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Biomedical subjects

B Shandling

Publications and source records attributed to B Shandling.

At least 91 records · Page 5Linked to original sources
PubMed1982

A modified Sugiura procedure.

The Sugiura procedure for esophageal varices combines splenectomy with esophagogastric devascularization, which destroys the intraesophageal portacaval shunt but preserves periesophageal portacaval shunts. We have modified the total vagotomy and pyloroplasty and sutured esophageal anastomosis of the original operation. A single left thoracoabdominal incision is used. Esophagogastric devascularization is performed without dividing the main vagus trunks; only a proximal gastric vagotomy is done, thereby avoiding a pyloroplasty. The esophageal transection and reanastomosis are performed with the circular End-to-End Anastomosis stapler and protected with a loose-fundal wrap. Fifteen of 20 patients have had good to excellent results, with rapid recovery and no recurrent esophagogastric bleeding or any hepatic encephalopathy in follow-up of two months to two years. Four patients, who were bleeding massively at the time of operation and who were in Child's class C with gross ascites, muscle wasting, ad coagulopathy, died in the postoperative period. Conceptually, the operation is original and exciting because it preserves hepatic blood flow and the beneficial periesophageal shunt, while destroying the harmful intraesophageal shunt. Our early experience encourages us to continue using this operation, except in those patients who bleed massively and are in Child's C, end-stage, class.

Esophageal and Gastric Varices↗
PubMed1982

Lipoblastoma in infants and children.

Lipoblastoma and lipoblastomatosis are rare benign tumors of embryonal fat with a tendency to local invasion but not to metastasize. To date, there have been 60 cases described in the international literature. There has never been a report in a child older than 8 yr. The main clinical characteristics are the presentation, usually below 3 yr of age, the rapid growth of the mass and the peripheral location, mainly in the extremities. Although CT scan may show a fatty tumor, there is no single test to make the differential diagnosis (which includes benign lipoma, liposarcoma and myxoliposarcoma) and the treatment should be based on clinical findings. We have treated four patients with this condition. Two were intrathoracic, one was intraperitoneal, and one was a tumor of the upper arm. All presented as rapidly-growing tumors and were clinically assumed to be malignant. We recommend complete but conservative excision of the tumor; there are reported recurrences after inadequate excision. This is a benign tumor and radical cancer surgery should be avoided.

Abdominal Neoplasms↗
PubMed1982

Hepatic hemangioma in childhood: medical management or surgical management?

Between 1955 and 1980 there were 14 patients treated at The Hospital for Sick Children with hemangiomas of the liver. Eight were seen at birth and 13 within the first 6 wk of life. The presenting clinical feature was that of massive hepatomegaly. Two children who had presented in the neonatal period were found to have had cardiac failure. Six patients were anemic and required blood transfusions. Before 1976 all patients who did not have cutaneous hemangiomas underwent laparotomy. Since 1976 only one laparotomy was done, the remaining 5 patients all having been treated symptomatically without operation. All the tumors involuted in the first year of life. Follow-up ranged from 1 to 20 yr and all are living and without symptoms. We recommend no active treatment if complications are absent. Steroids and radiotherapy are not used. If anemia and/or cardiac failure supervene, appropriate nonoperative management is necessary. Surgical treatment is indicated only if medical management fails or for rupture of the lesion.

Child↗
PubMed1982

The vulnerability of the vas deferens (II): the case against routine bilateral inguinal exploration.

The results of operative manipulation of the vas deferens have unknown results. In order to document early and late structural changes in the vas after simple operative manipulations, the vasa deferentia of 120 Wistar rats were subjected to 4 different manipulations. Subsequently, they were removed at intervals (up to 6 mo) and examined after appropriate staining. Finger or vascular clamp grasping resulted in mild inflammation at 6 wk, which resolved thereafter. Forceps grasping disrupted the muscle layers in 30%-40% of the vasa. Hemostat clamping damaged muscle layers in 100% of the vasa and resulted in abscess formation in 30%. Healing in forceps grasped and hemostat clamped specimens was negligible and haphazard with minimal evidence of normal collagen or elastin at 6 mo. All differences were significant (p less than 0.05). These results suggest that operative manipulations of the vas should be minimized and limited to digital maneuvers. Damage from other manipulations is appreciable, long-term, and only minimally repaired at 6 mo.

