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Pediatr Surg Int

Two unusual cases of megacolons.

Chacko J. Sparnon AL. Little KE.
Department of Paediatric Surgery, Women's and Children's Hospital, 72 King William Road, North Adelaide, South Australia 5006.
A 13-year-old boy with features of intestinal obstruction was found at laparotomy to have a sigmoid volvulus. A 7-year-old girl with a similar presentation had a tight stricture at the rectosigmoid junction causing obstruction. In both cases the proximal colon was grossly loaded with faeces. In the first child, a colostomy after resecting the sigmoid colon was considered the safer option, whereas in the second, an innovative method to decompress the proximal loaded colon using a sterilised colostomy bag was employed, enabling a primary anastomosis to be performed.

A stercoraceous ulcer of the colon in neglected Hirschsprung''s disease.

Golinsky D. Freud E. Steinberg RM. Blumenfeld A. Kidron D. Hirsch A. Zer M.
Department of Pediatric Surgery, Schneider Children's Medical Center of Israel, 14 Kaplan Street, Petah-Tikva, Israel 49202, USA.
A large, nonspecific, chronic ulcer was found in the sigmoid colon of a 13-year-old child with neglected, undiagnosed Hirschsprung's disease (HD). There is no known association between HD and colonic ulcers, suggesting that the ulcer was a true stercoraceous ulcer of the colon and not an intrinsic defect of the aganglionotic bowel.

Abdominal wall plasty for a premature infant with congenital diaphragmatic hernia.

Hasegawa T. Yoshioka Y. Sasaki T. Iwasaki Y. Tazuke Y. Sumimura J. Ban H. Dezawa T.
Department of Pediatric Surgery, Kinan General Hospital, 510 Minato, Tanabe City, Wakayama, Japan 646.
This paper reports a premature infant with a congenital diaphragmatic hernia (CDH) who underwent an abdominal wall plasty to enlarge the abdominal cavity, one of twin infants born at 32 weeks weighing 1,255 g. After stabilization, the herniated viscera were reduced from the pleural cavity and the abdominal wall muscle and skin layers were replaced by a Gore-tex patch without closure of the diaphragmatic defect. Respiratory and circulatory conditions were stable during the perioperative period. Postoperatively, a roentogenogram showed expansion of the lung. However, his condition deteriorated 24 h after surgery, triggered by intratracheal suction, and he died on the 4th day of life despite the use of high-frequency oscillation, catecholamines, and vasodilators. Postmortem examination showed severely hypoplastic lungs. Abdominal wall plasty may be a less invasive initial procedure, however, further studies, such as comparison with the standard method or conservative management, are needed using a large clinical group or animal models to justify the usefulness of this procedure.

Pancreatic inflammatory pseudotumour: an uncommon childhood lesion mimicking a malignant tumour.

Morris-Stiff G. Vujanic GM. Al-Wafi A. Lari J.
Department of Paediatric Surgery, University Hospital of Wales, Cardiff, UK.
We describe a rare case of pancreatic inflammatory pseudotumour that clinically presented as a malignant tumour in an 11-year-old boy. We also review all six previously described cases, including three that occurred in children. Complete surgical removal is regarded as the best choice of therapy, and follow-up in our case showed no evidence of disease after 3 years. It is important to be aware of this lesion, since it can be confused with a malignant tumour both radiologically and clinically.

Leiomyoma of the esophagus and bronchus in a child.

Al-Bassam A. Al-Rabeeah A. Fouda-Neel K. Mahasin Z.
Department of Surgery, Section of Pediatric Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
Leiomyomas of the esophagus and/or the bronchus have rarely been reported in children. To our knowledge, the simultaneous presence of this tumor in both the esophagus and a bronchus in a child has not been previously reported. A 7-year old boy presented with respiratory and esophageal symptoms and was found to have a leiomyoma of the esophagus and right main bronchus. The esophageal leiomyoma was treated with limited myotomy, but bronchoscopic resection was possible for the bronchial lesion. The postoperative result was excellent, with normal swallowing and no residual respiratory problems at 1-year follow-up.

Temporal stability of acetylcholinesterase staining in colonic and rectal neural tissue.

Byard RW. Carli M.
Department of Paediatrics, University of Adelaide, North Adelaide, Australia.
Confirmation of the clinical diagnosis of Hirschsprung's disease on standard rectal suction biopsy requires demonstration of aganglionosis in 60 adequate serial sections of submucosa. Positive staining for acetylcholinesterase (AChE), demonstrating an increase in nerve fibres within the lamina propria, muscularis mucosae, and subjacent submucosa, is a useful adjunctive test. In this study, sections of distal colonic muscularis propria and rectal mucosa were stained for AChE over a period of days following storage at 4 degrees C and at room temperature (15-20 degrees C). Positive staining of neural tissue was demonstrated in specimens stored at 4 degrees C for up to 14 days, at which time the experiment was discontinued due to tissue autolysis. Positive staining of the myenteric plexus in colonic specimens stored at room temperature also continued until tissue dissolution became marked at 5 days. This study has demonstrated stability of AChE staining of intestinal neural tissue in specimens stored at 4 degrees C for 14 days, which suggests that reliable staining for AChE should still be achievable if rectal biopsies are taken in clinics/hospitals without access to staining facilities, provided that tissues are transferred (fresh and moist, at 4 degrees C) to a reference laboratory for staining within several days of the biopsy procedure.

Long-term functional, manometric, and endosonographic evaluation of patients operated upon with the Duhamel technique.

Bjornland K. Diseth TH. Emblem R.
Department of Pediatric Surgery, The National Hospital, Oslo, Norway.
Long-term functional results, anal endosonography (AES), and anal canal manometry were recorded in 48 patients aged 10 to 24 years (median 18) operated upon with the Duhamel technique for Hirschsprung's disease; 60.4% had perfect fecal control, 31.3% occasional staining and/or gas incontinence, and 8.3% constant fecal soiling, and 10.4% complained of constipation. Compared to normals, the patients had significantly reduced anal canal resting and squeeze pressures. AES visualized scar tissue in both the internal and external anal sphincter.

Is a normally functioning gastrointestinal tract necessary for normal growth in late gestation?

