Large congenital transmesenteric hernia: a missed small-bowel atresia?

Internal hernias are uncommon diagnoses and represent rare causes of intestinal obstruction. Diagnoses are frequently made perioperatively. We present herein an illustrated case of transmesenteric hernia diagnosed in a pregnant woman who consulted for severe abdominal and dorsal pains. As CT scan was not possible because of the obstetric history, a decision to perform surgery was made because of acute pain, no history of previous surgery, and a plain erect X-ray disclosing early signs of intestinal obstruction. Perioperative findings were an ileal volvulus through a transmesenteric fossa circled by a unique ileocolic branch. This particular vascular disposition suggests transmesenteric hernias may be the first step in the constitution of congenital small-bowel atresia.

Treves' field congenital hernias in children: an unsuspected rare cause of acute small bowel obstruction

The Treves' field congenital hernias (TFCH) are an unusual cause of bowel obstruction that may result in irreversible damage of the small bowel or a fatal outcome, unless treated timely and properly. We analyzed retrospectively the medical records of four patients who underwent surgery for TFCHs over a period of 9 years. The types of TFCHs, only diagnosed at surgery, were identified as transmesenteric through a defect in Treves' field in three patients, and as hernia into Treves' field pouch in one patient. Patients had non-specific clinical manifestations, and imaging findings demonstrated only small bowel obstruction. Delay in accurate preoperative diagnosis, and especially patient-related delay, led to a primary enterectomy-anastomosis for necrotic small bowel in the patients with transmesenteric hernias. One infant with necrotic bowel died postoperatively. It may be difficult to diagnose TFCHs in children preoperatively. Misdiagnosis of bowel obstruction caused by this type of internal hernia might lead to small bowel necrosis or death. The risk of this complication seems to be more influenced by pre-hospital delay. Awareness of the severe consequences of delay in diagnosis, high clinical suspicion, early recognition, and proper surgical intervention are essential in the successful management of TFCHs.

Spigelian hernia: a case report and review of the literature

Spigelian hernia is a rare abdominal hernia that occurs through Spigelian aponeurosis. The Authors present a case of Spigelian hernia associated with narrowing of sigmoid colon and diverticular pathology. They also described historical background, surgical anatomy and etiopathogenesis of this hernia. By a remarkable revision of literature, they sum up epidemiology and clinical features of Spigelian hernia. Furthermore, they discuss diagnostic and therapeutic principles.

Hypospadias associated undescended testis in a Spigelian hernia

BACKGROUND

First described in 1764, Spigelian hernias are rare. The patient profile is of an overweight, 50-year-old with associated respiratory disease. However we report the case of a four-month-old, with an associated hypospadias and cryptorchidism, where the testis was lying in a spigelian hernia.

AIMS

To highlight this unusual presentation of cryptorchidism.

CONCLUSION

Embryological development is a complex event that relies on the sequencing of hormonal surges for anatomical development. In this case report we postulate that the findings are secondary to hormonal disruption.

Congenital Spigelian hernia with cryptorchidism: probably a new syndrome

Nearly 28% of pediatric Spigelian hernias reported in the literature are associated with ipsilateral cryptorchidism. However, the pathogenetic relationship between the two has not been satisfactorily explained in the past. This paper describes a male neonate born with cryptorchidism and imperforate anus. Anal stenosis following the treatment of imperforate anus had let to the development of multiple hernias including Spigelian hernia on the right side. Surgical exploration revealed the right testis being located within the Spigelian hernia. Based on the sequence of events, it is hypothesized that Spigelian hernia in this case is a sequela of maldescended testis and raised intraabdominal pressure. As this explanation is also applicable to all of the previously reported cases, the author suggests that the combination of Spigelian hernia and ipsilateral cryptorchidism could probably form a hitherto unrecognized new syndrome.

[Prenatal diagnosis and management of laparoschisis. Case report]

The prenatal diagnosis of laparoschisis may be established by ultrasound early in the end of the first pregnancy trimester. The visualisation of the abdominal wall defect may predict a good fetal prognosis in the absence of the other anomalies and may establish the most favorable moment of birth. Identification of several risk factors for this malformation could lead to the decrease of its incidence.

[How is an abdominal hernia formed?]