Animals↗
PubMed1981

Results of bowel resection for Crohn's disease in the young.

Thirty patients (21 boys and 9 girls) underwent bowel resections for Crohn's disease from 1965 to 1979. They ranged in age from 6 to 18 yr. The follow-up period varied from 3 mo to 14 yr. There were no deaths. Seventeen developed clinical or radiologic evidence of recurrent Crohn's disease. Seven of these required reoperation and six are now well without sign of further recurrence. Eleven of 18 achieved catch-up growth in weight; 10 of 15 achieved catch-up growth in height. At the time of follow-up four had active disease, seven had evidence of recurrence but were generally well, and 19 were well without any evidence of recurrence.

Adolescent↗
PubMed1981

The vulnerability of the vas deferens.

Transection of the vas deferens is considered a disaster, but other manipulations may have unpredictable and hitherto undocumented effects. In order to delineate the structural changes in the vas deferens after operative manipulation, 40 Wistar rats (300-500 g) were divided into four groups and subjected to four different operative manipulations (grasping with fingers, nontoothed Adson forceps, bulldog vascular clamp, clamping with "mosquito" hemostat). Histologic studies performed at 6 wk postmanipulation demonstrated a variable intra- and transmural inflammatory reaction in all groups. Thirty percent of the specimens grasped by the forceps showed disruption of the muscle wall. One-hundred percent of the specimens clamped by the hemostat showed mural disruption and marked inflammatory reaction; in addition 30% had an associated abscess. Therefore all manipulation of the vas deferens should be minimized to avoid triggering inflammation and secondary obstruction. Grasping with a nontoothed forceps results in appreciable damage. Clamping with a hemostat is as serious as complete transection.

Animals↗
PubMed1981

An assessment of the surgical treatment of adhesive small bowel obstruction in infants and children.

At The Hospital for Sick Children, Toronto, Canada, adhesive small bowel obstruction (SBO) ranks seventh as a cause of pediatric bowel obstruction. Between January 1968 and December 1979, 131 infants and children had adhesive SBO proven at laparotomy or autopsy: 123 had 1; 7 had 16 adhesiotomies; 1 died without surgery; 100 had 1 prior operation; and 31 had multiple operations. Over 80% of the SBOs developed within 2 yr of the prior operations. Appendectomy and subtotal colectomy were the most common prior operation. Postoperative morbidity occurred in 29 children; 20 were observed longer than 24 hr before laparotomy. The rate of wound infection ranged from 4% to 50%; it was lowest for those children who had lysis of adhesions only, and highest for those who had lysis and decompressive enterotomy or perforation repair. Results indicate that delaying adhesiotomy and entering the GI tract during adhesiotomy are associated with increased morbidity (p less than 0.01), and therefore should be avoided. Prophylactic antibiotics may have a protective role during anterolysis.

Adolescent↗
PubMed1981

Ruptured spleen--when to operate?

