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Biomedical subjects

M W Gauderer

Publications and source records attributed to M W Gauderer.

At least 55 records · Page 3Linked to original sources
PubMed1991

Pediatric abdominal lymphangiomas: a plea for early recognition.

Abdominal lymphangiomas are usually classified together with mesenteric cysts. However, they differ by location, histology, and potential for recurrence, and should be considered a separate clinical entity. Thirteen children, aged 2 weeks to 11 years (mean, 5.8 years), with abdominal lymphangiomas were identified over the past 16 years at this institution. Of these, 12 were symptomatic. Abdominal pain (11), vomiting (8), increased abdominal girth (8), and nausea (6) predominated. Other presentations were less frequent. Symptoms were present for an average of 2 months (7 less than 1 week) before correct diagnosis. An abdominal mass was palpable in 10 cases. Intestinal gangrene secondary to volvulus was present in 2. Although multiple imaging modalities were used ultrasonography (8/8) and computed tomography (CT; 4/4) proved most expedient and reliable. In 2 cases, the lymphangioma could not be completely resected. There was 1 recurrence. Although intraabdominal cystic lesions are described in the literature as relatively symptom-free, our experience suggests otherwise. In this series, abdominal pain and an abdominal mass were common. Catastrophic complications can occur and excision is facilitated by earlier diagnosis and the benefit of smaller size. Ultrasound and CT can accurately diagnose the lesion and should be used liberally in children with intermittent or ill-defined abdominal pain, leading to prompt recognition and definitive treatment.

Abdominal Neoplasms↗
PubMed1991

Pneumatosis cystoides intestinalis in children beyond the first year of life: manifestations and management.

Beyond infancy, pneumatosis cystoides intestinalis (PCI) is rare. Data concerning pathogenesis and treatment are limited. Our experience with 12 children was examined to define predisposing factors, presentation, treatment, and outcome. Nine children were immunosuppressed, thus identifying an important etiologic subgroup. Presentation was variable but included abdominal pain, distention, diarrhea and hematochezia. Clostridium difficile was found in 3 patients and cytomegalovirus in 1. Radiographs showed free air in 3. Nine were treated with antibiotics and bowel rest, 1 with bowel rest alone, 1 with oral metronidazole, and 1 with observation. PCI resolved in 7 of 9 treated with antibiotics, although 1 child with leukemia had severe hematochezia secondary to colonic ulceration and required hemicolectomy. No other patient required laparotomy. The free air resolved in 2 of 3. There were 2 deaths, both from sepsis. One had free air on admission but no perforation was found at autopsy. Treatment recommendations remain unclear; however, C difficile and cytomegalovirus are important pathogens that should be identified and treated promptly. In symptomatic patients, bowel rest and antibiotics seem beneficial. Operative intervention should be reserved for patients with peritoneal signs, progressive deterioration, obstruction, or persistent, severe bleeding. Free air alone is not an indication for operative management in children with PCI.

Adolescent↗
PubMed1991

Pelvic abscesses: CT-guided transrectal drainage.

Percutaneous drainage of pelvic abscesses has been performed by using a number of approaches, including transabdominal, transgluteal, and transrectal. The authors present a technique for the drainage of pelvic abscesses by a transrectal route with use of computed tomographic (CT) guidance. Equipment for the technique included a plastic introducer tube, standard needle, angiographic guide wire, and pigtail catheters. The pelvic abscesses of 10 patients (six after appendectomy, three after colon resection, one secondary to diverticulitis) were successfully drained by using the new technique. No complications or recurrences were experienced. After initial catheter placement, patients were treated with use of gravity drainage and appropriate antibiotics. Success of drainage was determined with sequential CT scans. Compared with the transgluteal approach, the transrectal approach offered increased patient comfort and minimal risk of potential complications such as injury to the sciatic nerve or tracking of the abscess. Use of the plastic introducer tube promoted operator safety by protecting the guiding finger. On the basis of this initial series, CT-guided transrectal drainage appears to be an effective and well-tolerated method for the drainage of pelvic abscesses.

Abscess↗
PubMed1990

The spectrum of appendiceal disease in cystic fibrosis.

