The incidence of spermatic cord structures in inguinal hernia sacs from male children.

Inguinal herniorrhaphy is a common surgical procedure in children. Controversy exists regarding the usefulness of microscopic examination of hernia sacs, and changes in reimbursement schemes have heightened this controversy. We summarize our experience with histologic examination of these specimens to establish benchmarks for the number of spermatic cord structures in inguinal hernia sacs from male children. A 14 1/2 consecutive calendar year review of pathology reports and histologic sections of hernia sacs was conducted at a tertiary care children's hospital. Of 7,314 males (range newborn to 19 years old), 65% had bilateral and 29% had unilateral herniorrhaphy (6% unknown). Seventeen cases contained vas deferens (0.23%); 22 had epididymis (0.30%); and 30 had embryonal rests (0.41%). Either vas deferens or epididymis was found in 0.53% of patients. No cases contained bilateral vas deferens, bilateral epididymis, or vas deferens in one side with epididymis in the contralateral side. Three hernia sacs contained co-existing vas deferens and epididymis. Our study helps to provide surgeons with information for preoperative counseling regarding potential injury to the vas deferens or epididymis. This study provides baseline comparison data for quality improvement programs. We believe that each institution should weigh the costs, risks, and benefits of performing microscopic examinations on hernia sacs, depending on their own experience and data.

Metachronous multiple aneurysmal bone cysts.

We report on a 9-year-old boy with metachronous aneurysmal bone cysts involving the tibia and pubis respectively. The patient has been clinically and radiographically followed for 3 years.

Implantation and expansion of split-thickness skin grafts: a new source of prefabricated pedicle flaps and grafts.

The objective of this study was to determine whether a split-thickness skin graft can be implanted deep to the skin and whether it can be expanded. We also wanted to find out whether this implanted and expanded split-thickness skin graft can be used as a new source of skin grafts and as a pedicle flap. A tissue expander mounted on a Dacron sheet backing was specially designed for this experiment. Six female Hanford minipigs weighing 20 to 25 kg were operated on in three stages. In stage one, a split-thickness skin graft 0.03 in thick was harvested from the back, placed dermal side out over the expander, and sutured to the Dacron backing. The expander with the overlying split-thickness skin graft was then implanted deep to the panniculus carnosus muscle. Daily expansion was started 2 weeks after implantation to obtain a total volume of 1300 to 2500 cc. In the second stage, performed 4 to 6 weeks after implantation, the skin over the expander was elevated superficial to the panniculus carnosus muscle as a ventrally based flap, and the panniculus carnosus muscle was next elevated as a dorsally based flap lined on its deep surface with the implanted/expanded skin. Full-thickness skin grafts obtained from this implanted/expanded skin and from normal skin were transplanted to two 3 x 3 cm skin defects. The panniculus carnosus muscle implanted/expanded skin flap was then turned 180 degrees and sutured to a dorsally created skin defect. In the third stage, 4 weeks later, we noted the quality, texture, and appearance and obtained punch biopsies from normal skin, normal skin graft, implanted/expanded skin graft, and panniculus carnosus muscle implanted/expanded flap for histopathologic examination. All skin grafts "took" well, survived implantation, and were expanded successfully. The initial surface area of implanted split-thickness skin graft showed a net increase of 8 to 193 percent (mean percentage net increase 90 percent). This implanted/expanded skin also was retransplanted successfully to a skin defect. In all six minipigs, a skin-lined panniculus carnosus muscle implanted/expanded skin flap was constructed and survived transfer to an adjacent skin defect. The smallest flap of panniculus carnosus muscle implanted/expanded skin measured 10 x 12 cm and the largest 12 x 28 cm (mean surface area 228 cm2).

Late occurrence of malignancy following resection of a histologically mature sacrococcygeal teratoma. Report of a case and literature review.

A sacrococcygeal adenocarcinoma is reported in a male patient nearly 40 years old following resection of a histologically mature sacrococcygeal teratoma. The adenocarcinoma arose within soft tissue of the presacral area and residual coccyx and extensively invaded the coccygeal stump that had not been removed in toto with the teratoma during initial surgery at 2 months of age. The patient died nearly 2 years later with local and regional recurrence of tumor and metastases to lymph nodes, liver, lung, bone, and brain. At autopsy there was no evidence of origin from deep internal organs such as the stomach, pancreas, or other sites. Brief comments are made about malignant tumors complicating sacrococcygeal teratomas in both the pediatric age group and adults, and attention is focused on other lesions entering into the differential diagnosis, particularly retrorectal cyst/hamartoma or tailgut cysts. This case underscores an extremely rare but potentially fatal outcome of a patient with sacrococcygeal teratoma.