Sixty-three patients with splenic injuries were treated during a 5-yr period from 1974-1979. The decision to operate was based on the patient's clinical course, not on the presence of splenic injury alone. Those who were stable on admission or after initial resuscitation were treated nonoperatively. This consisted of strict bed rest, nasogastric suction, and i.v. fluids--including blood--as required. Those who bled massively were operated on promptly. At operation, the spleen was repaired if possible or excised if damaged beyond repair. Forty patients were treated nonoperatively. Sixteen of these required blood transfusions (mean 31.2 +/- 5.3 ml/kg). One patient in this group developed a large defect on spleen scan at 3 wk post injury. There was no other morbidity and no mortality following nonoperative treatment. Nineteen required operation all within 16 hr of admission. Fifteen underwent splenectomy, 2 partial splenectomy, and 1 splenorrhaphy. In 1 the bleeding had stopped. All required blood before operation (mean 80.4 +/- 10.1 ml/kg). Seven in this group died (6 from head injuries and 1 from bleeding). Thus surgery was avoided in 2 out of 3 and the spleen saved in 3 out of 4 patients with documented splenic injuries. We believe that where adequate facilities exist nonoperative treatment of splenic injuries is both safe and effective. When bleeding is massive from the beginning or replacement requirements exceed 40 ml/kg, operation is indicated.

Adolescent↗
PubMed1981

Major hepatic tumor resection using profound hypothermia and circulation arrest.

In spite of recent reports of more aggressive investigation and treatment of malignant liver tumors in infants and children, there is still an alarming morbidity and mortality in the operative aspect of this tumor. Our operative approach to partial hepatectomy follows that laid down by many authors, but we seem to have the same intraoperative problems in removing the huge tumor confined to one liver lobe. The blood loss in such operations may equal or exceed the child's blood volume while intraoperative cardiac arrest is not unknown. The bleeding can be most acute in the course of the retrohepatic caval and hepatic veins dissection. Once bleeding becomes excessive, the dissection must continue in a hurried fashion leading to the above problems. Since 1977, six children have been admitted to our hospital with huge malignant liver tumors involving almost all of one liver lobe and part of the other. Each was explored through a long midline abdominal incision finding what was felt to be a resectable liver tumor. The incision was then carried upwards via a sternal split or a right thoracoabdominal incision and the liver mobilized. The patient was then put on cardiopulmonary bypass and cooled to a rectal temperature below 20 degrees C. Circulation arrest at this low temperature provided 1 hr or less of bloodless dissection, and an extended hepatic lobectomy was easily carried out. The patients were rewarmed on bypass and normal hemodynamics restored. Bleeding from the liver edge was controlled and the remainder of the operation completed. What was previously the most difficult aspect of a liver tumor operation has become the easiest part of the entire procedure. This operative approach is recommended in highly selected large tumor cases.

Adolescent↗
PubMed1981

Balloon embolization of a bleeding gastroduodenal artery in a 1-year-old child.

Severe stress can produce ulceration and uncontrollable hemorrhage in the pediatric age group. Modern angiographic techniques, using embolization of a Silastic balloon to occlude a visualized bleeding vessel, can successfully control hemorrhage and avoid surgical intervention and its resultant disordered gastric physiology. Recently this technique was used to control hemorrhage from the gastroduodenal artery in a 1-year-old child with severe respiratory sepsis. This is the youngest reported child in whom the technique has been used to control bleeding from this vessel.

Aneurysm↗
PubMed1980

Conservative management of ruptured spleen.

For many years it was accepted that splenic injury was best managed by splenectomy. However, it has more recently been realized that patients whose spleen has been removed are more liable to life-threatening infection. This is of particular consequence if splenectomy is performed in childhood, with a long life expectancy. The extra mortality rate associated with sepsis after splenectomy is noted from reports in the literature, and the immunological functions of the spleen are discussed. It is pointed out that with the present diagnostic means splenic rupture or splenic injury need not necessarily indicate splenectomy. The features of conservative management are outlined, and the results in 75 patients, of whom only 21 underwent splenectomy, are stated.

Blood Transfusion↗
PubMed1980

Polymer membrane covering of eviscerated bowel in neonate.

When a siliconized nylon pouch prematurely separates leaving incompletely covered bowel, a difficult if not urgent problem develops. To reapply a new pouch is to invite infection and further separation. In two such instances, we have applied a new polymer membrane to the dome of bowel partly covered with some granulations. This method avoids further emergency operations and hastens the formation of a ventral hernia. Within seven to 14 days, the exposed peritoneal contents were covered with granulations. This polymer membrane seems to have all the benefits of a biological dressing under which it aids the more rapid growth of granulations.

