children

During the period 12 March 1980 to 10 March 1981 a consecutive series of 1200 Xhosa (Black) infants and young children, ranging in age from the newborn to the prepubertal, who attended the general outpatients department for a variety of medical complaints were examined for umbilical herniation. None had undergone any surgical operation, and patients with conditions possibly associated with umbilical herniation were excluded. Evidence of umbilical protrusion was found in 742 (61.8%), with a similar incidence in males and females. The overall incidence was reflected in each age group by a preponderance of children with umbilical hernia. This study confirms the validity of a generally-held impression that in Black children there is a strong tendency towards the persistence of umbilical hernia when it appears after separation of the cord.

Surgical separation of conjoined (Siamese) xiphopagus twins

Conjoined twins of the xiphopagus type have been separated 24 hours after spontaneous delivery. Indication for early intervention was impending rupture of a large omphalocele as well as deterioration of one severely malformed twin who did not survive surgery, whereas the other one showed normal development up to 15 months after separation.