Blakelock R. Upadhyay V. Kimble R. Pease P. Kolbe A. Harding J.
Department of Paediatrics, University of Auckland, Auckland, New Zealand.
It is known that neonates with congenital abnormalities of the intestine tend to be growth-retarded. We wished to explore the hypothesis that normal fetal gut function is needed for normal growth in late gestation. If this is true, then different populations of babies with different congenital gut abnormalities would be expected to have similar impairments of growth and be small at birth. This growth retardation would be more marked in term than in preterm babies and would be independent of other congenital anomalies. To test these hypotheses, we examined 43 babies born with gastroschisis (GS) in Auckland, New Zealand; 69 babies born with GS in Birmingham, England; and 60 babies born with intestinal atresia (IA) in Auckland. For Auckland babies with GS, the mean weight standard deviation score (WSDS) (i.e., birth weight relative to the mean birth weight for gestation) for term babies was lower than that for preterm babies (-0.932+/-0.180 vs -0.064+/-0.237, P=0.014). This was also true for Birmingham babies with GS (-0.991+/-0.193 vs -0.36 +/-0.153, P=0.028). For babies with IA, the mean WSDS for term babies was lower than that for preterm babies (-0.627+/-0.266 vs 0. 057+/-0.211, P=0.034). There was no significant difference between the mean WSDS of babies with and without major congenital abnormalities (-0.402+/-0.201 vs -0.271, P=0.70). Our results demonstrate that term babies born with GS are significantly growth-retarded compared with premature babies born with GS. Term babies born with a proximal IA are also growth-retarded. This strongly suggests that in late gestation, the normal growth is dependent on a normally functioning gastrointestinal tract that allows exposure of the proximal intestinal mucosa to ingested amniotic fluid.

Laparoscopic versus conventional appendectomy in children.

Hay SA.
Pediatric Surgery Unit, Ain Shams University, Cairo, Egypt.
Over a period of 6 months, 48 children who underwent conventional appendectomy (CA) were compared to 34 children who had laparoscopic appendectomy (LA) for acute and recurrent subacute appendicitis. Their ages ranged from 4 to 12 years (mean 8). LA took significantly longer, 76 min, versus 50 min for CA. Less than 2 days' hospitalization was required in 95% of LA cases and 45% of CA cases. Time to return to normal activity averaged 7 days for LA and 12 days for CA (P < 0.001). Wound complications were fewer and the cosmetic appearance was most satisfactory in LA patients. LA is a safe operation that has the advantage of being exploratory, with shorter hospitalization time, early ambulation, and superior cosmetic results.

The significance of biliary sludge in children with sickle cell disease.

Al-Salem AH. Qaisruddin S.
Division of Pediatric Surgery, Department of Surgery, Qatif Central Hospital, Qatif, Saudi Arabia.
The prevalence of cholelithiasis was studied prospectively by abdominal ultrasound (US) examination in 305 children with sickle cell disease aged 1-18 years (mean 10.45). Gallstones were present in 60 children (19.7%); an additional 50 had biliary sludge only (16.4%). On follow-up of 35 of the 50 children with sludge, 23 (65.7%) had developed gallstones and 5 had already had a cholecystectomy. Five continued to have sludge on follow-up while 7 were reported to have no sludge. Children with US evidence of sludge should be followed up regularly by US, and those who develop gallstones should undergo elective cholecystectomy. For those with biliary sludge only, we recommend elective cholecystectomy if there are hepatobiliary symptoms.

Hepatic duct stone associated with chlamydia sepsis: a rare condition in childhood.

Celayir S. Sarimurat N. Ekiz O. Emir H. Pasaoglu M. Senyuz OF.
Department of Pediatric Surgery, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey.
Stone formation in the biliary system is a rare condition in infants. A few cases of bile stones in the biliary tree have been reported with underlying predisposing factors, such as sepsis and antibiotic usage. This article describes a surgically treated 16-week-old infant with recurrent cholangitis who had a bile stone in the hepatic duct after chlamydia sepsis.

Pyogenic liver abscess complicating a ventriculoperitoneal shunt.

Huang LT. Chen CC. Shih TT. Ko SF. Lui CC.
Department of Pediatrics, Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao Sung Hsiang, Kaohsiung, 833, Taiwan.
Pyogenic liver abscess is a rare complication of ventriculoperitoneal (VP) shunting. We report a 4-month-old female with this complication who was successfully treat ed by computed tomography-guided percutaneous transhepatic catheter drainage, shunt externalization, and parenteral antibiotics. Liver abscess is a possible intra-abdominal complication of VP shunting, and imaging studies are good adjuncts in making the clinical diagnosis.

Surgical aspects of an outbreak of Yersinia enterocolitis.

Shorter NA. Thompson MD. Mooney DP. Modlin JF.
Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
Eleven patients with Yersinia enterocolitica infections were identified in the Upper Valley of New Hampshire and Vermont during October and November of 1995. Three children presented with an appendicitis-like picture. Two underwent appendectomy, one of whom was the outbreak's index case. Both appendectomy patients presented with lower abdominal pain, fever, vomiting, and a right lower quadrant mass associated with leukocytosis. Both had terminal ileitis, and in both, cultures of peritoneal fluid and a mesenteric lymph node grew Y. enterocolitica. Even during an outbreak there is no consistently reliable nonoperative way to separate a sporadic case of appendicitis from one whose appendicitis-like symptoms are due to Yersinia. In addition, a small percentage of Yersinia patients will present with true appendicitis as a complication of their disease.

Prenatal and neonatal intussusception.

Year 1998
Wang NL. Yeh ML. Chang PY. Sheu JC. Chen CC. Lee HC. Hung HY. Hsu CH.
Department of Pediatric Surgery, Mackay Memorial Hospital, Taiwan, Republic of China.
Intussusception found in the 1st month of life is rare and usually discussed as one entity, neonatal intussusception, but in fact, includes the intussusceptions occurring both prenatally and neonatally, of which the clinical presentations and results are different. Four full-term babies with prenatal intussusception presenting as intestinal atresia (IA) and three premature babies with neonatal intussusception mimicking necrotizing enterocolitis (NEC) are presented. Prenatal intussusception, as one of the causes of IA produces prominent signs of intestinal obstruction immediately after birth. Preoperative evaluation usually fails to yield a definitive diagnosis, but surgery is usually performed in time and is successful. In neonatal intussusception, full-term infants usually have a pathological lead point and the colon is almost always involved. A barium enema is thus useful in diagnosis. Premature babies, on the other hand, rarely have a colonic component, and the clinical features are insidious and similar to NEC. This results in diagnostic confusion that may lead to a dangerous delay in appropriate surgical correction. A high level of suspicion about this condition in cases diagnosed presumptively with NEC is important. Serial abdominal sonograms may be helpful in the early diagnosis of neonatal intussusception.

Active collagen synthesis in infantile hypertrophic pyloric stenosis.

Year 1998
Miyazaki E. Yamataka T. Ohshiro K. Taira Y. Puri P.
Children's Research Centre, Our Lady's Hospital for Sick Children, Dublin, Ireland.
M-57 antibody, which is capable of distinguishing newly-synthesized type I procollagen from fully-processed, mature collagen, was used to examine the expression of collagen synthesis in hypertrophic pyloric muscle from patients with infantile hypertrophic pyloric stenosis (IHPS). Seven specimens from IHPS patients were removed at the time of operation; age-matched normal pyloric tissue of 5 post-mortem cases was obtained as controls. Immunohistochemistry was performed using antibody of the amino-terminal end of the procollagen type I propeptide (M-57). Newly-synthesized procollagen (M-57) was strongly detected in both the connective tissue septa between circular muscle bundles, and among the circular-muscle fibers in patients with IHPS. No M-57 staining was observed among the circular-muscle fibers in controls. Our findings show that the hypertrophic circular muscle in IHPS is actively synthesizing collagen, and this may be responsible for the characteristic "firm" nature of the pyloric tumor.

