Gastroschisis: an 18-year review.

From 1972 to 1990, 69 cases of gastroschisis were treated at Akron Children's Hospital Medical Center. Eighty-one percent of these patients underwent primary closure of their abdominal wall defect. Thirteen of 69 patients (19%) required Silastic silos with final closure in an average of 7.8 days. There was no sex predilection, the average birth weight was 2,473 g, and the mean gestational age was 36.3 weeks. Twenty-six percent had associated anomalies, the majority were intestinal atresia, volvulus, and/or undescended testicles. Seventy-seven percent of the infants were delivered vaginally. Fourteen children were delivered via cesarean section. Seven cesarean sections were done solely for prenatal ultrasonic identification of an abdominal wall defect. There was no improvement in hospital stay, complications, days until enteral feeds were tolerated, days intubated, or number of surgical procedures in this group. In 14 patients, mesh sheeting (Marlex, Silastic) was used in the final closure. Sixty-four percent of these incurred wound breakdown necessitating removal of the mesh. This compares with a 3.2% wound breakdown in the nonmesh group. The average hospital stay was 43.9 days and the average time to enteral feeds 20.2 days. Sixty-four percent of the patients required postoperative intubation for an average of 5.5 days. The overall mortality rate was 4.3%. The present data do not support gastroschisis alone as an indication for cesarean section. The data indicate that mesh be avoided in the final closure if possible and support a favorable prognosis for most babies.

The use of cultured epithelial autografts in the wound care of severely burned patients.

Commercially prepared cultured epithelial autografts permit closure of deep burn wounds when insufficient uninjured skin is available for split-thickness grafting. This technique was used in seven patients with a mean total body surface area (TBSA) burn of 66% and full-thickness burn of 52%. All patients survived with a mean initial take of 69% and final take of 80% for the cultured epithelial autografts. Patients with a TBSA burn greater than 80% required at least a second application of the grafts. We feel our approach to wound preparation and postoperative wound care has contributed to our success with this technique.

Laparoscopic cholecystectomy in an infant.

Use of the laparoscopic approach in traditionally open procedures has developed rapidly in recent years. Despite this intensive rate of evolution, most procedures have been done in adult patients, with pediatric patients largely excluded. This paper reviews a case report of a laparoscopic cholecystectomy in a 19-month-old male. This effort presents new data and techniques to encourage further investigation into minimally invasive surgery in the pediatric age group.

Childhood intussusception.

Intussusception of the intestine continues to be a significant surgical disease of childhood. The currently accepted therapy is to do a barium enema, followed by a laparotomy, if necessary. To evaluate our results in treating this disease, the charts of the last 169 patients admitted to the hospital, with the diagnosis of intussusception, were reviewed. Intussusception was confirmed in 157 patients, 92 of whom underwent successful reduction by barium enema (59 per cent). Sixty-four were treated with laparotomy (41 per cent). Of these 64, 34 were reduced manually (22 per cent) and 30 required resection (19 per cent). Two patients died (1.3 per cent). Our experience is in general agreement with that of other reported series, and we conclude that hydrostatic barium enema reduction is the treatment of choice for intussusception during childhood. Laparotomy should be reserved for those patients in whom the barium enema was unsuccessful.

Duodenal leiomyoma: a case report of hematemesis in a teenager.

A leiomyoma of the duodenum presenting in a 17-year-old girl represents an unusual cause for a massive upper gastrointestinal bleed in a teenager.

Prepyloric antral diaphragm: delays in treatment.

Six cases of prepyloric antral diaphragm were encountered at Children's Hospital Medical Center of Akron between 1965 and 1985, with approximately 150 cases reported in the literature during this time. In our series, a delay from onset of symptoms to treatment existed for a period of 4 months to 6 years. We suggest that prompt endoscopic confirmation and surgical therapy for this lesion, when suspected by clinical and radiologic abnormalities, would decrease the physical and psychologic morbidity of unexplained recurrent vomiting in these children.

Arnold-Chiari malformation. Report of four cases with contamination of the central nervous system by amniotic contents.

