Lobar emphysema and atelectasis syndrome, a nosological unity.

Shrinking and atelectatic pulmonary processes--atelectasis syndrome--and lobar emphysema show morphological similarities: congenital malformations of the bronchial structure, external compression of the bronchi as well as inflammatory processes. Ventilation mechanics determine whether in the described processes an atelectasis or an emphysema manifests itself clinically. Usually, one finds over-expansions in connection with atelectasis syndrome and atelectases together with lobar emphysema. Both processes can be reversible, if we are not dealing with bronchial malformations. Longer lasting processes as well as acute, life threatening forms require operation. The belief that atelectasis syndrome and lobar emphysema constitute a nosological unity is illustrated by our cases of 9 patients with atelectasis syndrome and 16 patients with lobar emphysema.

[Risk score and postoperative complications in pediatric surgery]. / Risikoscore und postoperative Komplikationen in der Kinderchirurgie.

We have developed a risk score meeting the special demands of pediatric surgery. It conveys an objective impression of the patients' preoperative condition and enables us to predict their individual intra- and postoperative behavior. This study compiles the course of 1425 operations carried out between 1986 and 1990. They were divided into low, intermediate and high risk. In addition, the patients were classified into six different age groups. We demonstrate that the number of points assigned by our risk score is highly correlated with the rate of complications that occurred, that accompanying malformations and diseases are correctly picked up and weighed by the score as far as their importance for the postoperative course is concerned, that the score is suitable for ascertaining which patients have a high probability of developing complications: the specificity is close to 100% for more than 12 points on the score, and the proportion of correctly predicted lethal courses (sensitivity) is also close to 100%. The significance of the risk score lies first in the possibility of giving patients exact data on the intra- and postoperative risk, and secondly in the provision of an objective measure of quality control--which is legally prescribed in Germany--and comparison with other hospitals. Third, the risk score gives clear starting points for research aiming at improvement in the field of surgery in sick children, and lastly it forms the basis for reliable preoperative recognition of high-risk as needed patients for modern payment methodology of the per-cose costs and thus makes it possible to charge accordingly.

[Mortality and postoperative cause of death in pediatric surgery]. / Letalität und postoperative Todesursachen in der Kinderchirurgie.

We analysed our patients in pediatric surgery from 1959 to 1990 in regard to post-operative causes of death according to the Petren scheme. "Post-operative infection" as a cause of death dropped from 45% to 2%, "post-operative pneumonia" from 10% to 4%. Death due to accompanying congenital defects has increased from 3% to 15%. The cause of death "main disease" remained the same with 18%. Post-operative causes of death due to wrong diagnoses ranged at 2%, wrong treatment as cause of death decreased from 18% to 4%. In the 41 years' range of our survey, 115,598 children were operated as in-patients. During the first 5-year-period postoperative mortality was 2.2%, during the last 5-year-period 0.12%.

New morphological findings in so-called negative appendectomies.

Appendices of children operated on because of clinical signs of acute appendicitis and presenting normal histological findings were revised by means of special assays. These findings were then compared with appendectomies during abdominal surgery, catarrhal and early phlegmonous appendicitis. We found pathological changes of the epithelium and the lymphatic tissue in more than two thirds of the specimens originally classified as normal. Therefore the term of "negative appendectomy" has to be redefined.

Clinical findings in middle lobe syndrome and other processes of pulmonary shrinkage in children (atelectasis syndrome).

Processes of atelectasis and pulmonary shrinkage are not confined to the right middle lobe. This fact is illustrated by case reports of five of our nine such patients. All cases shared common clinical and morphologic similarities: congenital malformations of the bronchial skeleton, compression, and chronic inflammation produce comparable pulmonary morphology that always includes atelectasis. Atelectasic processes of longer duration require surgical resection; this led to cures in all the authors' patients.

[The value of C-reative protein analysis for the differential diagnosis of non-acute appendicitis]. / Der Wert der CRP - Untersuchung in der Differentialdiagnose der nicht-akuten Appendizitis.

Appendicitis is one of the most common causes for laparatomy in children. Diagnosis can be very problematic, especially if appendicitis is combined with gastro-enteritis. Furthermore, difficulties can be encountered in diagnosis of diseases such as mucoviscidosis, leukosis, immunosuppressive or chemotherapy are present. In addition to the common clinical examination we have to look for other methods to complete the indication for appendectomy. Therefore in 1985 we added the CRP-determination to our diagnostics for patients with suspected appendicitis. In a retrospective study 269 patients who had signs of acute appendicitis were examined. We found that the determination of the CRP-level, in conjunction with the standard parameters of appendicitis, represents a valuable addition to the diagnostic armamentarium. However our data shows, that the CRP-level in itself cannot be regarded as a sole criteria for an unambiguous diagnosis of non-acute appendicitis, as it is the case with any other appendicitis parameter.