Abdomen can be compared in broad outline with an irregular cylinder, limited at the top by the diaphragm and below by the pond. The walls of this cylinder are musculo-aponevrotic and present "zones of weakness" seats of the hernias of the abdominal wall. We propose a topographic anatomical approach of abdominal hernias.

Congenital lumbar hernia in association with carpus equina varus

A rare case of congenital lumbar hernia associated with carpus equina varus is described in a week old baby. The treatment is described with limited review of the literature.

Congenital varicella syndrome

The fetal consequences of chickenpox complicating pregnancy depends on the period of gestation at which the infection is contracted. The extremely rare classical form of congenital varicella syndrome, resulting from maternal varicella infection in the first trimester of pregnancy, is being reported here. The unusual features in this baby are bilateral hypoplastic lower extremities, fracture of bones, a normal electroencephalogram and phantom hernias of the anterior abdominal wall.

Planned totally extraperitoneal laparoscopic Spigelian hernia repair

A Spigelian hernia is a congenital defect in the tranversus aponeurosis fascia. Traditionally, an open anterior hernioplasty was used to repair these defects. Recently, laparoscopic approaches have been described. This report describes the first application of the totally extraperitoneal laparoscopic approach to a planned repair of a Spigelian hernia. The patient was a 62-year-old white female with a reducible left lower quadrant anterior abdominal wall bulge consistent with a Spigelian hernia. At the time of surgery, we exposed the posterior rectus fascia and modified our extraperitoneal inguinal hernia technique by passing the balloon dissector in a more lateral orientation. This created a unilateral preperitoneal space with adequate room for dissection and mesh fixation. The Spigelian defect was easily identified. Its preperitoneal fat contents were reduced, and a 5-mm laparoscopic tacking device was used to secure a piece of prolene mesh. The patient was discharged home with no complications. Placement of the mesh in the preperitoneal space avoids direct interaction of the mesh prosthesis and the intraperitoneal viscera. In conclusion, we find that a laparoscopic totally extraperitoneal approach is technically feasible and advantageous when a Spigelian hernia is diagnosed preoperatively.

Internal hernia with triple hiatus of congenital origin: report of a case

We report herein the case of a 65-year-old woman who was referred to our department with prolonged ileus symptoms despite conservative therapy. A plain abdominal radiograph showed intestinal gas shadows with an air-fluid level in the lesser curvature of the stomach. As no improvement was achieved by the insertion of a short tube, a long tube was inserted. A loop formation of the long tube in the subphrenic region was detected on an abdominal radiograph, and an enterogram showed an interruption in the ileum in the lower abdomen. The patient was diagnosed as having an adhesional ileus and a strangulated ileus due to a lesser sac hernia. A laparotomy was performed which revealed that the small intestine had herniated into the lesser sac space through a hiatus of Treitz' fossa and a hiatus in the transverse mesocolon. Furthermore, part of the small intestine had herniated through an omental hiatus. The herniated intestine was manually reduced and the hiatus was closed. However, as the right ovary was found to have adhered to the ileum and stenosis was seen, we were forced to perform partial resection of the ileum. Considering that this patient had no history of laparotomy in the upper abdomen, abdominal injury, or acute abdomen, it was surmised that the three abnormal hiatuses were congenital.

The management of exomphalos

BACKGROUND/PURPOSE

The management of exomphalos in the authors' department over a 26-year period is reported together with a technique for delayed closure of the ventral hernia resulting from conservative treatment of exomphalos major.

METHODS

Patients were classified into exomphalos minor and major. Exomphalos minor was treated by early surgical closure. Exomphalos major was treated preferentially conservatively with delayed repair of the ventral hernia.

RESULTS

There were 104 patients (68 boys and 36 girls; exomphalos minor, 45; exomphalos major, 59). Forty-two patients with exomphalos minor underwent operation. Three patients died before surgery, and 9 others postoperatively of overwhelming sepsis. Fifteen babies with exomphalos major needed early operation (skin closure only in 3 and prolene mesh repair in 12), there were 2 preoperative and 4 postoperative deaths. Forty-two patients were treated conservatively, among these, 8 died of sepsis. Thirty-four children had closure of the ventral hernia (prolene mesh, 7 and native tissue, 27); there was no morbidity. Two children died after laparotomy for adhesive intestinal obstruction.