Laparoscopic pyloromyotomy: a safer technique.

Year 1998
Bufo AJ. Merry C. Shah R. Cyr N. Schropp KP. Lobe TE.
Section of Pediatric Surgery, University of Tennessee, Memphis Bonheur Children's Medical Center, Memphis, Tennessee.
A modified technique of laparoscopic pyloromyotomy was used to treat infantile hypertrophic pyloric stenosis. Introducing a 5-mm periumbilical port for visualization, two stab wounds are made on either side laterally to directly insert 2.7-mm instruments for manipulation. From the left, the stomach is grasped - not the duodenum! From the right, an inexpensive disposable arthroscopy knife is used to incise the serosa and begin the myotomy, which is completed with a laparoscopic spreader until the muscle is separated sufficiently to relieve the obstruction. Twenty-nine children treated with laparoscopic pyloromyotomy were compared to 125 children treated with the conventional open Ramstedt pyloromyotomy. There were no statistically significant differences in the presentation or results between groups, suggesting that the laparoscopic technique is a safe and equal alternative.

Pathogenesis of infantile hypertrophic pyloric stenosis: recent progress.

Year 1998
Ohshiro K. Puri P.
Children's Research Centre, Our Lady's Hospital for Sick Children, Dublin, Ireland.
Although infantile hypertrophic pyloric stenosis (IHPS) is the most common condition requiring surgery in the first few months of life, its pathogenesis is not fully understood. Reviews of the recent progress in the pathogenesis of IHPS show: (1) there is increasing evidence to suggest that smooth-muscle cells in IHPS are not properly innervated; (2) because non-adrenergic, non-cholinergic nerves are mediators of smooth-muscle relaxation, it is likely that the absence of these nerves in pyloric muscle is the cause of excessively contracted hypertrophic circular pyloric muscle; (3) there are abnormal amounts of extracellular matrix proteins in hypertrophic pyloric muscle. Circular muscle cells in IHPS are actively synthesizing collagen, and this may be responsible for the characteristic "firm" nature of the pyloric tumor; and (4) the increased expression of insulin-like growth factor-I, transforming growth factor-beta 1, and platelet-derived growth factor-BB and their receptors in hypertrophic pyloric muscle suggests that increased local synthesis of growth factors may play an important role in smooth-muscle hypertrophy in IHPS.

Increased insulin-like growth factor-I mRNA expression in pyloric muscle in infantile hypertrophic pyloric stenosis.

Year 1998
Ohshiro K. Puri P.
Children's Research Centre, Our Lady's Hospital for Sick Children, Dublin, Ireland.
The etiology of infantile hypertrophic pyloric stenosis (IHPS) is unknown. Insulin-like growth factor-I (IGF-I) is a polypeptide hormone that elicits various biological activities (cellular growth, replication, and differentiation) by binding to its receptors. IGF-I has been suggested to play an important role in both gastrointestinal (GI) maturation and smooth-muscle-cell (SMC) hypertrophy. Full-thickness muscle biopsy specimens were obtained from 8 IHPS patients (age range 14-64 days, mean 28.1 days) at pyloromyotomy and from 8 age-matched controls (15-60 days, mean 33.8 days) without GI disease at autopsy. In-situ hybridization was performed using an IGF-I-specific and digoxigenin (DIG)-labeled oligonucleotide probe and visualized by nitroblue tetrazolium staining. In normal controls, IGF-I mRNA expression was absent or weak in both circular and longitudinal smooth-muscle layers of pyloric muscle. In contrast, the pyloric muscle in IHPS patients demonstrated strong IGF-I mRNA expression in the circular smooth-muscle layer and moderate expression in the longitudinal smooth-muscle layer. The increase in IGF-I mRNA in pyloric muscle in IHPS suggests that SMCs are actively synthesizing IGF-I, contributing to the development of pyloric muscle hypertrophy.

Endoscopic treatment of recurrent tracheo-oesophageal fistulae: long-term results.

Year 1998
Willetts IE. Dudley NE. Tam PK.
Paediatric Surgical Directorate, John Radcliffe Hospital, Headington, Oxford, UK.
Recurrent tracheo-oesophageal fistula (RTOF) occurs in 5%-15% of patients following oesophageal atresia repair. Re-thoracotomy is technically challenging and associated with significant morbidity, including a re-fistulation rate of 10%-22%. Endoscopic occlusion of the RTOF with tissue adhesives (fibrin glue, Histoacryl) is reported to be safe and highly effective. However, long-term results of such therapy are absent from the literature. A postal survey of 13 institutions reporting the use of such treatment regimes for RTOF in the literature between 1974 and 1995 was performed, and data collected concerning the long-term outcomes of their reported patients. Eleven institutions responded to the request for data, providing 22 patients (age range 1 month to 12 years) for review. All had undergone initially successful RTOF closure by endoscopic methods and had been followed up for a median of 107 months (range 3-264 months). There was no morbidity or mortality directly related to the procedure. Overall, only 55% of these endoscopically treated fistulas remained closed long-term. Fistula recurrence invariably occurred within 12 months of successful therapy (median 46 days, range 9-335). Most patients required multiple endoscopic procedures to achieve successful RTOF closure (median 2.0, range 1-4 attempts), although significantly fewer attempts were required with fibrin glue therapy. Surgical re-exploration remains the treatment of choice in the fit child. Endoscopic therapy offers a safe and elegant alternative to high-risk surgery in the sick child, although repeated treatments may be required for successful RTOF closure.

Gastrointestinal tract perforation due to blunt abdominal trauma.