Bandages↗
PubMed1980

The pharmacologic treatment of newborn diaphragmatic hernia--a 2-year evaluation.

From 1968 to 1976 inclusive, 69 neonates with diaphragmatic hernias had corrective surgery within 18 hr of birth and the survival rate was 41%. During the same time, all babies with similar hernias who were operated on later than 18 hr from the time of birth survived. Our present interest has been focused on the pulmonary artery and its hypertension with the subsequent development of right to left shunting through the patent ductus arteriosus. During 1977 and 1978, we attempted to enter 19 consecutive newborns 18 hr of age or less with symptomatic Bochdalek diaphragmatic hernias into a "Collins protocol" for treatment. This included four stages: newborn nursery initial resuscitation, operation, cardiac catheterization, and ICU monitoring and pharmacological therapy. There was a total of seven survivors (36%), however for a number of reasons only eight babies really had a complete entry into this protocol and of these eight, five survived. Although this study is far from complete, some initial information and concepts are forthcoming. It is now apparent to us that there are three distinct groups into which these very early newborns fall: minimal pulmonary hypoplasia, unilateral hypoplasia and bilateral hypoplasia. The first group probably does not need pharmacologic support, while in the last it probably does not help. Further interest in other more specific pulmonary pharmacologic agents is now being considered as well as some way of early recognition of which baby is going to fit into which group, so that only the ones that need this treatment will get it.

Acetylcholine↗
PubMed1980

Regional analgesia for postoperative pain in pediatric outpatient surgery.

Of 156 children undergoing elective inguinal herniotomy under general anesthesia, 81 also had a regional nerve block using Bupivacaine. All were treated as outpatients and recovery was assessed by postanesthetic room nurses and by interrogating the parents as to the child's behavior at home. It was concluded that the use of supplemental regional anesthesia reduced the general anesthetic requirements and the need for postoperative analgesics, thereby providing more rapid recovery to normal activity.

Ambulatory Surgical Procedures↗
PubMed1980

Nonsurgical management of appendiceal mass in late presenting children.

Thirty-seven late presenting children with appendiceal mass were treated between 1965 and 1975 with i.v. fluids, alimentation according to the state of gastrointestinal function, and no antibiotics. They ranged in age from 18 mo to 16 yr and all had had symptoms for at least 5 days (mean 8.7), an abnormal WBC (mean 19.9), and a fixed palpable mass without rebound tenderness. Children were discharged when clinical findings resolved. All returned for interval appendectomy. Eighty-one percent (31 children) had clinical improvement within 5-22 days (mean 10.9). Nineteen percent (7 children) had recurrence or worsening of symptoms and required abscess drainage within 2-10 days after observation began. No child in either group received antibiotics nor did any die. Only one recurrence of symptoms after discharge was recorded before interval appendectomy. Pathologic specimens revealed fibrosis in 46%, subacute inflammation in 35%, and acute inflammation in 19%. Nonoperative management of the appendiceal mass without antibiotics in children is safe as long as diligent observation is maintained. Interval appendectomy can be performed as late as 20 wk after symptom resolution or drainage, however, over 50% of the interval appendectomy specimens reveal acute and subacute inflammation.

Adolescent↗
PubMed1980

Recognition of bilateral neonatal testicular torsion.

Two cases of bilateral neonatal testicular torsion are reported and combined with 6 previously reported ones. These infants with bilateral testicular torsion are compared with neonates with unilateral torsion. Both have similar signs and symptoms: (1) a swollen bluish-red firm scrotum at birth, and (2) no evidence of spontaneous pain. Infants in neither group had any systemic symptoms. Immediate investigation with reduction is mandatory to prevent testicular atrophy.

Humans↗