A retrospective review of 1,220 cystic fibrosis (CF) patients between 1965 and 1989 identified 60 patients who underwent appendectomy. Ten had appendectomy prior to referral and 16 had an incidental appendectomy (primarily meconium ileus). Among the remaining 34 patients, acute appendicitis was present in 19 (1.8% incidence). "Classic appendicitis"--acute abdominal pain shifting to the right lower quadrant (RLQ), focal RLQ tenderness, and elevated white blood cell (WBC) count--was present in 15. Four additional inflamed appendixes were removed in patients following incorrect preoperative diagnosis. Thirteen of these 19 were perforated. Complications included wound infection (2), pelvic abscess (1), ileal obstruction requiring ileostomy (1), and pelvic hematoma (1). There were no deaths. One patient with acute RLQ pain and tenderness had a normal appendix. Seven patients (mean, 20 years) had chronic, intermittent, focal RLQ pain and tenderness not originating periumbilically with a normal WBC count and temperature. At exploration, these appendixes were enlarged and tensely distended with inspissated mucus. Microscopic examination showed no inflammation. Appendectomy resulted in resolution of symptoms without complications. Four additional patients with intermittent RLQ pain and tenderness and a history of recurrent intussusception presented with ileocolic intussusception. Persistent postreduction symptoms in three and failure of reduction in the fourth necessitated celiotomy at which time tensely distended appendixes were removed. Appendectomy led to resolution of symptoms. Three additional enlarged noninflammed appendixes were incidentally removed in asymptomatic patients undergoing unrelated intraabdominal procedures. Appendiceal disease in CF patients represents a spectrum ranging from simple mucous distention to acute appendicitis with perforation. CF patients with pain secondary to a noninflamed distended appendix represent a distinct syndrome cured by appendectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Pain↗
PubMed1990

Pediatric blunt liver injury: establishment of criteria for appropriate management.

There is no consensus regarding the most appropriate management of pediatric blunt liver injury. This study addresses this issue by reviewing our experience with blunt liver trauma in relationship to the grade of injury. Forty-one pediatric patients with blunt abdominal trauma and documented liver injury were managed from 1979 to 1989. Fifteen (37%) underwent celiotomy. Three children had extensive parenchymal injuries (grade IV or V) requiring resection and three others died intraoperatively, secondary to exsanguinating hemorrhage of associated injuries (grade V) to the hepatic veins and inferior vena cava. The need for celiotomy was obvious in these patients. In 9 of the 15 children who underwent exploration (60%), bleeding from the liver injury (grade II or III) had ceased by the time of celiotomy. These children did not appear to benefit from the operation. Twenty-six of the 41 patients (63%) were selected for nonoperative management because they were hemodynamically stable after initial resuscitation and did not show signs of associated intraabdominal injuries requiring surgical intervention. These children underwent evaluation by abdominal computed axial tomography scan (grade I, II, III, and IV injuries). Blood transfusions were given to keep the hematocrit above 30%. Seventeen of the 26 children managed nonoperatively (65%) did not require blood replacement. The mean (+/- SEM) transfusion volume for the remaining nine children was 14.8 +/- 2.5 mL/kg. Blunt liver injury represents a spectrum from a minimal parenchymal hematoma to massive liver disruption. We conclude that celiotomy is necessary for hepatic injury hemodynamically stable injured children with transfusion requirements less than 40 mL/kg can be managed nonoperatively in an appropriate setting.

Adolescent↗
PubMed1989

The spectrum of cholelithiasis in the first year of life.

Cholelithiasis is being diagnosed with increased frequency in the very young. We encountered 12 patients over a 5-year period in whom cholelithiasis was diagnosed prior to age 1 year. The earliest diagnosis was made in utero during the seventh gestational month. While most of the children suffered from complex medical disorders, 4 of the 12 had no recognizable predisposing factors. Eight of the 12 were treated at some point prior to diagnosis with central parenteral nutrition. Three presented with infectious complications requiring prompt operative intervention. Two children underwent elective cholecystectomy nearly 2 years after the diagnosis for symptoms of biliary colic. Of the remaining seven, spontaneous stone resolution was documented in three, while four remain asymptomatic after a minimum of years follow-up. The spectrum of presentations in this series highlights the uncertainties regarding the etiology, natural history, and treatment of this increasingly more common disorder.

Cholelithiasis↗
PubMed1989

Splenic injury: nonoperative management in three patients with infectious mononucleosis.

Three patients with infectious mononucleosis and splenic injury were managed nonoperatively. Mechanisms of injury included significant left upper quadrant trauma during a football game in a 17-year-old boy, a minor fall in a 16-year-old girl, and no apparent trauma in the remaining patient, a 28-year-old man. All had significant abdominal pain and two were hypotensive upon admission. All had computerized tomographic scan documentation of splenic enlargement, significant injury, and free peritoneal blood. Paracentesis was not performed. Only the first patient received transfused blood. The hospitalization period ranged from nine to 14 days. Gradual and finally complete healing (return to normal size) was documented in all three patients. Follow-up is 66, 14, and 10 months. Although clearly controversial and not free from danger, successful nonoperative management of the injured enlarged spleen in select patients with mononucleosis is possible in an appropriate setting.