Year 1998
Ciftci AO. Tanyel FC. Salman AB. Buyukpamukcu N. Hicsonmez A.
Department of Pediatric Surgery, Hacettepe University Medical Faculty, Ankara, Turkey.
A retrospective clinical study was performed to evaluate the etiology, diagnosis, and management of gastrointestinal tract perforation (GITP) due to blunt abdominal trauma (BAT) in order to find a predictor to avoid delay in diagnosis. Thirty-five children with GITP out of 805 BAT victims (4.3%) over a 21-year period formed the study group. Different parameters including preoperative (mechanism of injury, abdominal and X- ray findings at presentation, diagnostic modalities), operative (type and site of GITP, intra-abdominal associated injuries, surgical method), and postoperative (complications, mortality) status were analyzed. The patients were subdivided according to their initial clinical presentation as group I: evidence of peritonitis (n = 19, 54%); group II: abdominal findings such as distension, minimal tenderness, and guarding (n = 10, 29%); and group III: normal abdominal findings (n = 6, 26%). These groups were also statistically compared to each other with regard to the parameters mentioned above. The Mann-Whitney U, Wilcoxon rank-sum, and Kruskal-Wallis tests were used for statistical analysis. P < 0.05 was considered to be statistically significant. There were 28 boys and 7 girls; the mean age was 8.2 +/- 2.4 years. Mechanisms of injury were motor vehicle accidents (MVA) (60%), falls (26%), and bicycle accidents (BA) (14%). Group I patients presented with significantly higher transaminase levels and white blood cell counts than groups II and III. Group I patients and MVA victims were operated upon significantly earlier than group III patients and BA victims because of significantly earlier development of clinical signs of peritonitis. A significantly higher number of multiple perforations was encountered in Group I and MVA victims than in groups II and III and BA victims. The presence of multiple perforations correlated significantly with the earlier development of clinical signs of peritonitis. The analysis of site of perforation with regard to the other parameters did not differ significantly. Fifty-four percent (n = 19) of the patients presented with peritonitis; a pneumoperitoneum was detected in 46% (n = 16). Diagnosis was accomplished by plain radiographs, ultrasound, computed tomography, and, most importantly, frequent abdominal examination of the patient. The sites of perforation were the stomach (4), duodenum (2), jejunum (11), ileum (12), jejunum and ileum (3), colon (2), and ileum and colon (1). Simple closure was the most common surgical procedure (n = 21), followed by resection and anastomosis (n = 12) and simple closure plus creation of a proximal ostomy (n = 2). Two deaths (5.7%) were directly due to head injuries. Our experience revealed that in spite of advanced imaging and laboratory modalities, frequent evaluation of the patient by an experienced surgeon is still the most important tool for early diagnosis and appropriate treatment. A child with BAT should be an inpatient and a high index of suspicion is always required, even in the presence of normal abdominal findings.

Is acute appendicitis different in patients with sickle cell disease?

Year 1998
Al-Salem AH. Qureshi ZS. Qaisarudin S. Varma KK.
Division of Pediatric Surgery, Qatif Central Hospital, Saudi Arabia.
Nine patients with sickle cell disease (SCD) were operated upon at our hospital for acute appendicitis, comprising only 0.43% of the total appendicectomies performed at our institution. Three appendices were acutely inflamed and six (66.7%) were perforated. Histologic evaluation of the six perforated specimens revealed congestion and haemorrhage by sickled erythrocytes (RBCs) in addition to acute transmural inflammatory cell infiltrates. The mucosa was extensively ulcerated, with haemorrhage both within the lumen and in the appendiceal wall. The blood vessels were dilated and packed with sickled RBCs. Two of the three acutely inflamed appendices showed features of acute transmural appendicitis, with marked congestion and haemorrhage by sickled RBCs. The third did not show any acute inflammatory cell infiltrate, however, the mucosa was partly ulcerated with both mucosal and intraluminal haemorrhage. These findings suggest that acute appendicitis is different in patients with SCD: while it is not common, when it does develop it has a rapid course with a high incidence of perforation due to blockage of appendiceal vessels by sickled RBCs, leading to transmural necrosis.

Timing of colonic necrosis in hemolytic uremic syndrome.

Year 1998
Saltzman DA. Chavers B. Brennom W. Vernier R. Telander RL.
Department of Surgery, University of Minnesota, Minneapolis, USA.
Hemolytic uremic syndrome (HUS) consists of an acute onset of microangiopathic hemolytic anemia, thrombocytopenia, and renal dysfunction. HUS-associated colitis can be seen in up to 100% of patients and is usually associated with severe abdominal pain and distention. Colonic perforation is a complication of HUS that has a reported incidence of 1%-2%, and although there are several case reports in the literature describing perforation of the colon, it is still very difficult to discern the abdominal symptoms associated with HUS colitis from perforation. Four cases of colonic perforation are reported here from a consecutive series of 57 patients, in which a trend in the length of time from the onset of symptoms of HUS to colonic perforation was determined. A review of the literature for cases of HUS-associated colonic perforation was also performed. The time from the onset of HUS symptoms to colonic perforation in our series was similar to that found in the literature review (11 +/- 5 vs 14 +/- 8 days). Awareness that this complication has a tendency to occur towards the end of the 2nd week during the course of HUS is essential to avoid an unnecessary and untimely surgical intervention.

Conservative management of fistula in ano in infants.

Year 1998
Watanabe Y. Todani T. Yamamoto S.
Department of Pediatric Surgery, Kagawa Medical University, Japan.
We analyzed the natural course of fistula in ano (FIA) and/or perianal abscess (PAA) in 97 children (male: 90, female: 7) and recommend conservative management in infants. Nearly one-half of these children had no recurrent episodes, and 80% of the infants recovered spontaneously within their 1st year of life. A radical operation was required in only 6 children after 2 years of age. Two-thirds of the children with a PAA did not develop fistula. Of the children who developed FIA, 42% had no recurrence. Although the duration of FIA was relatively longer than that of PAA, 55% of the children were cured within 1 year. PAA and/or FIA in infants is likely to be a period-limited disorder that occurs mainly in infancy and spontaneously resolves within 1 year of life. Fistulotomy or fistulectomy should be avoided in infants.

Coeliac axis thrombosis associated with the combined oral contraceptive pill: a rare cause of an acute abdomen.

Year 1998
Arul GS. Dolan G. Rance CH. Singh SJ. Sommers J.
Department of Paediatric and Neonatal Surgery, Queens Medical Centre, Nottingham, NG7 2UH, UK.
We report a case of coeliac axis thrombosis and splenic infarction presenting in a girl of 14 years who had been on the oral contraceptive pill (OCP), Marvelon (ethinyloestradiol 30 microg plus desogestrel 150 microg, Organon, Cambridge, UK), for 3 weeks. She had no other risk factors for thrombo-embolism. Diagnosis was made with duplex Doppler ultrasound and confirmed with dynamically-enhanced comput-ed tomography and magnetic resonance angiography, thus avoiding the need for percutaneous arteriography. Though mesenteric thrombo-embolic disease is recognised in association with use of the combined OCP, it has not previously been reported to affect the coeliac axis. Paediatricians and surgeons should be aware of the risks to young girls on the OCP, and consider it in their differential diagnosis of the acute abdomen.

Antenatal rupture of a diverticular rectal duplication with neonatal perineal fistulization.

Year 1998
Delarue A. Garcia-Meric P. Martin C. Piguet C. Andre N. Galli G. Guys JM.
Federation de Chirurgie Pediatrique, Hopital Timone-Enfants, Marseille, France.
A cystic pelvic malformation was found in a fetus on antenatal sonography (US) at 26 weeks of gestational age that was no longer present 3 weeks later on control US. The male child presented at birth with a right-sided perineal mass that fistulized with meconial drainage. A radiopaque enema showed a low posterior rectal fistula filling a poorly delineated pouch. Surgery performed through a posterior sagittal approach allowed identification and closure of the fistula and pouch drainage. The diagnosis of a diverticular rectal duplication was considered, although no intestinal lining was observed macroscopically or histologically. The child's anorectal function was normal after a 20-month follow-up. Labeling of the malformation and embryological hypotheses are discussed since the case does not fulfill all the criteria of an intestinal duplication. Surgical techniques are discussed, with an emphasis on the sagittal posterior approach.