CONCLUSION

Mortality rate was related to sepsis, complications of delayed presentation, and severe congenital anomalies. There were no ill effects attributable to mercury or iodine absorption. Delayed ventral hernia repair by double breasting of the fibrous tissue sheet underlying the skin was found to be a reliable technique with low morbidity.

Congenital spigelian hernia and cryptorchidism: cause or coincidence?

Congenital spigelian hernia (SH) is very rare in the pediatric age group. This is a report of two cases of SH in 1-week and 3-month-old male infants. A review of the literature revealed only 35 cases of SH in children younger than 17 years of age, bringing the total including our 2 cases to 37. There were 25 males and 12 females, a ratio of 2.1:1. Their ages ranged from 6 days to 17 years (mean 4.52 years). The hernia was situated on the right side in 13, the left side in 19, and was bilateral in 4. In one case the side of the hernia was not mentioned. In 29 cases the hernia was spontaneous while in 5 it was caused by trauma. In 3 children the hernia developed postoperatively, in 2 following repair of a congenital diaphragmatic hernia and in 1 following excision of a mediastinal neuroblastoma. Two children presented with a strangulated SH. Eleven of the 35 previously reported children had associated conditions; in 5 there was an ipsilateral undescended testis (UDT). Our two infants with SH also had an ipsilateral UDT. The significance of this association is discussed.

Giant congenital epigastric hernia

Epigastric hernia is rare in children. When it occurs, as in adults, it is usually small. This is a report of a giant, congenital epigastric hernia which was repaired early to prevent complications. Though there was a brief period of postoperative respiratory difficulty, the final outcome was satisfactory. This case is interesting due to its massive size and congenital nature.

Congenital hernia of the abdominal wall: a differential diagnosis of fetal abdominal wall defects

A 28-year-old woman was referred at 33 weeks of gestation with suspected fetal intestinal atresia. Sonography showed a large extra-abdominal mass on the right of the normal umbilical cord insertion. Following Cesarean section at 36 weeks and immediate surgical treatment, the malformation was not definable either as an omphalocele or as gastroschisis. This reported case involves a previously undocumented malformation of the fetal abdominal wall described as a 'hernia' of the fetal abdominal wall.

Laparoscopic repair of bilateral spigelian and inguinal hernias

Spigelian hernias are rare and difficult to diagnose. Treatment has previously been limited to open surgical repair. We report the successful laparoscopic repair of bilateral spigelian and inguinal hernias using mesh.

Undescended testicle associated with spigelian hernia

The authors encountered a patient with a spigelian hernia (SH) and undescended testicle (UDT), making the fourth reported case with this combination. This patient provides further evidence that congenital SH predisposes neonates to UDT.

Enterocytic gene expression is altered in experimental gastroschisis

Gastroschisis is a congenital anomaly in which exposure of the intestines to amniotic fluid throughout fetal life results in nutrient malabsorption. To begin to understand the molecular basis underlying epithelial changes in this condition, we investigated enterocytic gene expression during fetal development. Gastroschisis was surgically created at 24 days gestation (term = 31 days) in fetal rabbits; sham-operated and unoperated fetuses served as controls. Bowel was harvested at 28 and 31 days gestation. Cellular lactase expression was detected using immunohistochemistry, and apolipoprotein A-I and cellular retinol binding protein II (CRBPII) mRNA levels were quantitated using Northern blot analysis. Despite absence of gross histological changes in the mucosa, lactase protein expression and apolipoprotein A-I and CRBPII mRNA expression were decreased in intestine from gastroschisis compared to sham-operated animals. Expression of GAPDH (a housekeeping gene) increased over the same period, suggesting that the changes in enterocytic absorptive gene expression associated with gastroschisis were relatively specific. In conclusion, a decrease in expression of a variety of genes involved in nutrient absorption and trafficking within the enterocyte may contribute to the absorptive defects seen in this gastroschisis.

[Hernia in children]

Congenital hernia seems to be the right term to define "hernia in childhood". Especially in newborn and infant, it is possible to observe numerous different pathologies which have nothing in common apart their congenital origin. Some as inguinal or umbilical hernia are very commonly encountered and others us omphalocele, gastroschisis or diaphragmatic hernia are quite rare and involved in the field of prenatal diagnosis and neonatal surgery.

