Abnormal crypts of Morgagni: the cause of perianal abscess and fistula-in-ano.

Fistula-in-ano in infants is thought to begin with a cryptitis that proceeds to a perianal abscess. Of 52 patients in 15 years, 51 were male, 45 were under 12 months, 7 had multiple tracts, and 2 recurred in 6 years; all of which points to a developmental anomaly. We believe the anomaly to be a markedly irregular thickened dentate line that harbors from 3 to 13 deep (3 to 10 mm) abnormal crypts (AC), which foster cryptitis. There have been no recurrences since we started doing cryptotomies on these AC in addition to the fistulotomy. The cause may be a defect in the dorsal portion of the cloacal membrane which fuses with the hindgut during the seventh week.

A new look at the multifactoral etiology of gallbladder disease in children.

The etiology of gallbladder disease in children is multifactoral. Seven of these factors are fairly well known: obstruction of biliary ductal system, hemolytic disease, estrogen effect, obesity, familial, metabolic, and stress related. Our biggest group of patients, 19 out of the total 61 or 31 per cent, were found to have had prior abdominal/renal surgery or partial bowel obstruction. It has been shown that ileal resections result in gallstones due to loss of bile salt absorption; however, volvulus and partial obstruction from adhesive bands have never been incriminated before. A number of teenagers appear to develop acalculous cholecystitis and have symptoms a good many months before stones develop. These patients who have delayed (greater than 36 hours) excretion of oral cholecystogram dye also have positive duodenal drainage studies after cholecystokinin. Gallbladder disease in children is not a rarity as surgical textbooks would lead one to believe.

Cholelithiasis and cholecystitis in children after repair of congenital duodenal anomalies.

Duodenal surgery, particularly the correction of duodenal anomalies, may be associated with an increased incidence of subsequent cholelithiasis and cholecystitis in children. We review the case histories of two children. Each child experienced acute cholecystitis with gallstones nine years after the correction of duodenal anomalies (annular pancreas, duodenal stenosis) in the neonatal period. At reoperation, intense fibrosis was noted in the hepatoduodenal area, while cholangiography demonstrated abnormalities of the common hepatic and common bile ducts. These cases suggest that the correction of duodenal anomalies may favor the subsequent development of gallstones in children. Fibrosis may have compressed the common bile duct, with stasis permitting gallstone formation. Intrinsic bile duct abnormalities, which may accompany duodenal anomalies, could also play a role. Thus, a history of previous duodenal surgery in a child with abdominal pain may strengthen a tentative diagnosis of cholecystitis. Also, at the time of exploration, the surgeon should be alert to the possibility of biliary tract abnormalities.

Preoperative irradiation and chemotherapy for initially unresectable hepatoblastoma.

Three cases of hepatoblastoma that were deemed unresectable, both by angiographic study and exploration, became resectable following combined therapy of dactinomycin, vincristine, and irradiation.