The doughnut sign: an ultrasound finding in pediatric intestinal Burkitts lymphoma.

Year 1998
Hasegawa T. Sumimura J. Mizutani S. Tazuke Y. Okuda S. Dezawa T.
Division of Pediatric Surgery, Kinan General Hospital, Tanabe City, Wakayama, Japan.
This paper describes a doughnut-like ultrasound (US) finding in pediatric intestinal Burkitt's lymphoma. A 9-year-old boy had a fist-sized, hard, non-movable mass in the lower abdomen. US showed a thickened, layered ring like a doughnut. The outer, low-level echoes seemed to be consistent with mucosa and muscle layers and the inner, high-level echoes seemed to be intraluminal air or mucus. The serum lactic dehydrogenase level was high. At surgery, a solid, hard tumor 15 x 10 cm in size was found in the jejunum. The intestinal wall was diffusely thickened with an intact mucosa. From this experience, the US doughnut sign may be a helpful diagnostic finding in pediatric intestinal Burkitt's lymphoma.

The value of early postoperative oesophagography following repair of oesophageal atresia.

Year 1998
Nambirajan L. Rintala RJ. Losty PD. Carty H. Lloyd DA.
Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK.
The aim of the study was to examine the relationship between anastomotic leaks and the development of symptomatic anastomotic strictures after primary repair of oesophageal atresia (OA) with or without tracheo-oesophageal fistula (TOF) and the prognostic value of the anastomotic appearance on postoperative oesophagography. The records and X-ray films of 49 patients with OA with or without TOF admitted between January 1990 and June 1995 were reviewed retrospectively. Of these, 37 had a primary repair (34 immediate and 3 delayed) and a postoperative contrast swallow was done between day 5 and day 30 (median day 7). Radiological leaks were documented. In addition, the maximum transverse diameters of the upper pouch and anastomotic region and the length of the anastomotic narrow segment were measured; the ratio of upper-pouch diameter to that of the anastomosis was calculated (anastomotic index, AI). The need for dilatation of symptomatic anastomotic strictures and for repeat dilatation as a separate episode were documented. Of the 37 patients, 4 developed an anastomotic leak (11%), 3 radiological and 1 clinical. A symptomatic stricture occurred in 55% of patients. There was no correlation between a leak and later development of a symptomatic stricture, although the small number of patients with leaks precluded definite conclusions. No radiological leak progressed to a clinical leak. There was no correlation between the AI or the length of the anastomotic narrow segment and the need for dilatation, the need for repeat dilatation, or the number of dilatations. In this study, the presence of a leak, the AI, and the length of the narrow segment on early postoperative contrast swallow did not correlate with the later development of a symptomatic stricture. A radiological leak was of no clinical significance. Since major leaks are apparent clinically, an early routine contrast study did not influence management and is not necessary.

Esophageal replacement with colon in children.

Year 1998
Khan AR. Stiff G. Mohammed AR. Alwafi A. Ress BI. Lari J.
Department of Pediatric Surgery, University Hospital of Wales, Cardiff, UK.
Between 1974 and 1994, 25 colonic interposition procedures were performed for esophageal replacement in 23 cases of esophageal atresia (EA) and 2 corrosive strictures. Nine patients had one-stage and 16 had two-stage reconstructions. The transthoracic route was used in 16 cases (64%) and the retrosternal route in 9 (36%). Average age at the time of operation in EA patients was 17 months (range 12-33), and the children with corrosive injuries were 3 and 6 years old. Mean age at follow-up was 11.8 years (2.3-20.5 years). There was no mortality in the series. One patient developed full-graft necrosis and had a gastric pull-up procedure later. One child had partial graft necrosis (3 cm at the cervical end), however, enough colon was available for reconstruction. Ten patients developed a leak from the cervical anastomosis (40%) and 7 developed a stricture at the cervical esophago-colonic anastomosis (28%). The strictures were treated by repeated esophageal dilatation, and 3 patients required revision of the anastomosis (12%). Other complications included acid reflux in 2 cases (8%), small-intestinal obstruction in 1 (4%), redundancy of the colon in 1 (4%), and chest infections in 2 (8%). Follow-up included assessment of the patient's symptoms, serial growth measurements (height and weight), and where relevant, endoscopy and a contrast swallow or meal. There was a 52% improvement in weight and height percentiles post-operatively. Each of the 19 patients who had barium swallows showed rapid transit and emptying without any significant delay or hold-up. Overall long-term results were excellent in 13 patients (52%), good in 7 (28%), and fair in 5 (20%). The colon conduit thus provides an excellent substitute esophagus in pediatric patients.

Congenital esophageal atresia with tracheoesophageal fistula occurring in both members of dizygotic twins.

Year 1998
Ishimaru E. Kubota A. Yonekura T. Sakakura S. Noguchi J. Ueda S. Oyanagi H. Kitayama Y. Imura K.
Department of Pediatric Surgery, Osaka Medical Center for Maternal and Child Health, Japan.
The authors present a pair of dizygotic twins with congenital esophageal atresia with tracheoesophageal fistula who underwent successful single-stage surgical repair. To our knowledge, this is the second set of dizygotic twins with this congenital anomaly in the literature.

Congenital para-oesophageal hiatal hernia in infancy.

Year 1998
Jawad AJ. al-Samarrai AI. al-Mofada S. al-Howasi M. Hawass NE. al-Beiruti Z.
Department of Paediatric Surgery, King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia.
Congenital para-oesophageal hiatal hernia (PEHH) is a rare problem in infancy, however, it constitutes a clinical entity that mandates surgical repair once the diagnosis is made. In the paediatric age group, acquired PEHH has been described as a major complication in a number of patients who were treated surgically for gastro-oesophageal reflux (GER) by Nissen fundoplication. PEHH is a frequently encountered condition in elderly patients; it accounts for 5% of diaphragmatic hiatal hernias. In both paediatric and adult patients PEHH, whether congenital or acquired in origin, is usually associated with potentially lethal complications such as gastric volvulus, incarceration, and perforation. In clinical practice true PEHH is extremely rare. The term has been expanded to include large gastric hiatal hernias where most of the stomach and the gastro-oesophageal junction are in the chest. Six infants with congenital PEHH are presented, together with an attempt to understand its possible aetiology and a review of its current surgical management.

Traumatic injuries of the alimentary tract in children.