Congenital spigelian hernia with cryptorchidism

Congenital spigelian hernia (SH) is a rarity. The authors present two cases of congenital SH with undescended testis, and examine the significance of the concurrence of these events.

Gastroschisis increases small bowel nitric oxide synthase activity

In gastroschisis, the eviscerated fetal bowel frequently is damaged and this results in hypoperistalsis and malabsorption. The mechanistic link that ties gastroschisis-induced intestinal damage to dysfunction may be nitric oxide (NO) and the enzyme responsible for producing it, NO synthase. Using a fetal rabbit model, the authors investigated the hypothesis that the hypoperistalsis and malabsorption associated with gastroschisis may be attributable to abnormal small bowel NO synthase activity. Using the 3H-arginine-to-3H-citrulline conversion assay, they measured NO synthase activity in the small bowel of full-term fetal rabbits with and without gastroschisis. The mean total small bowel NO synthase activity of fetal rabbits with gastroschisis was 2.5 times greater than that of control littermates without gastroschisis (n = 6; 5,726 +/- 834 v 2,208 +/- 537 mean pmol/mg protein/min; P = .004). This increased NO synthase activity also was studied by measuring the individual isoforms of NO synthase, and the site of increased NO synthase activity was localized to the small bowel epithelium and neurons. After detecting and localizing the gastroschisis-induced increase in NO synthase activity, the authors explored the mechanism of this increase using NADPH-diaphorase staining. With this histological staining technique, no quantitative increase was found in the small bowel NO synthase of the rabbits with gastroschisis. This suggests that the increased NO synthase activity found in these rabbits is the result of accelerated enzyme kinetics. These findings suggest that the increased NO synthase activity caused by gastroschisis may contribute to the common clinical sequelae of malabsorption and intestinal dysmotility.

The effect of gestational age at birth on morbidity in patients with gastroschisis

Infants born with gastroschisis frequently present with an eviscerated intestinal segment that is inflamed and thickened. The damaged segment of intestine displays absorption and motility disturbances for a variable period of time after gastroschisis repair. Clinical and animal research suggests that the damage to the eviscerated intestine is caused by prolonged exposure to amniotic fluid and/or progressive constriction on the intestine and its blood supply by the umbilical ring. Some obstetricians and pediatric surgeons have advocated early elective delivery to decrease the exposure of the bowel to these potentially damaging influences. Fifty-five patients underwent gastroschisis repair at the authors' institution during the last 6 years. Many of these patients had early elective delivery after their pulmonary maturity was judged adequate based on their amniotic lecithin/sphingomyelin ratios. The patients were divided into three groups according to gestational age at the time of delivery. Elective early delivery did not lessen the need for silo closure or hasten the time until enteral feeding could be tolerated. The hospital stay was not shortened for the early delivery group. This retrospective review supports the concept that patients with sonographically identified antenatal gastroschisis are best managed by delivery at full term.

Neonatal lipid utilization increases with injury severity: recombinant human growth hormone versus placebo

Increased lipid oxidation has been observed in injured adult and pediatric patients who receive growth hormone (GH). In infants, whose bodies make fat more readily (de novo lipogenesis), this effect has not been tested. After surgery for necrotizing enterocolitis or gastroschisis, 22 neonates (average gestational age, 35 weeks; average postnatal age, 7 days) were provided basal protein-calorie parenteral repletion, and were prospectively randomized to receive either recombinant human GH (rhGH, 0.2 mg/kg/d) or placebo for 6 days. Injury severity was established by serial serum C-reactive protein (CRP) levels (high v low stress: CRP > or = 6.0 mg/dL v < 6.0 mg/dL). Indirect calorimetry was used to measure energy expenditure (MEE), respiratory quotient (RQ), net lipid oxidation (Fe), and lipid oxidative O2 consumption (VO2f). Among the GH+ group, MEE, Fe, and VO2f were significantly higher for the high-stress patients (MEE: 52.87 +/- 13.35 v 42.57 +/- 9.47 kcal/kg/d; P < .03: Fe; 18.32 +/- 27.74 v 0.81 +/- 13.47 kcal/kg/d; P < .02; VO2f: 7.21 +/- 9.86 v 0.01 +/- 7.42 L/d, P < .02), and RQnp was significantly lower in the high-stress patients (RQnp: 0.93 +/- 0.14 v 1.05 +/- 0.11; P < .02). In addition, Fe and RQnp were directly proportional to carbohydrate intake (CHO) in the high-stress patients (CHO to Fe: Pearson r = -.701; CHO to RQnp: Pearson r = .714; P < .05). Lipid oxidation was directly proportional to stress severity, was higher in the GH group (18.32 v 11.91 kcal/kg/d for the placebo group), and was depressed in response to increased CHO intake in all groups. Lipid is an important energy source in acutely injured, especially severely stressed neonates. Lipid substrate utilization is improved with GH supplementation during acute metabolic stress. In addition, excess carbohydrate delivery reduces the amount of lipid utilized for energy metabolism. An appropriately balanced, mixed-fuel formula should be used for caloric repletion in this infant population.