Adolescent↗
PubMed1989

Is there a place for parents in the operating room?

The presence of a parent in the operating room (OR) during induction of anesthesia is controversial. In order to assess the feasibility, safety, and acceptance of this practice, we evaluated a near-4-year experience with 3,086 patients less than 15 years of age, who were operated on at a free-standing ambulatory surgical center. The age distribution was: 1 to 23 months, 790; 2 to 5 years, 1,190; 6 to 10 years, 775; and 10 to 15 years, 331. The distribution of patients by service was: otorhinolaryngology, 1,597; pediatric surgery, pediatric urology, and plastic surgery, 948; ophthalmology, 443; orthopaedics, 72; and dental, 26. No premedication was employed. Anesthetic gases were delivered via a mask while the parent held or remained close to the child. Vascular access was established after the induction. Only five patients (tonsillectomy, four; circumcision, one) were admitted to the base hospital and subsequently discharged. Advantages of parental presence in the OR during anesthesia induction are decreased psychological trauma (child), smoother induction (child), and decreased parental anxiety. Possible disadvantages include disruption of OR routine, unpredictability of parental behavior, and increased time and cost. Because of careful preoperative preparation of parents by the nurses and anesthetists, the first three problems rarely occurred. The cost of supplies used by each parent was minimal. Practically all parents chose to accompany the child to the OR. The feedback during follow-up from those parents has been excellent. Nurses, anesthesiologists, and surgeons are enthusiastic about the program. In the examined setting, this approach has proven safe, simple, and effective.

Adolescent↗
PubMed1989

Jejunostomy button as a new method for long term jejunostomy feedings.

The button jejunostomy provides long term access for jejunal feedings incorporating the benefits of the gastrostomy button device. Although this procedure requires a celiotomy, we believe the relative simplicity of the procedure and its advantages over other types of jejunostomies warrant its use in patients with clinically significant gastroesophageal reflux who require long term enteral nutrition.

Adult↗
PubMed1988

Moxalactam vs tobramycin-clindamycin. A randomized trial in secondary peritonitis.

One hundred five patients with peritonitis were randomized to receive either tobramycin sulfate plus clindamycin phosphate or moxalactam alone before surgical intervention. Fifty-nine patients were evaluable. A mean of 3.1 (moxalactam) and 3.5 (tobramycin-clindamycin) pathogens per patient were identified. Overall success rate was 85% (tobramycin-clindamycin, 24/30; moxalactam, 26/29). When patients with appendicitis were excluded, there was an observed but not statistically significant advantage of moxalactam over tobramycin-clindamycin (85% vs 67%). There were five deaths (tobramycin-clindamycin, four; moxalactam, one). Other complications included hypoprothrombinemia (tobramycin-clindamycin, five; moxalactam, five), renal dysfunction (tobramycin-clindamycin, three; moxalactam, one), and superinfection (tobramycin-clindamycin, nine; moxalactam, six). More wound infections were noted in the group given tobramycin-clindamycin. These data suggest that moxalactam is as safe and efficacious as tobramycin plus clindamycin. The observed benefits of this agent warrant study in a larger sample to verify advantages of moxalactam over combination therapy.

Abscess↗
PubMed1988

Cervical teratomas: an analysis. Literature review and proposed classification.

Cervical teratomas are uncommon lesions usually diagnosed at birth but occasionally reported in older children and adults. During a 58-year span, nine cervical teratomas were identified at our institution (four previously reported): three stillborns with giant tumors; five live newborns; and one adult with a malignant tumor. Of the five newborns, two prematures died within one hour of birth. Of the three survivors, 2 had respiratory distress at birth. These infants were treated with early excision and are well at 7, 6, and 2 years of age. The last patient also had cystic fibrosis. The adult died of metastatic disease 8 months after resection. A literature review disclosed 212 cases in addition to the five reported here. Previous attempts at categorizing cervical teratomas have failed to address clinical patterns and have little prognostic value. We propose a classification based on birth status, age at diagnosis, and the presence or absence of respiratory distress. Group I--stillborn and moribund live newborns: number (N), 27; mortality (M), 100%. Group II--newborn with respiratory distress: N, 99; M, 43.4%. Group III--newborn without respiratory distress: N, 37; M, 2.7%. Group IV--children age 1 month to 18 years: N, 31; M, 3.2%. Group V--adults: N, 23; M, 43.5%. Twenty-six patients in group II and one in group III died without excision of the mass. Seventy-three patients in group II, 36 in group III, and 31 in group IV had extirpation of the tumor. Operative mortality was 11%, 0%, and 3.2%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Female↗
PubMed1988

Feeding gastrostomy button: experience and recommendations.