Year 1998
Akel SR. Haddad FF. Hashim HA. Soubra MR. Mounla N.
Department of Surgery, American University of Beirut Medical Center, Lebanon.
Traumatic alimentary tract (AT) perforations in children secondary to instrumentation, though rare, can occur at any age, especially in neonates and young infants. Awareness of such a possibility is essential for prompt management to be initiated. Over a 10-year period (1986-1995), eight pediatric patients with AT perforations secondary to instrumentation were managed at the American University of Beirut Medical Center. Five had upper AT injuries that included three hypopharyngeal, one esophageal, and one gastric lesion. The remaining three patients had lower AT injuries involving the transverse colon in one and the rectum in two. All the patients but two (one with a hypopharyngeal and one with an esophageal injury) were managed surgically and all survived. These rare injuries are discussed in addition to the preventive measures to be taken.

Nonoperative management of intra-abdominal bleeding due to blunt trauma in children: the risk of missed associated intestinal injuries.

Year 1998
Sarihan H. Abes M.
Karadeniz Technical University, Faculty of Medicine, Department of Pediatric Surgery, Trabzon, Turkey.
Nonoperative management of intra-abdominal bleeding (IAB) from blunt injuries in children has been advocated for many years. Nonoperatively managed patients, however, are at risk for missed associated intestinal injuries. To evaluate this question, we reviewed the charts of 120 children who had traumatic IAB; 106 were initially managed nonoperatively and observation failed in 2. Fourteen underwent emergency operation. Forty patients had isolated liver and/or splenic injuries while the others had injuries associated with several organs. During observation peritonitis developed in 3 patients and further radiologic examinations failed to confirm an intestinal injury. Diagnostic peritoneal lavage demonstrated contaminated blood and fecal particles from injured intestines in 3 patients; they underwent emergency operation at 10, and 26 h after admission. There was no mortality or morbidity associated with delayed treatment. These data suggest that the majority of patients with IAB may be successfully treated nonoperatively, but associated intestinal injuries should be suspected in all cases.

Does gut atresia cause polyhydramnios?

Year 1998
Kimble RM. Harding JE. Kolbe A.
Department of Paediatrics, University of Auckland, New Zealand.
Fetal gut atresia is variably associated with polyhydramnios. In order to determine which pregnancies will develop polyhydramnios, the case notes of 80 babies with gut atresia and stenosis were reviewed. Maternal polyhydramnios developed in all cases of pure oesophageal atresia (n = 8), all cases of Type III duodenal atresia (DA) with a non-bifid bile duct (n = 8), 80% of cases with type I DA (n = 10), and 24% of atresias of the small intestine (n = 34). Polyhydramnios did not develop in any case where there was not total obstruction except in 1 baby with DA and a bifid bile duct (BBD). These included stenosis of the oesophagus and duodenum (n = 17) and DA type III with a BBD (n = 3). These results support the role of fetal swallowing and fluid absorption by the fetal gastro-intestinal tract in the regulation of amniotic fluid volume.

Rectal biopsy for Hirschsprungs disease: what is the optimum method?

Year 1998
Alizai NK. Batcup G. Dixon MF. Stringer MD.
Department of Paediatric Surgery, Leeds General Infirmary, UK.
During a 3-year period, 258 infants and children underwent rectal biopsy to exclude Hirschsprung's disease (HD) and related disorders; 32 (12%) were found to have HD. Major morbidity occurred in 3 (2%) of 148 patients undergoing rectal suction biopsy (RSB) and 22 (13%) of 168 suction biopsies were inadequate for diagnosis. In 102 children over 6 months of age, Storz rectal cup biopsy forceps were used with no significant morbidity and adequate biopsies were obtained in 96% of cases. Open rectal biopsy was performed in 8 patients. The RSB tube is safe and reliable, but attention to technique is important. For children over 6 months of age undergoing rectal biopsy for HD, the Storz rectal cup biopsy forceps yields superior results.

Principal modifications of the Duhamel procedure in the treatment of Hirschsprungs disease. Analysis based on results of an international retrospective study of 2,430 patients.

Year 1998
Vrsansky P. Bourdelat D. Pages R.
Service de Chirurgie Pediatrique, Hopital Delafontaine, Saint-Denis, France.
In the literature, many articles refer to the DUHAMEL technique or some of its modifications in the treatment of Hirschsprung's disease, however, no complete review of all of them has been published to date. The authors present an analysis of the principal modifications of this technique based on the results of an international retrospective survey that evaluated a series of 2,430 patients as well as data from the literature. The important role of the internal anal sphincter in the physiology of continence is emphasized; understanding its function is an imperative prerequisite for a successful Duhamel procedure. The original technique, which used two crushing Kocher clamps as proposed by Duhamel in 1956, as well as a majority of the modifications with various spur-crushing instruments are no longer in use. At present, surgeons generally use staplers for the colorectal anastomosis.

Anorectal function and endopelvic dissection in patients with repaired imperforate anus.

Year 1998
Chen CC. Lin CL. Lu WT. Hsu WM. Chen JC.
Department of Surgery, National Taiwan University Hospital, Taipei, Republic of China.
Fifty-eight patients with anorectal malformations were closely followed up for postoperative anorectal function. Constipation was noted shortly after anorectoplasty in 10 of 28 low anomalies (35.7%) treated with limited sagittal anorectoplasty (LSARP), in 18 of 25 high or intermediate anomalies (72.0%) treated with posterior sagittal anorectoplasty (PSARP), but in none of 5 high or intermediate anomalies treated with Rehbein's mucosa-stripping endorectal pull-through and anterior sagittal perineal anorectoplasty (R-ASAP). The constipation resolved mostly within 1-2 years after repair under conservative management, but persisted beyond 2 years after repair in 3/25 children with LSARP and 10/25 with PSARP. Anal soiling was noted in 1/23 (4.3%) LSARP and 6/22 (27.3%) PSARP patients, but normal anorectal function was attained in 20/23 LSARP (86.9%) and 11/12 PSARP patients (50.0%) by the time of toilet training. Manometric studies disclosed that the resting rectal pressure (RRP) was lower and the anorectal pressure gradient (ARPG) higher in the constipated than the non-constipated children, while the RRP was higher and the ARPG lower in the soiled than the non-soiled patients. The ARPG after R-ASPA was close to that of non-constipated and in between that of the constipated and soiled patients. The rectoanal sphincter inhibitory reflex was not related to defecation status or surgical procedures, but showed a tendency toward positive conversion with time or after exclusion of esctatic terminal bowel in the severely constipated. It is concluded that anorectal function in patients with repaired imperforate anus seems to be more affected by the extent of endopelvic dissection than by preservation of the terminal bowel or sphincter muscles.

Paratubal cysts in young females as an incidental finding in laparotomies performed for right lower quadrant abdominal pain.