A decade of gastroschisis in the era of antenatal ultrasound

BACKGROUND

Gastroschisis is an uncommon condition in which viscera protrude at the base of the umbilical cord. To investigate the possible relationships between antenatal ultrasound findings, patient demographics, smoking, alcohol consumption and this condition, 21 causes are reviewed.

METHODS

The medical records and antenatal ultrasounds of 21 children diagnosed with gastroschisis at the Adelaide Children's Hospital between 1 January 1985 and 31 December 1992 were reviewed.

RESULTS

Antenatal ultrasound was employed in 15 cases, and the diagnosis was accurately made in 13 (86.7%) of these. There were 17 live births, two elective terminations and two pre-term abortions. Seven of the 21 cases had associated anomalies. The anomalies included five atresias, a ventricular septal defect (VSD), and a dislocated gall-bladder. Postoperative complications (which included one death) occurred in seven of the 17 patients. Bowel dilatation or thickening was first detected on five ultrasound examinations performed before 21 weeks' gestation, and four ultrasounds after 21 weeks. The nine cases with bowel changes on ultrasound were associated with a high atresia rate and a longer hospital stay, but not with an increased complication rate. Maternal race, parity, and alcohol consumption were not associated with increased risk of fetal gastroschisis. All mothers were under 27 years of age. There were nine mothers who smoked during pregnancy and a disproportionate number of mothers who lived outside the metropolitan area with gastroschisis-affected offspring.

CONCLUSIONS

Bowel changes seen on antenatal ultrasound increase the chances of intestinal atresia and longer hospitalization. Smoking during pregnancy may be associated with an increased risk of gastroschisis.

Gastroschisis in the decade of prenatal diagnosis: 1983-1993

Fifty cases (24 males, 26 female) of gastroschisis were admitted to the Regional Neonatal Surgical Unit at the Royal Hospital for Sick Children in Yorkhill, Glasgow, between January 1983 and October 1993. The mean birthweight was 2.17 kgs and mean gestation was 35.8 weeks. Prenatal diagnosis was made by ultrasound scan in 39 cases (78%) and 33 (66%) were delivered in the Regional Obstetric Unit and Fetal Medicine Centre at the Queen Mother's Hospital, Yorkhill, Glasgow, immediately adjacent to the neonatal surgical unit. Spontaneous vaginal delivery occurred in 23 (46%) but Caesarean section was performed in 27 (54%). Sixteen Caesarean sections were emergencies and 11 elective (5 on account of dilated bowel loops). Associated bowel problems were noted in 11 (22%)--atresia (5), stenosis (2), ischaemia (1), duodenal perforation (1), ileal perforation (1) and jejunal band obstruction (1). Primary closure was achieved in 42 (84%) and there were 5 deaths (10%). Prenatal diagnosis and mode of delivery showed no direct correlation with mortality (10%) in this series. Emergency Caesarean section was necessary for fetal indications in 28%. The prediction of compromised or damaged intestine by prenatal ultrasound was unreliable and the majority of cases of atresia and stenosis escaped detection. However, it is concluded that prenatal diagnosis and delivery in a regional centre offers the best outcome for the fetus. Further study is needed to define "at risk" pregnancies and fetuses and to determine the role of intervention.

Congenital ventral hernia in association with focal dermal hypoplasia

Focal dermal hypoplasia is a rare, X-linked dominant syndrome characterized by dysplasia of the skin, skeleton, and central nervous system. We report an infant who was born with severe focal dermal hypoplasia and an epigastric hernia. Operative timing and approach to abdominal wall defects in the presence of severe cutaneous dysplasia are discussed.