Ileus in the newborn: a study of decreasing mortality.

The authors' experience with operative therapy for ileus-duodenal, small intestinal, colon, and rectal-in newborns is presented with an analysis of the improvements in prognosis over the last 30 years. For the time period 1980-1989, the following survival rates were achieved: duodenum: 100%; small bowel: overall 96.8%, for uncomplicated cases 100%; congenital megacolon: overall 89%, for uncomplicated cases 100%; ileus of all intestinal portions together: 97.5%, for uncomplicated cases 100%.

Tracheal stenosis by innominate artery compression in infants: surgical treatment in 35 cases.

This is a report on 35 cases of innominate artery compression of the trachea and its surgical correction by means of aortotruncopexy. Diagnostic procedures of choice were tracheoscopy and magnetic resonance imaging, which offers representative images of inspiration and expiration, shows the anatomical relations between aortic arch and trachea and reveals the extent of tracheal compression. Surgical treatment is indicated if narrowing of the tracheal lumen exceeds 70%. By fixation of the aortic arch and the proximal innominate artery to the back of the sternum, tracheal compression is relieved. There was no unsuccessful operation in the 35 children. One late death occurred from cardiac failure, unrelated to tracheal compression.

Indication and results of thoracic surgical procedures in premature infants.

This analysis concerns three groups of malformations: Congenital diaphragmatic hernia, patent ductus arteriosus, and oesophageal atresia. We registered a total mortality rate for all congenital diaphragmatic hernias and defects of 28.5%; the rate in full-term neonates was 27.6% and in premature infants 33.6%. Of 65 infants with a patent ductus arteriosus and a birth weight less than 1500 g, 14 died (21.5%). In most cases death was caused by sepsis. Among the 159 patients with oesophageal atresia who were treated in our hospital, 58 were premature infants. During the last 20 years, the total mortality rate among our patients was 28.9%. We had a mortality rate of 44.8% in premature infants and of 19.8% in full-term neonates. An analysis of the last 10 years showed a survival rate of 97% in healthy infants (group A in Waterston's classification). In group C, the most disadvantageous group (premature infants, severe anomalies), the rate was 61%.

Surgery for benign and malignant diseases of the thyroid gland in childhood.

From 1970 to 1986, 51 children and adolescents aged 5-18 years were operated on for diseases of the thyroid gland, among them 42 with benign diseases (juvenile goiter 21, adenoma 17, Graves' disease 3, Hashimoto's thyroiditis 1) and nine with malignancies (papillary carcinoma 4, follicular carcinoma 3, medullary carcinoma 1, anaplastic carcinoma 1). In benign entities, females were three times as often affected as males, whereas both sexes were equally affected in malignancies. Positive family histories were found in 23.3% of the children with adenomas in 71.4% of the children with juvenile goiters. Subtotal strumectomy was carried out in 30 instances and enucleation in 12. Iodized salt and L-thyroxine were given postoperatively as recurrence prophylaxis. Recurrence was seen in two children (4.8%) who had no recurrence prophylaxis. Symptoms in children with malignancies were palpable cervical lymph nodes and solitary nodes in the thyroid gland. Total thyroidectomy was done in all instances, followed by radio-iodine treatment in eight cases and cobalt 60 irradiation in one case. Two children died, of diffuse metastases and irradiation fibrosis of the lung respectively. The peculiarities of diseases of the thyroid gland in childhood that require surgery are discussed.

[Surgical therapy of neonatal necrotizing enterocolitis]. / Die operative Therapie der neonatalen nekrotisierenden Enterocolitis.

Between 1972 and 1988, a total of 57 patients with an average birth weight of 1988 g and an average gestational age of 34.1 weeks were operated on for neonatal necrotizing enterocolitis. In 48% of the cases, the critical indication for surgery was determined by clinical examination; in 52% of the cases, the indication was based upon a radiological diagnosis of pneumoperitoneum. The affected intestinal portions were first resected. Then, the proximal and distal limbs were sewn together and brought out through a separate short incision. Utilizing this procedure, the lethal rate sank from above 80% to below 30%. Taking into account unrelated causes of death, no significant increase in risk has been associated with the use of this procedure on prematurely born patients and patients exhibiting acute intestinal perforations.