Year 1998
Vlahakis-Miliaras E. Miliaras D. Koutsoumis G. Miliaras S. Spyridakis I. Papadopoulos MS.
Pediatric Surgery Department, Medical Faculty, Aristotelian University, Thessaloniki, Greece.
Paratubal cysts represent remnants of the paramesonephric or mesonephric duct, the former being more common. Most of them are asymptomatic, but they may rarely give rise to clinical problems due to enlargement or torsion. In this study, we looked for paratubal cysts or other pathological lesions of the right uterine adnexa in young females operated upon for right lower quadrant (RLQ) abdominal pain. Our material consisted of 338 white female patients aged 4-14 years. Laparotomy revealed only acute appendicitis in 283 cases, while 44 had acute appendicitis plus a coincidental paratubal cyst. Most of these cysts were smaller than 1 cm in diameter. However, 2 additional cases had torsion of a large paratubal cyst, while 5 had a ruptured corpus luteum. We suggest that a thorough search of the right adnexa for the presence of paratubal cysts during laparotomies performed for RLQ pain is a useful procedure. This approach also allows detection of other pathological lesions of the right adnexa that often produce symptoms similar to acute appendicitis.

Cryptorchidism in boys with congenital abdominal wall defects.

Year 1998
Koivusalo A. Taskinen S. Rintala RJ.
Children's Hospital, University of Helsinki, Finland.
Cryptorchidism (CPT) has been suggested to be common in boys with congenital abdominal wall defects (CAWD). It has been hypothesized that the low intra-abdominal pressure in both omphalocele (OMP) and gastroschisis (GS) and brain malformations in patients with OMP contribute to the high incidence of CPT. To determine the incidence of CPT in boys with OMP and GS and to assess the relationship of CPT to the size of the AWD, prematurity, and concomitant anomalies, the hospital records and autopsy reports of 113 boys with CAWD (OMP n = 75; GS n = 38) were reviewed. Twelve (16.0%) boys with OMP had undescended testes; 5 (41.0%) of those had bilateral and 4 (23.5%) intraabdominal undescended testes. The occurrence of CPT in OMP patients did not correlate with the size of the AWD, birth weight, or gestational age. However, congenital cardiac anomalies and cleft lip and palate were significantly more common (P < 0.05) among those with CPT. Two (5.0%) boys with GS, both of whom were born prematurely, had unilateral CPT. In patients with OMP, the incidence of CPT was significantly higher than that of healthy children. There was a correlation between CPT and congenital midline defects such as cardiac anomalies and cleft lip and palate. In patients with GS, the incidence of CPT only slightly exceeded that of normal children and may have been related to prematurity.

Operative complications of hernia repair in childhood.

Year 1998
Tiryaki T. Baskin D. Bulut M.
No information.
In a training center, 1,131 inguinal hernias were repaired in 1,000 consecutive patients in 6 years. The documents of these patients were reviewed retrospectively for surgical complications. A total of 38 complications were encountered in 35 patients, including wound infection (1.9%), recurrence (0.9%), tethered testis (0.3%), bladder injury (0.3%), was deferens injury (0.2%), iatrogenic orchiectomy (0.1%), and postoperative death. Most of them occurred in the early years of the clinic, and nearly one-half were technical in nature. Careful training, stressing the importance of gentle handling of the tissues, and meticulous dissection with emphasis on learning groin anatomy should reduce the incidence of such complications.

Antenatal detection of hiatus hernia.

Year 1998
Chacko J. Ford WD. Furness ME.
Department of Paediatric Surgery, Women's and Children's Hospital, North Adelaide, South Australia.
A routine ultrasound scan in a primigravida at 29 weeks' gestation showed that her fetus had a fluid-filled viscus above the diaphragm in the mid-line. This was initially thought to be the stomach, either as part of a congenital Bochdalek diaphragmatic hernia or an hiatus hernia. Subsequent scans suggested that this was the stomach with an additional loop of bowel. After birth, laparotomy confirmed that the stomach had herniated into the chest through a very lax oesophageal hiatus. The stomach was easily reduced into the abdomen with no evidence to suggest a congenital short oesophagus, the crura were tightened, and an anterior fundoplication performed.

Spontaneous gastrointestinal perforation in very-low-birth-weight infants--a rare complication in a neonatal intensive care unit.

Year 1998
Resch B. Mayr J. Kuttnig-Haim M. Reiterer F. Ritschl E. Muller W.
Pediatric Department, Graz University, Austria.
Over a 6-year period (1989-1995), gastrointestinal (GI) perforation was diagnosed in nine preterm infants (mean gestational age 27 weeks, mean birth weight 872 g). Three presented with necrotizing enterocolitis (NEC), two with indwelling-tube-induced perforation of the stomach, one with small-left-colon syndrome, and another with meconium ileus. Spontaneous intestinal perforation occurred in two similar very-low-birth-weight (VLBW) infants, in the distal ileum, on days 8 and 9 of life, respectively. The only clinical sign was extensive abdominal distension, and abdominal X-ray studies revealed free peritoneal air. All findings were distinct from those associated with NEC. Their further clinical course was complicated by reperforation on day 32 and 39, respectively. They subsequently recovered and presented without GI problems at the corrected ages of 4 and 2 months, respectively. In contrast to high mortality of 57% in the group with non-spontaneous intestinal perforations, spontaneous perforation seems to have a good prognosis even in VLBW infants if diagnosed and treated promptly.

Progressive pan-colonic fibrosis secondary to oral administration of pancreatic enzymes.

Year 1998
Moss RL. Musemeche CA. Feddersen RM.
Packard Children's Hospital, Stanford University School of Medicine, Division of Pediatric Surgery, Palo Alto, California 94304, USA.
Most patients with cystic fibrosis require oral administration of pancreatic enzymes to treat pancreatic insufficiency. Recent use of higher-strength enzyme preparations in large doses has been found to be associated with fibrotic strictures of the colon. We report a case of pancolonic fibrosis due to pancreatic enzyme use.

Intra-pancreatic splenic artery pseudoaneurysm. A rare complication of chronic calcific pancreatitis.

Year 1998
Srinivas M. Kataria R. Bhatnagar V. Tandon N. Iyer KV. Gupta AK. Mitra DK.
Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.
The authors present the case of a 12-year-old boy with a history of chronic upper abdominal pain. Based on ultrasonography, endoscopic retrograde cholangio-pancreatography, and computerized tomography, a diagnosis of chronic calcific pancreatitis with dilation of the main pancreatic duct and a pseudocyst of the proximal pancreas was made. At surgery, in addition to confirmation of the above findings, a pseudoaneurysm arising from the splenic artery was found in the head and body of the pancreas. Pancreaticoduodenal resection including the pseudoaneurysm was performed. Postoperatively the child developed diabetes, which is easily managed with small doses of insulin.

Infantile hemangioendothelioma of the liver associated with anomalous dilated and tortuous vessels on the placental surface.

Year 1998
Kanai N. Saito K. Homma Y. Makino S.
Department of Pathology, Jichi Medical School, Tochigi, Japan.
An unusual vascular anomaly of the placenta and infantile hemangioendothelioma (IH) of the liver is described. The patient was an infant with a low birth weight for dates whose placenta showed markedly dilated and tortuous vessels, mainly venous but some arterial, on the fetal surface. Only one case of such a placental-vessel anomaly and no similar case associated with IH of liver has been described previously, although cutaneous hemangiomas have occasionally been reported to occur with IH.