The antenatal diagnosis and management of abdominal wall defects: the northern region experience

One hundred and twenty abdominal wall defects were notified to the Northern Region Fetal Abnormality Survey in the five years 1988 to 1992. Gastroschisis occurred in 56, exomphalos in 43, amnion rupture in 11, ectopia vesicae in seven and ectopia cordis in three. Ultrasound failed to identify gastroschisis in 14 and incorrectly diagnosed exomphalos in eight. There was no associated chromosome abnormality and the survival rate, excluding first trimester loss, was 87%. Ultrasound failed to identify exomphalos in ten and incorrectly diagnosed gastroschisis in two. Another structural abnormality was present in 40% and a chromosome anomaly in 28%. Excluding spontaneous first trimester loss, the survival rate was 34%. Delivery of babies away from the regional paediatric surgical centre did not adversely affect the outcome in gastroschisis or exomphalos although closure was delayed, on average, by 2 h. There was one survivor of 11 fetuses with amnion rupture sequence. Six of the seven babies with ectopia vesicae and two of the three with ectopia cordis survived.

A population-based study of gastroschisis: demographic, pregnancy, and lifestyle risk factors

Gastroschisis, an abdominal wall defect, most often occurs in infants of young mothers. To identify risk factors for gastroschisis, we conducted a case-control study in the population surveyed by the California Birth Defects Monitoring Program (CBDMP). From structured questionnaire data, we compared sociodemographic, reproductive, and lifestyle factors for 110 mothers of infants with gastroschisis with those for 220 age-matched mothers of normal infants. Univariate matched-pair analysis showed significant associations of gastroschisis with mother's education, yearly family income, marital status, a history of mother's mother smoking, mother's father's absence from home during the mother's youth, more than one elective abortion, a short interval between menarche and first pregnancy, siblings from different fathers, and use of either a recreational drug (either cocaine, amphetamine, marijuana, or LSD), alcohol, or tobacco during the trimester preceding pregnancy. For cocaine, amphetamine, and marijuana, use of more than one drug showed a stronger association than single drug use. The association was stronger if both parents used drugs. Although many variables were correlated, odds ratios (OR) were significant (95% confidence intervals) in multivariate conditional logistic analysis for: yearly family income < $10,000 [OR = 4.34 (1.54, 12.22)] or $10,000-$49,999 [OR = 3.93 (1.43, 10.80)]; mother's mother's smoking status not known [OR = 3.99 (1.66, 9.56)]; mother's father's absence from home during her youth [OR = 3.11 (1.14, 8.46)]; and drug use by mother [OR = 2.21 (1.21, 4.03)], father [OR = 1.66 (1.02, 2.69)], or both [OR = 3.05 (1.48, 6.28)]. The best predictive model explained 32% of the deviance. Young, socially disadvantaged women with a history of substance use were at highest risk for a child with a gastroschisis.

Laparoscopic cholecystectomy combined with ventral hernia repair

Laparoscopic cholecystectomy is an integral part of the general surgery operative inventory. The conventional approach may need to be modified to fit different clinical situations. We present the first reported case of a laparoscopic cholecystectomy combined with a ventral hernia repair.

Preservation of the umbilical cord at the primary fascial closure in infants with gastroschisis

Recently, the survival of patients with gastroschisis has been dramatically improved and it has reached more than 90%. Over the last 10 years, 20 of 21 cases (95%) survived in our hospital. We have been using the primary fascial closure of the abdominal wall as a standard operative procedure. The umbilical cord was usually excised at the operation in order to secure the suture line and prevent wound infection. The survivors sometimes complained of the absence of the umbilicus. However, it was somewhat difficult to create a new umbilicus later by use of the surrounding skin. In the last five cases, we tried to carry out the primary fascial closure with preservation of the umbilical cord. All patients could obtain good cosmetic results with near-normal appearance. Omphalitis or cellulitis was never observed, but a small umbilical hernia occurred in one case.