Four patients with the Arnold-Chiari malformation had massive prenatal contamination of the spinal cord and brainstem (and also of the cerebral ventricles in one case) by amniotic squamous cells and lanugo hair, which had entered through open meningomyeloceles. Amniotic contents were present in the subarachnoid space, central canal, fourth ventricle, and aqueduct and were also embedded in neural tissue, causing severe gliosis, fibrosis, and blockage. The mechanism of the complication and its implications in the prognosis of patients with the Arnold-Chiari malformation are discussed.

Sacrococcygeal myxopapillary ependymomas and ependymal rests in infants and children.

The occurrence of sacrococcygeal myxopapillary ependymal tissue appears to be exceedingly rare. We report on five cases of this lesion in infants, four of which occurred in the first year of life. These cases, the youngest on record, should be added to the thirteen cases previously reported. The lesions were completely removed, and the patients have been followed without recurrence for five months to six years. These lesions arise from the coccygeal medullary vestige, which corresponds to the original site of the final closure of the posterior neuropore. The unique embryology of this region can account for the presence of sacrococcygeal teratomas, lipomas, chordomas, as well as the above described lesion. The presence of ependymal rests, as described by Bale, in most patients with postanal dimples, suggests that the incidence of this lesion should be greater. This lesion has a potential for lymph node and pulmonary metastasis and when clinically palpable, should be completely excised.

Bowel lengthening for short gut syndrome.

A technique has been utilized that decreases the diameter of the intestine by one-half and doubles the length. In this procedure, no adsorptive surface is sacrificed and no obstructing segments are interposed. Our experience demonstrates the feasibility of dividing the small bowel longitudinally and maintaining vascular integrity and peristaltic function. Further investigation in its clinical application appears indicated.

Crohn's disease in children.

Forty-one children with Crohn's disease were seen over a 10 year period. Fifty percent of these patients were diagnosed at ages 13 to 16 years. The colon and small bowel were involved in half of the patients. Twenty-six patients required surgery for resection of bowel or diversionary procedures. Sixty percent of the patients with small bowel disease alone responded to medical therapy. We have been unable to document that growth failure can be predictably reversed by surgery. There were no deaths in this series and no patient was lost to follow-up. At present, only one patient is unable to perform the full-time activities of daily living. The longest period of follow-up is 10 years.

Elevated GGTP/SGOT ratio. An early indicator of infantile obstructive cholangiopathy.

Early surgical intervention in cases of extrahepatic biliary atresia improves prognosis. The ratio of serum gamma-glutamyl transpeptidase to SGOT is elevated in infants with infantile obstructive cholangiopathy. This appears to be a sensitive method for distinguishing infants with extrahepatic biliary atresis from those with neonatal hepatitis. This distinction was evident as early as 5 to 14 days of age and was clearly manifest in ten of 12 infants with biliary atresia. The ratio was also elevated in patients with alpha 1-antitrypsin deficiency who had bile duct proliferation. We do not claim that the ratio can clearly distinguish extrahepatic biliary atresia from neonatal hepatitis, but we do suggest that an elevation raises a strong presumption of biliary obstruction and invites early consideration of laparotomy and examination of the biliary tree.

Foreign bodies in the larynx and tracheobronchial tree in children. A review of 225 cases.

In a study of 225 patients with foreign bodies in the larynx, trachea and bronchi, 77% were 36 months of age or less. The male-female ratio was 2:1. Food or food derivatives were the causative agent in 70% of the cases, with 38% due to a portion of nut. The foreign body involved the right and left bronchus with equal frequency. A choking episode followed by an audible wheeze (55%) was the most common presenting complaint. Obstructive emphysema was demonstrated in 60% and was best demonstrated by inspiration-expiration chest roentgenograms or fluoroscopy. A radio-opaque object was seen in 13%. Two hundred ten foreign objects (93%) were removed by endoscopy. Four patients required pulmonary resection for bronchiectasis and in three patients bronchotomy was performed. Five patients expelled the foreign body spontaneously, two patients were transferred to another hospital, and one foreign body was not recovered. There was no mortality.