Prevention of secondary cardiovascular instability after intestinal ischemia and reperfusion improves survival.

Previous studies of small intestinal ischemia and reperfusion (I/R) in immature rats report secondary systemic organ injury and low survival rates; however, in these studies the cardiovascular stability of the rat was not established. To prevent the secondary hemodynamic deterioration accompanying intestinal I/R, we have developed a model that utilizes aggressive fluid resuscitation. Under anesthesia, 4-wk-old male Sprague-Dawley rats (n = 189) underwent 90 min of I/R (superior mesenteric artery occlusion) or sham (SH) operation while receiving lactated Ringer with 5% dextrose at 15 (IR15, SH15) or 65 (IR65, SH65) ml.kg-1 x h-1 i.v. The results indicate that aggressive fluid resuscitation in the IR65 group significantly attenuated the hypotension, hemoconcentration, metabolic acidosis, and amount of gross bowel injury observed in the IR15 group, while increasing postreperfusion renal and intestinal blood flow, prolonging survival time of nonsurvivors, and improving overall group survival. These findings suggest that maintenance of hemodynamic stability is necessary in models of bowel I/R. Furthermore, this model allows for selective study of the isolated effects of intestinal I/R without the additional complications resulting from secondary cardiovascular instability.

Reperfusion injury following testicular torsion and detorsion in prepubertal rats.

Acute testicular torsion is a surgical emergency which requires immediate intervention. Although damage to the gonad has been well documented, it remains unknown whether the majority of injury occurs during the period of torsion (ischemia) or following detorsion (reperfusion). The aims of this study were to determine: (1) whether damage following testicular torsion-detorsion has a reperfusion component similar to that described in other tissues, and (2) whether iron-catalyzed oxygen radical formation or altered calcium homeostasis plays a role in this injury. To study this, anesthetized prepubertal rats underwent 720 degrees intravaginal testicular torsion and were divided into groups of torsion only (ischemia) and torsion with reperfusion (ischemia/reperfusion). Reperfusion groups were treated prior to detorsion with either deferoxamine (iron chelator), diltiazem (calcium channel blocker), or saline vehicle. The results indicated that detorsion produces a qualitatively distinct reperfusion injury from that of non-reperfused testicles; however, such damage was not ameliorated by deferoxamine or diltiazem. Thus, testicular torsion-detorsion appears to have a significant reperfusion component that appears to not be mediated by iron-catalyzed oxygen radical formation or calcium injury.

Obstructive jaundice associated with polysplenia syndrome in an older child.

Polysplenia syndrome includes malrotation and various forms of heterotaxy. Associated with this and malrotation are extrahepatic biliary anomalies. Actual obstruction, other than in associated biliary atresia, is extremely rare, and rarer still in older children. An 11-year-old girl presented with obstructive jaundice, malrotation, and heterotaxy, which were found in association with common bile duct anomalies and intermittent common bile duct obstruction. This case illustrates that the differential diagnosis of obstructive jaundice, even in older children, should include congenital anomalies, and that biliary anomalies should be considered in cases of malrotation and heterotaxy.

Impairment of macrophage activation and granuloma formation by protein deprivation in mice.

Protein-calorie malnutrition predisposes to infection by intracellular pathogens, but the basis for this predisposition is unclear. We studied the effect of protein deprivation on mouse peritoneal macrophage function and on granuloma formation during infection by bacille Calmette-Guerin (BCG). Injection of lipopolysaccharide (LPS) to induce inflammation elicited fewer peritoneal cells from mice fed a 2.5% protein diet than from mice fed an isocaloric chow in which protein calories constituted 24% of the total. LPS-elicited macrophages from protein-deprived mice demonstrated a reduction in spreading, total cell protein, cell lactate dehydrogenase, and release of superoxide anion (O2-) in response to stimulation. Priming in vitro by interferon (IFN)-gamma for enhanced release of O2- was also significantly impaired in protein-deprived mice. This defect was reversible by repletion with 24% protein diet for 10 days. Impairment of macrophage function in protein-deprived mice was further evidenced by an impaired capacity to express Ia antigen in response to IFN-gamma and by reduced production of IL-1 activity in response to LPS. Infection by BCG in protein-deprived mice was characterized by impaired granuloma development in liver, lungs, and spleen. Thus, in this model, protein deprivation significantly impaired macrophage activation, as assessed by morphologic, metabolic, and functional criteria. This impairment might compromise immune effector mechanisms dependent on macrophage activation, including rejection of intracellular pathogens.