Gastroschisis in successive siblings: further evidence of an acquired etiology

In recent years, we have treated two families that had successive siblings with gastroschisis. In the first family, the delivery of their second child, a boy with gastroschisis, was followed 11 months later by the delivery of a girl also with gastroschisis. The mother admitted to use of tobacco, alcohol, and marijuana during both pregnancies; the father was the same for both children. In the other family, the second child was a boy with gastroschisis, and the third, born 6 years later, was also a boy with gastroschisis. The mother denied any use of tobacco, alcohol, or recreational drugs; these two boys had different fathers. Gastroschisis in siblings has been reported only rarely, and has been noted in both identical and dizygotic twins. Our second set of siblings is the first documented case involving paternity by different fathers. Although a genetic factor cannot be excluded completely, teratogenic factors operative through the mother seem most probable. In conjunction with other reports of "epidemics" of gastroschisis, these two families amid our own recent outbreak of gastroschisis strongly suggest that the teratogenic factors may be environmental.

"Bucket handle" avulsion of intestine in gastroschisis

Two infants with gastroschisis had most of the midgut avulsed during cesarean section. There was only 12 and 20 cm of small bowel remaining, with an intact ileocecal valve in each case. Cutaneous enterostomy followed by anastomosis was done in both patients. The first child is 4 years old and is now on total enteral feedings after prolonged intravenous support. The second infant is still on partial parenteral nutrition. The cases illustrate the vulnerability of the fetus with gastroschisis during extraction by cesarean section.

[The treatment of newborns with gastroschisis]

Gastroschisis is considered by the authors to be an embryopathy. The main principles of management of newborns with gastroschisis are: warming of the newborn, rehydration, measures against pseudoobstruction of the intestine. An effective method which could be recommended for all kinds of operations for defects of the anterior abdominal wall is a "manual enlargement of the abdominal cavity" during operation.

Prenatal differentiation of ventral abdominal wall defects. Are amniotic fluid markers useful adjuncts?

We retrospectively reviewed 29 cases of ventral abdominal wall defects to evaluate the usefulness of amniotic fluid markers in the prenatal assessment of those disorders. Amniotic fluid alpha-fetoprotein (AF-AFP) values were available in 17 cases diagnosed prior to 22 weeks' gestation and acetylcholinesterase (AF-ACE) values, in 21 cases. All 7 fetuses with a gastroschisis had an elevated AF-AFP, while only 2 of the 10 fetuses with an omphalocele had elevated values (P = .002). ACE was present in 80% of the cases of gastroschisis versus 27.3% of the cases of omphalocele (P = .03). With equivocal sonographic findings, a normal AF-AFP and negative AF-ACE may be more compatible with an omphalocele.

Intestinal obstruction due to axial twisting of bowel in transmesenteric hernia

A baby, born with gastroschisis, had an unrepaired large aperture in the mesocolon close to a short segment of colon. One day, the entire length of bowel proximal to the defect traversed the rent. The free segment of colon was affected by the resulting twist along the long axis of the bowel and became obstructed. A large mesenteric defect, albeit too wide to strangulate the bowel, is not totally innocuous and should always be closed.

Observations and current operative management of congenital lumbar hernias during infancy

Congenital hernias in the lumbar region are very uncommon. Approximately 10 per cent of all lumbar hernias are congenital and the vast majority are unilateral. We report our experience with seven congenital lumbar hernias in six infants treated during a five year period. All patients presented in the first year of life with abnormal protrusions in the lumbar region. In addition to the lumbar hernia, major associated malformations, including caudal regression anomalies, diaphragmatic hernia, ureteropelvic junction obstruction, cloacal exstrophy and lipomeningocele, were observed in 66 per cent of the infants and were consistent with lumbocostovertebral syndrome. In five patients, unilateral defects were repaired primarily. One patient with bilateral lumbar hernia underwent staged repair. The larger right-sided defect was repaired using a polytetrafluoroethylene prosthesis. At a second operation two months later, the small left-sided hernia was closed primarily. All patients have done well without recurrence with a follow-up period ranging from four to 48 months. Early repair of congenital lumbar hernias in infants after correction of other life-threatening conditions is advocated. Unlike the acquired variety, congenital lumbar hernia may include a more extensive deficiency of the entire lateral abdominal wall extending to the rectus sheath and inguinal ligament and satisfactory closure of the defect without prosthetic material may be difficult or impossible.