Isolated Carolis disease presenting as an exophytic mass in the liver.

Year 1998
Keramidas DC. Kapouleas GP. Sakellaris G.
Department of Pediatric Surgery, Aghia Sophia Children's Hospital, Athens, Greece.
A case of isolated Caroli's disease in a 2-year-old female presented as an exophytic cystic mass of the liver. A palpable mass below the right costal margin and displacement of the right colon were the main points of clinical presentation. Preoperatively, sonographic signs of intraluminal vascular tracts were identified. At laparotomy, the mass was found at the inferior border of the right lobe of the liver next to the gallbladder and was easily removed by wedge excision. Intraoperative liver biopsies and histologic findings of the excised lesion confirmed the diagnosis.

Ileal atresia associated with an omphalomesenteric duct remnant.

Year 1998
Hasegawa T. Sakurai T. Tazuke Y. Ueda S. Kitano N. Dezawa T.
Division of Pediatric Surgery, Kinan General Hospital, Wakayama, Japan.
This paper describes an unusual case of ileal atresia associated with an omphalomesenteric duct (OMD) remnant. A 1-day-old male developed bilious vomiting and abdominal distension. At laparotomy, the distal portion of the ileum was connected to the umbilicus with a fibrous band. Around this omphalomesenteric band, the ileum was strangulated and necrotic; the end of the ileum was atretic. Apart from these structures, the cecum terminated without mesentery. This experience shows evidence of an OMD remnant as a possible cause of jejunoileal atresia.

Laparoscopic appendectomy and duodenocolonic dissociation (LADD) procedure for malrotation.

Year 1998
Lessin MS. Luks FI.
Division of Pediatric Surgery, Brown University School of Medicine, Providence, Rhode Island 02905, USA.
The treatment of "asymptomatic" intestinal malrotation remains controversial, particularly beyond the neonatal period. Two cases illustrate the application of laparoscopy for correction of malrotation: one in an older child and another in an asymptomatic infant. Both patients recovered well and were discharged 2 days after surgery. Laparoscopic appendectomy and duodenocolonic dissociation allows excellent visualization of the duodenocolic and Ladd's bands and easily accommodates appendectomy. The availability of this minimal-access technique should encourage correction of malrotation in the asymptomatic patient.

Congenital H-type urethroanal fistula.

Year 1998
Lal P. Gupta A. Krishna A. Taneja K.
Department of Surgery, University College of Medical Sciences, Delhi, India.
A case of congenital urethroanal fistula with a normal anterior urethra in a male child is reported. The fistula was demonstrated between the prostatic urethra and anorectum. This anomaly is usually associated with an atretic anterior urethra and has been variously described as a variant of a urethral duplication by some authors, and of an anorectal malformation (ARM) by others. We conclude that its rightful classification is as a variant of ARM in which the fistula is a result of persistence of the cloacal duct and corresponds to the anorecto-vestibular fistula with a normal anus (perineal canal) in a female.

Sutureless button and hole splenopexy.

Year 1998
Zivkovic SM.
University Children's Hospital, Belgrade, Yugoslavia.
A new technique for fixation of a mobile spleen is described. It offers the advantages of a minimally risky procedure that very effectively keeps a mobile spleen in its bed without foreign materials and is feasible even when the gastrosplenic ligament is absent and the splenic vessels are uncovered. Our "button and hole" sutureless splenopexy was performed in six patients from 1979 to 1995. Three had a gastric volvulus (GV) and an extremely mobile spleen; one of these also had a diaphragmatic eventration. Another three had torsion of the spleen; in one it occurred 9 months after repair of a diaphragmatic hernia. We achieved good results with splenopexy as the sole operation in two cases where a wandering spleen produced a GV.

Manual reduction with the index finger for infantile intussusception. A modification of Hutchinsons maneuver.

Year 1998
Hase T. Kodama M. Mizukuro T. Kishida A. Shimadera S. Ohno M. Shimada M.
Section of Emergency and Critical Medicine/Medical Coordination Center, Shiga University of Medical Science, Shiga, Japan.
Manual reduction with the index finger (modified Hutchinson's maneuver) enabling simple and safe manual reduction of infantile intussusception is described. The procedure was used in four patients, two boys and two girls, ranging in age from 2 to 15 months, as greater than normal compression was necessary and/or serosal splitting occurred during conventional reduction. The technique is as follows: in addition to the proximal bowel compression with Hutchinson's maneuver, the surgeon inserts his index finger into the intussusceptum via its neck. The finger enables the surgeon to sound a wider space between the intussusceptum and intussuscipiens, which is most likely to be responsive to bowel compression. Although the intussusceptions in the four patients were categorized as ileo-ileo-colic (three cases) and ileo-ileal (one case) types, this manual reduction technique was successful in all cases, no bowel rupture occurred, and hospitalization was no longer than with the conventional procedure. We conclude that this modified Hutchinson's maneuver may contribute to successful surgical reduction of infantile intussusception.

Management of multiple intestinal atresias and perforation with intraluminal stenting.

Year 1998
Dinsmore JE. Jackson RJ. Wagner CW.
Department of Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, USA.
Intraluminal stenting of the gastrointestinal (GI) tract in both multiple intestinal atresias and perforations was used in three patients. In the atresia patients (2), a piercing trocar was used to create continuity of the GI tract and as a guide to thread the intestine over the stent. All patients currently demonstrate normal growth and development on routine enteral feeds. None developed anastomotic leaks or strictures.

Gastric inflammatory myofibroblastic proliferation in children.

Year 1998
Estevao-Costa J. Correia-Pinto J. Rodrigues FC. Carvalho JL. Campos M. Dias JA. Carneiro F. Santos NT.
Department of Pediatrics, Faculty of Medicine, University of Porto, Portugal.
Gastric inflammatory myofibroblastic proliferation (IMP) is an extremely rare entity in children, which to our knowledge has only been mentioned in case reports. We describe the ninth pediatric case and review the literature concerning the etiology, clinical and laboratory features, pathology, treatment, and outcome. There has been a predominance in preschool females. Abdominal pain, upper gastrointestinal hemorrhage, and an abdominal mass, either isolated or associated, have been the main clinical features. Iron-deficiency anemia has been a constant finding. Lesions are elevated and involve the full thickness of the gastric wall, usually with ulceration of the luminal surface; extragastric extension suggesting malignancy is frequent. Diagnosis is made by histology after surgical excision. There was no mortality directly related to gastric IMP, and only one case recurred after surgical excision. The pathogenesis is controversial, but the finding of Helicobacter pylori in our case may indicate an inflammatory origin. Awareness of this benign lesion and its mimicry of malignancy is important so that inappropriately aggressive therapy can be avoided.

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