To circumvent the common problems and complications of long-term gastrostomy management, a skin-level nonrefluxing nonreactive gastrostomy "button" (GB) was designed. This silicon device is self-retaining, employing a one-way (in) valve. For feeding purposes, an adapter is inserted. Since initial results with five prototypes were encouraging, our experience with 90 buttons over a 20-month period forms the basis of this report. The GB is commercially available in three sizes: "small" (1.5 cm shaft length), medium (2.7 cm), and long (4.3 cm). A new narrow shafted prototype with an intermediary shaft length of 2.3 cm is under evaluation. We have analyzed our experience with the GB in 50 children (average age 4.1 years, average weight 12.8 kg) and six adults (average age 75 years) during this span. Ninety GBs were employed (small 46, medium 31, long 7, prototype 6) for a total of 485 patient months. In the pediatric age group, the average time with one or more GBs in place was 8.9 months. Of the 50 children, 30 had one GB only, 11 had two, six had three, and three had four GBs (total 82 GBs). The performance of each GB was under 1 month, 3 (mechanically defective); 1 to 3 months, 20; 3 to 6 months, 25; 6 to 12 months, 26; and over 12 months, 8 (two at 20 months). There were 31 changes in 20 children: leakage through GB shaft, 23 (valve incompetence); accidentally pulled out, 4; leakage around shaft (poor stoma), 2; and deterioration at feeding connection end, 2. One additional GB was purposely temporarily removed when the child underwent a colostomy closure. Seven GBs in children were removed since they were no longer needed. In two children, the GBs were replaced by a conventional catheter at 1 and 6 months post-GB insertion (chronic intermittent bowel obstruction requiring frequent drainage in one and multiple removals of the GB by the child in the other). Difficulties with early feeding adapters (frequent disconnections or shaft stretching) were encountered in five, but this is no longer a problem.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1988

Percutaneous endoscopic gastrostomy in the cancer patient.

A retrospective analysis of all patients with malignancy undergoing percutaneous endoscopic gastrostomy (PEG) was undertaken. PEG was attempted in 42 cancer patients from a total of 142 patients and successful in 38 (90.5%). The success rate in completing this procedure in cancer patients was significantly less than in noncancer patients (P = 0.04). The most common malignancy was oral-pharyngeal carcinoma (29%). Survival data was available in 35 of 38 patients (92%). Three patients died in less than one month. Forty six per cent of the patients survived three months or longer and 20 per cent 1 year or longer. The majority of the patients (68%) were able to return home after the PEG. There was no mortality related to the procedure. Local anesthesia was used in 95 per cent of the procedures. The major concerns derived from the study are the short-term survival in a small number of patients and aspiration in selective patients. Attempts should be made to identify these patients and avoid PEG since its benefits will be limited. When used selectively, PEG can improve the quality of life of the cancer patient.

Adult↗
PubMed1987

Surgery in patients with cystic fibrosis.

A 15-year review of children's hospital patients with cystic fibrosis (CF) who underwent surgery yielded 578 cases in 210 patients (mean 2.7 per patient). The median age was 16 years (range newborn to 43 years). Four hundred procedures were done under general anesthesia and 176 under local. There was one anesthetic complication, respiratory depression in a patient whose MediPort (Cormed, Inc, Medina, NY) was inserted using local anesthesia and sedation. The most frequent procedure was nasal polypectomy, with 165 procedures in 50 patients. The second most common procedures were vascular access procedures: 75 central lines and 29 MediPorts were implanted in 57 patients, complicated by two pneumothoraces. Thoracic procedures included 32 bronchoscopies, 8 lobectomies, 2 pneumonectomies, and 30 pleural strippings. There were three reoperations for bleeding in the pulmonary resection patients. Thirteen newborns underwent a total of 26 procedures for meconium ileus and its complications, with two deaths secondary to respiratory failure and sepsis. These, and one death postlobectomy were the only operative deaths in the entire series of 578 cases (0.5% mortality rate). There were four slings for rectal prolapse; two required removal secondary to infection. Eight patients underwent central splenorenal shunts for portal hypertension, 15 underwent cholecystectomy, 5 underwent Nissen fundoplication, 16 underwent inguinal herniorrhaphy, 2 underwent umbilical herniorrhaphy, 3 underwent orchidopexies, and 4 underwent miscellaneous pediatric surgical procedures. Eleven patients underwent appendectomy for appendicitis; four were ruptured at the time of diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