[Gastroschisis]

The results of management of 7 newborns with gastroschisis in 1980-1987 are discussed. Four of them were treated by the earlier described method of "manual distention" of the abdominal cavity by stretching the abdominal wall with the finger, 3 patients recovered. The method was not applied to the other 3 patients and all of them died. It is emphasized that the baby must be kept warm in the preoperative period and hypovolemia must be controlled. In view of the prolonged paralytic ileus complete parenteral feeding must be prescribed in the postoperative period until the function of the gastrointestinal tract becomes normal. All the modern principles of management of these patients must be scrupulously followed in order to accomplish successful treatment and improve the results.

First-trimester midgut herniation: a high-frequency transvaginal sonographic study

The application of high-frequency transvaginal sonography offers new opportunities in scanning for malformations during the first trimester of pregnancy. Scanning of the anterior abdominal wall and the umbilical cord insertion at this gestational age is feasible. A cross-sectional study of 61 embryos-fetuses from 7 to 12 weeks of gestation was performed to observe the physiologic midgut hernia. This herniation was detected in 64% of the cases at 8 weeks, in 100% during weeks 9 and 10, and in 25% at 11 weeks' gestation. None of the fetuses studied at 12 weeks had a midgut herniation. Vaginal sonography of the well-dated fetus at 12 weeks can confirm the final development of the anterior abdominal wall.

Congenital cranioventral abdominal wall, caudal sternal, diaphragmatic, pericardial, and intracardiac defects in cocker spaniel littermates

Five littermate Cocker Spaniels were born with concomitant pericardial, diaphragmatic, caudal sternal, and cranioventral abdominal wall defects. Three of the 5 pups had ventricular septal defects. A sixth pup with a cranioventral abdominal wall defect died 4 days after birth. No history of teratogen exposure was reported, and none of the pups from previous litters of the dam was affected. Each pup underwent successful surgical correction (without median sternotomy) of the diaphragmatic and cranial abdominal wall defects when they were 10 to 12 weeks old. The ventricular septal defects were not corrected. In 2 of 3 pups with ventricular septal defects, thoracic radiography 6 months after surgery revealed moderate generalized cardiomegaly. All pups were healthy one year after surgery.

Intestinal obstruction secondary to a congenital pre-iliac hernia

A previously undescribed type of congenital abdominal wall hernia is described. Presentation was with the symptoms and signs of subacute large bowel obstruction. The diagnosis was suggested by barium enema and confirmed at laparotomy.

Extended hemofiltration in a neonate: a case report and a review of the literature

Continuous arteriovenous hemofiltration (CAVH) has been used infrequently in the treatment of infants and children with acute renal failure. In this report we describe the use of CAVH in a critically ill neonate who was unable to be managed with either peritoneal dialysis or hemodialysis. The procedure was safe and effective in the management of fluid overload and multiple electrolyte disturbances including life-threatening hyperkalemia. The technical aspects of this procedure are described, and its potential benefits and complications are assessed with reference to the ten previously reported cases.

Closure of gastroschisis by mesh skin grafts in problem cases

Closure of gastroschisis can be achieved by primary adaptation of the abdominal wall, by implanting a dura patch or by covering the protruding gut with a silastic pouch. In the Pediatric Surgical Department of the University of Innsbruck this last method was used in 14 of 18 cases during the last 8 years. In three children multiple complications and infection resulted in the necessary removal of the silastic pouch from the still protruding gut. Lacking any other alternative, the defect was covered with mesh skin grafts, which took well and permanently closed the abdominal wall.

Developmental aspects of gastroschisis

The development of gastroschisis was studied experimentally as well as clinically, particularly concerning the characteristic fibrous coating of the protruding bowel loops, associated intestinal atresia, and postoperative hypoperistalsis without intestinal obstruction. Experimental investigation was carried out in the chicken embryo. The clinical study was a joint one, involving a total of 50 patients with gastroschisis seen at the Sophia Children's Hospital, Rotterdam, and the Royal Hospital for Sick Children, Glasgow, between 1972 and 1985. Some patients were followed antenatally. The results, correlating with previous experiments, were compared with data from the literature. The fibrous coating of the protruding bowel loops appeared to be a late occurrence and directly related to changes of the amniotic fluid secondary to the onset of renal function. Associated intestinal atresia and postoperative hypoperistalsis in the absence of an obstruction both appeared to be due to another late gestational event, consisting of ischemic changes of the bowel wall secondary to the compression of bowel loops and mesentery in the small abdominal wall defect.