The role of reperfusion injury in occlusive intestinal ischemia of the neonate: malonaldehyde-derived fluorescent products and correlation of histology.

Oxygen free radical reperfusion products may play a critical role in neonatal occlusive intestinal ischemia. We report a comparative analysis of light microscopy- and malonaldehyde (MDA)-derived fluorescent products as a measure of lipid peroxidation in occlusive intestinal ischemia in the rat. Weanling rats (n = 25) underwent cross clamping of the common mesenteric artery followed by various intervals of reperfusion; blood was sampled from the common mesenteric vein and the ileum was simultaneously biopsied. Blind-light microscopic scoring of the ischemic intestine was used. Fluorescent products were extracted using a chloroform/methanol/acidic water solvent extraction and measured with a spectrophotofluorometer using excitation/emission wavelengths of 360 and 430 nm, respectively. A trend was observed with prolonged reperfusion. Accumulation of fluorescent products correlated directly with the interval of reperfusion. Graded intervals of vascular occlusion produced progressive intestinal injury, but light microscopic analysis was not a sensitive index to distinguish the influence of graded reperfusion intervals. These data confirm a role for both ischemia and reperfusion in occlusive intestinal injury in the neonate and suggest that MDA accumulation may be a sensitive index of the reperfusion component of such injury.

Intraosseous infusion of fluids in the initial management of hypovolemic shock in young subjects.

Immediate aggressive fluid resuscitation of a child with life-threatening hemorrhagic shock provides the difference between life and death. Obtaining venous access in the hypovolemic child sometimes is difficult and time consuming. In order to evaluate the benefit of prehospital administration of intraosseous fluids into the tibial bone marrow as a method of gaining quick access to the systemic circulation and in resuscitating victims from severe hypovolemic shock, 13 puppies weighing 4.6 to 10 kg were subjected to progressive, controlled exsanguination until their mean arterial pressure (MAP) was 20% or less of their baseline MAP for 5 minutes (maxishock). Then an 18-gauge intraosseous needle was inserted into the tibial bone marrow and lactated Ringer's solution was infused at 300 mm Hg of pressure until a volume three times the blood loss had been administered. The MAP, central venous pressure, arterial blood gases, hematocrit, serum lactate, and urine output were recorded at 10, 20, 30, 45, 60, 90, and 120 minutes after the onset of maxishock. At the end of the experiment the left lung of each animal was sent to the pathology department to investigate the possibility of bone marrow emboli. The results were compared with a group of control dogs with maxishock and no treatment, and a group of dogs with maxishock treated with a canine military antishock trousers inflated to 50 to 55 mm Hg and no fluids. The average needle insertion time was 16 seconds; the rate of infusion of fluids varied from a maximum of 25.7 mL/min to a minimum of 4.5 mL/min, with a mean of 10.6 mL/min.(ABSTRACT TRUNCATED AT 250 WORDS)

Beckwith-Wiedemann syndrome with unusual hepatic and pancreatic features: a case expanding the phenotype.

We describe an infant with Beckwith-Wiedemann syndrome (BWS) who had hepatic and pancreatic findings not previously described in BWS. These were biliary dysgenesis and enlargement and cystic dysplasia of the pancreas. The biliary dysgenesis was characterized by proliferation of abnormally shaped ducts in the portal tracts. Massive enlargement and cystic dysplasia of the pancreas was associated with ductular proliferation, virtual absence of normal exocrine tissue, and an increase in endocrine tissue.

Stenosis of the foramen magnum and rostral spinal canal, with spinal cord deformity, in Jeune's asphyxiating thoracic dystrophy.

Ventilatory compromise in Jeune's asphyxiating thoracic dystrophy (JTD) generally is attributed to abnormalities in thoracic configuration that produce restrictive pulmonary disease and pulmonary hypoplasia. We present our findings following dissection and roentgenography of the base of the skull and the vertebral column in a premature infant with JTD. They suggest that malformations of the vertebral laminae in JTD may lead to compression of the distal medulla and rostral cervical spinal cord. Similar compression is known to contribute to ventilatory dysfunction in other osteochondrodysplasias. It is possible that vertebral laminar malformations may be partly responsible for ventilatory dysfunction in some patients with JTD. We recommend attention at necropsy in JTD to malformations of the neural arch and to their possible sequelae.

Congenital disseminated herpes simplex virus type II infection in a premature infant.

A rare case of congenital herpes simplex virus type II infection is reported in a 25-week premature infant. Transmission of infection was thought to be transplacental, and the infection was rapidly fatal ex utero due to extensive antenatal disseminated disease.